How Lexapro (escitalopram) works

Lexapro (escitalopram) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. It raises serotonin levels in the brain which regulates mood.

What is Lexapro (escitalopram) used for?

• Depression
• Anxiety

Brand names:

• Lexapro®
  • Tablets: 5 mg, 10 mg, 20 mg
  • Liquid: 1 mg/mL
• Escitalopram
  • Tablets: 5 mg, 10 mg, 20 mg
  • Liquid: 1 mg/ml

Generic name: escitalopram (es sye TAL oh pram)

All FDA black box warnings are at the end of this fact sheet. Please review before taking this medication.

What Is Escitalopram And What Does It Treat?

Escitalopram is an antidepressant medication that works in the brain. It is approved for the treatment of major depressive disorder (MDD) and generalized anxiety disorder (GAD).

Lexapro (escitalopram) is an antidepressant belonging to a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Escitalopram affects the levels of certain chemicals in the brain that may be altered in people suffering from depression or anxiety.

Lexapro is used to treat major depressive disorder in adults and adolescents at least 12 years old.

Lexapro is also used to treat anxiety in adults.

Symptoms of depression include:

• Depressed mood – feeling sad, empty, or tearful
• Feeling worthless, guilty, hopeless, and helpless
• Loss of interest or pleasure in your usual activities
• Sleep and eat more or less than usual (for most people it is less)
• Low energy, trouble concentrating, or thoughts of death (suicidal thinking)
• Psychomotor agitation (‘nervous energy’)
• Psychomotor retardation (feeling like you are moving and thinking in slow motion)
• Suicidal thoughts or behaviors

Generalized anxiety disorder (GAD) occurs when a person experiences excessive anxiety or worry for at least six months. Other symptoms include:

• Restlessness
• Fatigue (low energy, feeling tired all the time)
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling asleep or waking up in the middle of the night)

Escitalopram may also be helpful when prescribed “off-label” for obsessive compulsive disorder (OCD), eating disorders such as binge eating disorder or bulimia nervosa, panic disorder, posttraumatic stress disorder (PTSD), and premenstrual dysphoric disorder (PMDD). “Off-label” means that it hasn’t been approved by the Food and Drug Administration for this condition. Your mental health provider should justify his or her thinking in recommending an “off-label” treatment. They should be clear about the limits of the research around that medication and if there are any other options.

What Is The Most Important Information I Should Know About Escitalopram?

Do not stop taking escitalopram, even when you feel better. With input from you, your health care provider will assess how long you will need to take the medicine.

Missing doses of escitalopram may increase your risk for relapse in your symptoms.

Stopping escitalopram abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin).

Depression is also a part of bipolar illness. People with bipolar disorder who take antidepressants may be at risk for “switching” from depression into mania. Symptoms of mania include “high” or irritable mood, very high self-esteem, decreased need for sleep, pressure to keep talking, racing thoughts, being easily distracted, frequently involved in activities with a large risk for bad consequences (for example, excessive buying sprees).

Medical attention should be sought if serotonin syndrome is suspected. Please refer to serious side effects for signs/symptoms.

Warnings

You should not use Lexapro if you also take pimozide or citalopram (Celexa).

Do not use Lexapro within 14 days before or 14 days after you have used an MAO inhibitor, such as isocarboxazid, linezolid, methylene blue injection, phenelzine, rasagiline, selegiline, or tranylcypromine.

Some young people have thoughts about suicide when first taking an antidepressant. Stay alert to changes in your mood or symptoms. Report any new or worsening symptoms to your doctor.

Seek medical attention right away if you have symptoms of serotonin syndrome, such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea.

Do not give Lexapro to anyone under 12 years.

Do not stop using Lexapro without first asking your doctor.

Before taking this medicine

You should not use Lexapro if you are allergic to escitalopram or citalopram (Celexa), or if:

• you also take pimozide.

Do not use Lexapro within 14 days before or 14 days after you have used an MAO inhibitor. A dangerous drug interaction could occur. MAO inhibitors include isocarboxazid, linezolid, phenelzine, rasagiline, selegiline, and tranylcypromine.

Be sure your doctor knows if you also take stimulant medicine, opioid medicine, herbal products, or medicine for depression, mental illness, Parkinson’s disease, migraine headaches, serious infections, or prevention of nausea and vomiting. These medicines may interact with escitalopram and cause a serious condition called serotonin syndrome.

To make sure Lexapro is safe for you, tell your doctor if you have ever had:

• liver or kidney disease;
• seizures;
• low levels of sodium in your blood;
• heart disease, high blood pressure;
• a stroke;
• bleeding problems;
• sexual problems;
• bipolar disorder (manic depression); or
• drug addiction or suicidal thoughts.

Some young people have thoughts about suicide when first taking an antidepressant. Your doctor should check your progress at regular visits. Your family or other caregivers should also be alert to changes in your mood or symptoms.

Lexapro is not approved for use by anyone younger than 12 years old.

Ask your doctor about taking this medicine if you are pregnant. Taking an SSRI antidepressant during late pregnancy may cause serious medical complications in the baby. However, you may have a relapse of depression if you stop taking your antidepressant. Tell your doctor right away if you become pregnant. Do not start or stop taking Lexapro without your doctor’s advice.

If you are pregnant, your name may be listed on a pregnancy registry to track the effects of escitalopram on the baby.

If you are breastfeeding, tell your doctor if you notice drowsiness, agitation, feeding problems, or poor weight gain in the nursing baby.

Are There Specific Concerns About Escitalopram And Pregnancy?

If you are planning on becoming pregnant, notify your health care provider to best manage your medications. People living with MDD who wish to become pregnant face important decisions. Untreated MDD has risks to the fetus, as well as the mother. It is important to discuss the risks and benefits of treatment with your doctor and caregivers. For women who take antidepressant medications during weeks 13 through the end of their pregnancy (second and third trimesters), there is a risk that the baby can be born before it is fully developed (before 37 weeks).

For mothers who have taken SSRIs during their pregnancy, there appears to be less than a 1% chance of infants developing persistent pulmonary hypertension. This is a potentially fatal condition that is associated with use of the antidepressant in the second half of pregnancy. However, women who discontinued antidepressant therapy were five times more likely to have a depression relapse than those who continued their antidepressant. If you are pregnant, please discuss the risks and benefits of antidepressant use with your health care provider.

Caution is advised with breastfeeding since escitalopram does pass into breast milk.

What Should I Discuss With My Health Care Provider Before Taking Escitalopram?

• Symptoms of your condition that bother you the most
• If you have thoughts of suicide or harming yourself
• Medications you have taken in the past for your condition, whether they were effective or caused any adverse effects
• If you experience side effects from your medications, discuss them with your provider. Some side effects may pass with time, but others may require changes in the medication.
• Any other psychiatric or medical problems you have, including a history of bipolar disorder
• All other medications you are currently taking (including over the counter products, herbal and nutritional supplements) and any medication allergies you have
• Other non-medication treatment you are receiving, such as talk therapy or substance abuse treatment. Your provider can explain how these different treatments work with the medication.
• If you are pregnant, plan to become pregnant, or are breastfeeding
• If you drink alcohol or use drugs

How Should I Take Escitalopram?

Escitalopram is usually taken one time per day with or without food.

Typically patients begin at a low dose of medicine and the dose is increased slowly over several weeks.

The dose usually ranges from 10 mg to 20 mg. Only your health care provider can determine the correct dose for you.

The liquid should be measured with a dosing spoon or oral syringe which you can get from your pharmacy.

Consider using a calendar, pillbox, alarm clock, or cell phone alert to help you remember to take your medication. You may also ask a family member or friend to remind you or check in with you to be sure you are taking your medication.

What Happens If I Miss A Dose Of Escitalopram?

If you miss a dose of escitalopram, take it as soon as you remember, unless it is closer to the time of your next dose. Discuss this with your health care provider. Do not double your next dose or take more than what is prescribed.

What Should I Avoid While Taking Escitalopram?

Avoid drinking alcohol or using illegal drugs while you are taking antidepressant medications. They may decrease the benefits (e.g., worsen your condition) and increase adverse effects (e.g., sedation) of the medication.

What Happens If I Overdose With Escitalopram?

If an overdose occurs, call your doctor or 911. You may need urgent medical care. You may also contact the poison control center at 1-800-222-1222.

A specific treatment to reverse the effects of escitalopram does not exist.

What are the possible side effects of Escitalopram?

Common side effects

Headache, nausea, diarrhea, dry mouth, increased sweating, feeling nervous, restless, fatigue, or having trouble sleeping (insomnia). These will often improve over the first week or two as you continue to take the medication.

Sexual side effects, such as problems with orgasm or ejaculatory delay often do not diminish over time.

Rare/serious side effects

Low sodium blood levels (symptoms of low sodium levels may include headache, weakness, difficulty concentrating and remembering), teeth grinding, angle closure glaucoma (symptoms of angle closure glaucoma may include eye pain, changes in vision, swelling or redness in or around eye), serotonin syndrome (symptoms may include shivering, diarrhea, confusion, severe muscle tightness, fever, seizures, and death), seizure

SSRI antidepressants including escitalopram may increase the risk of bleeding events. Combined use of aspirin, nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen), warfarin, and other anti-coagulants may increase this risk. This may include symptoms such as gums that bleed more easily, nose bleed, or gastrointestinal bleeding. Some cases have been life threatening.

Are There Any Risks For Taking Escitalopram For Long Periods Of Time?

To date, there are no known problems associated with long term use of escitalopram. It is a safe and effective medication when used as directed.

What Other Medications May Interact With Escitalopram?

Escitalopram should not be taken with or within 2 weeks of taking monoamine oxidase inhibitors (MAOIs). These include phenelzine (Nardil®), tranylcypromine (Parnate®), isocarboxazid (Marplan®), rasagiline (Azilect®), and selegiline (Emsam®).

Although rare, there is an increased risk of serotonin syndrome when escitalopram is used with other medications that increase serotonin, such as other antidepressants, migraine medications called “triptans” (e.g., Imitrex®), some pain medications (e.g., tramadol (Ultram®), the antibiotic linezolid (Zyvox®), and amphetamines.

Escitalopram may increase the effects of other medications that can cause bleeding (e.g., ibuprofen (Advil®, Motrin®), warfarin (Coumadin®) and aspirin).

How Long Does It Take For Escitalopram To Work?

Sleep, energy, or appetite may show some improvement within the first 1-2 weeks. Improvement in these physical symptoms can be an important early signal that the medication is working. Depressed mood and lack of interest in activities may need up to 6-8 weeks to fully improve.

Summary of FDA Black Box Warnings

Suicidal thoughts or actions in children and adults

Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications. This risk may persist until significant remission occurs.

In short-term studies, antidepressants increased the risk of suicidality in children, adolescents, and young adults when compared to placebo. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24. Adults age 65 and older taking antidepressants have a decreased risk of suicidality. Patients, their families, and caregivers should be alert to the emergence of anxiety, restlessness, irritability, aggressiveness and insomnia. If these symptoms emerge, they should be reported to the patient’s prescriber or health care professional. All patients being treated with antidepressants for any indication should watch for and notify their health care provider for worsening symptoms, suicidality and unusual changes in behavior, especially during the first few months of treatment.

Dosing information

Usual Adult Dose for Generalized Anxiety Disorder:

Initial dose: 10 mg orally once a day; increase if necessary after at least 1 week of treatment to 20 mg once a day
Maintenance dose: 10 to 20 mg orally once a day
Maximum dose: 20 mg orally once a day

Comment: Treatment should be periodically reassessed to determine the need for ongoing treatment; efficacy beyond 8 weeks has not been systematically studied.

Use: Acute treatment of generalized anxiety disorder

Usual Adult Dose for Depression:

Initial dose: 10 mg orally once a day; increase if necessary after at least 1 week of treatment to 20 mg once a day
Maintenance dose: 10 to 20 mg orally once a day
Maximum dose: 20 mg orally once a day

Comments:
-Acute episodes may require several months or longer of sustained pharmacological therapy beyond response to the acute episode.
-Patients should be periodically reassessed to determine the need for maintenance treatment.

Use: Acute and maintenance treatment of major depressive disorder

Usual Geriatric Dose for Depression:

Recommended dose: 10 mg orally once a day

Use: Acute and maintenance treatment of major depressive disorder

Usual Pediatric Dose for Depression:

12 years and older:
-Initial dose: 10 mg orally once a day; increase if necessary after at least 3 weeks of treatment to 20 mg once a day
-Maintenance dose: 10 to 20 mg orally once a day
-Maximum dose: 20 mg orally once a day

Comments:
-Acute episodes may require several months or longer of sustained pharmacological therapy beyond response to the acute episode.
-Patients should be periodically reassessed to determine the need for maintenance treatment.

Use: Acute and maintenance treatment of major depressive disorder

What to avoid

Ask your doctor before taking a nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), celecoxib (Celebrex), diclofenac, indomethacin, meloxicam, and others. Using an NSAID with Lexapro may cause you to bruise or bleed easily.

Avoid alcohol.

Avoid driving or hazardous activity until you know how this medicine will affect you. Your reactions could be impaired.

SSRI’s vs SNRI’s – What’s the difference between them?

The main difference between SSRIs and SNRIs is that SSRIs prevent the reuptake of serotonin and SNRIs prevent the reuptake of serotonin and norepinephrine. Serotonin and norepinephrine are substances that the brain uses to send messages from one nerve cell to another. They are also called neurotransmitters.

SSRI stands for selective serotonin reuptake inhibitor and SNRI stands for serotonin and norepinephrine reuptake inhibitor. SSRIs and SNRIs are two classes of medications that may be used for the treatment of depression, and sometimes for other conditions as well.

Common SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Brisdelle, Paxil, Pexeva), sertraline (Zoloft), and there are others.

Common SNRIs include desvenlafaxine (Khedezla, Pristiq), duloxetine (Cymbalta, Irenka), venlafaxine (Effexor, Effexor XR), and there are others.

SSRIs and SNRIs work similarly, that is by preventing the reuptake of certain neurotransmitters in the brain (SSRIs: serotonin; SNRIs: serotonin and norepinephrine). Neurotransmitters are chemicals which nerve cells release to “talk” to other nerve cells. Neurotransmitters may also be called chemical messengers.

Reuptake is the process in which the neurotransmitter is reabsorbed back into the nerve cell once the stimulus has passed. Both SSRIs and SNRIs are a type of reuptake inhibitor, which means that they prevent the neurotransmitter from being reabsorbed back into the nerve cell that released it. This means that the neurotransmitter stays for a longer period in the gap between the two nerve cells (the gap is called the nerve synapse).

The benefits of antidepressants such as SSRIs and SNRIs are thought to be due to their effect on neurotransmitters, or the effect keeping them in the nerve synapse for longer has on the way the brain operates. The truth is, experts, don’t really know what causes depression, or even how antidepressants work. In the past, depression has been thought to be caused by a chemical imbalance in the brain or by a deficiency in serotonin. We know now it’s not that simple, but well-conducted trials have shown that antidepressants such as SSRIs and SNRIs are beneficial for depression which is why they are commonly prescribed.

What conditions do SSRIs and SNRIs treat?

SSRIs tend to be more commonly prescribed than SNRIs because they are effective at improving mood and tend to be less likely than some SNRIs to cause side effects.

Other conditions that SSRIs are approved to treat, in addition to depression, include:

• Anxiety
• Bulimia
• Fibromyalgia
• Hot flashes
• Obsessive-compulsive disorder
• Panic disorder
• Post-Traumatic Stress Disorder
• Premenstrual dysphoric disorder.

In addition to depression, some SNRIs are approved to treat:

• Anxiety
• Bipolar depression
• Chronic muscle or joint pain
• Diabetic neuropathy
• Fibromyalgia
• Low back pain
• Osteoarthritis pain
• Panic disorder
• Social phobia.

Do SSRIs and SNRIs have different side effects?

SSRIs and SNRIs have similar side effects. Commonly reported side effects that may occur with either SSRIs or SNRIs include:

• Blurred vision
• Constipation
• Dizziness
• Drowsiness (fluoxetine is more likely to cause insomnia)
• Dry mouth
• Gastrointestinal upset (such as constipation, diarrhea, or nausea)
• A Headache
• Hot flushes
• Insomnia
• Nausea
• Sexual dysfunction (such as reduced desire or erectile dysfunction).

SSRIs and SNRIs may also cause:

• An increase in suicidal thoughts and behaviors, particularly in children and young adults under the age of 25 years. This is most likely to occur when starting therapy
• Serotonin syndrome – this is caused by excessive levels of serotonin in the body and is more likely to occur with higher dosages of SSRIs or SNRIs, or when SSRIs or SNRIs are administered with other medications that also release serotonin (such as dextromethorphan, tramadol, and St. John’s Wort). Symptoms include agitation, confusion, sweating, tremors, and a rapid heart rate
• An increase in the risk of bleeding, especially if used with other medications that also increase bleeding risk.

Some SSRIs and most SNRIs have been associated with a discontinuation syndrome when they have been stopped suddenly. For this reason, it is best to withdraw all antidepressants slowly.

Pros and cons of Lexapro (escitalopram)