Article

Escitalopram: What It Is, How to Take It, and What Can Go Wrong
February 04, 201901,043

What is Escitalopram?

We all have days when we feel down or a bit jittery. While it is completely normal to feel like this for a short while, many of us will go through periods in our lives when this feeling lasts for a bit longer than it should. In the US, 1 in every 3 people will suffer from depression or an anxiety disorder at some point in their lives, making it one of the leading causes of disability in the country.1 Thankfully, there are many treatments available to help us recover when our mental health needs some tender loving care. The two most frequently used treatments are psychotherapy and medication.

There are many possible causes of depression and anxiety and even experts are still unsure about why or how it happens. One possible cause is a decrease in the level of an important chemical called serotonin available in the brain. This chemical is responsible for making us feel good so when it doesn’t work in the brain as it should, we can start to feel pretty lousy.2 One type of medication that is often prescribed by doctors to increase the level of serotonin available in our brain is called escitalopram.2

 

How does escitalopram work?

Escitalopram belongs to a group of antidepressant medications called serotonin-reuptake inhibitors (or SSRIs for short). SSRIs work by increasing the levels of serotonin available in the brain.2,3

Serotonin is a hormone found in the brain, platelets, digestive tract and pineal gland. It is both a neurotransmitter (a substance that nerves use to send messages to one another) and a vasoconstrictor, which causes blood vessels to narrow.20

Once released from the end of a neuron, serotonin particles are absorbed into the next neuron through tiny holes called receptors. SSRIs work by temporarily blocking these receptors so that the serotonin stays in this empty space a little longer, in other words by inhibiting the reuptake of serotonin.2

By keeping the serotonin levels high in these synapses, the whole rail network functions more efficiently. Another group of medications, called serotonin-norepinephrine reuptake inhibitors (SNRIs) stop both serotonin and another chemical called norepinephrine from being absorbed. Both SSRIs and SNRIs are antidepressants.4

Escitalopram is an SSRI medication and is one of the most frequently prescribed antidepressants in the developed world.15 It comes in the form of a salt called escitalopram oxalate (not the kind of salt you sprinkle over your food though!) and is the generic name of the medication.14 You would probably recognize it by its brand name Lexapro. Escitalopram is only available by prescription from a doctor and is used to help patients suffering from several disorders including depression and social anxiety disorder.3

 

What is Social Anxiety Disorder?

We all get a little shy sometimes (or most of us, at least). This is completely normal. When this shyness or fear of interacting with other people begins to severely affect your life, however, it can be a sign of social anxiety disorder. Social anxiety disorder (SAD) is one of the most common mental health disorders in the US with a lifetime prevalence between 3% and 10%, and yet it is one of the most undertreated.4

Those who suffer from social anxiety disorder often mistake their extreme nervousness around other people as simply a part of who they are so will not think to tell their doctor about it. Thankfully, SAD is usually easy to treat when it is diagnosed.

 

Symptoms of Social Anxiety Disorder

The signs and symptoms of social anxiety disorder usually occur when a sufferer is either in, about to be introduced to or simply thinking about, a social situation where they might be scrutinized or observed by strangers.4 Some of these symptoms include4:

  • extreme nervousness
  • racing heart
  • sweating
  • excess blushing
  • twitching and/or trembling
  • dry throat/mouth
  • feeling faint

 

People with SAD often feel insecure around others, hate being the center of attention and may feel uncomfortable around “important” people.4 They may have difficulty maintaining friendships or romantic relationships. This is not because they don’t want social connection. On the contrary, many people with SAD crave the affection and friendship of others. They know that their anxiety is irrational but struggle to control the way they feel when they are around other people.

 

Treatment of Social Anxiety Disorder

Once a diagnosis is made, your doctor will likely use a combination of psychological therapy and medication to treat SAD.4 Social anxiety is often successfully treated using this approach.

The therapy which is often used is called cognitive-behavioral therapy (CBT). The type of CBT that is used in social anxiety disorder teaches people how to recognize and deal with their fears. Many people who complete this therapy say that they have overcome their social anxiety and can live normal lives.

Medication is also used in the short-term to help people with SAD deal with their condition and works hand-in-hand with psychological therapy to help them overcome social anxiety. It is important to remember that medication will not cure SAD. It simply controls the symptoms for a short period of time while the CBT begins to work.4

Some medications often used to treat social anxiety disorder include:

  • escitalopram (Lexapro)
  • sertraline (Zoloft)
  • clonazepam (Klonopin)
  • lorazepam (Ativan)

 

In a very small number of cases, medications used to treat social anxiety can make the anxiety worse. If this happens, speak to your doctor immediately to try a different medication.

 

Uses for escitalopram

Escitalopram is used for a number of different mental health conditions. It is most widely used to treat depression and anxiety disorders and has been approved to treat both depression and some anxiety disorders.6

Social anxiety is not the only type of anxiety that escitalopram is successfully used to treat. Several other types of anxiety disorders which are treated with escitalopram include general anxiety disorder and panic disorder.

Even though the FDA approves medication for use in specific conditions, doctors often use medications for other purposes too. This is called off-label use and is very common amongst doctors. Sometimes, medications have shown promise for conditions for which the drug is not approved, and doctors will prescribe it in the hope that it will have a good effect on a patient. Escitalopram is sometimes used off-label to treat conditions such as menopause.16

 

Escitalopram Dosage

Adult Dosage

The common adult dosage is escitalopram 10mg daily.7

Your doctor will likely start you at this dosage and keep you there for 2-4 weeks before deciding whether to increase the dosage further. The maximum daily dosage is usually 20mg escitalopram. Tablets will often come as either Lexapro 10mg or Lexapro 20mg tablets.

If you are elderly or have a liver problem, your doctor will probably keep you at a lower dosage and usually not higher than 10mg per day. This is because escitalopram is not processed by the body as well in people who have liver problems or are older in age.14

Your dosage of escitalopram should only ever be changed under a doctor’s supervision.

Child Dosage

Escitalopram is not recommended for use in children. There is very little evidence to prove that it works in young children. Also, the side effects of escitalopram are generally stronger in children than in adults. If escitalopram is to be used in a child, it should only ever be done under the supervision of a child psychiatrist.14

 

Escitalopram Side Effects

Like all medications, escitalopram can have some unwanted side effects. Some are very common, relatively harmless and may go away after a little while. Others happen very rarely and may cause serious problems.

Common Side Effects

Some escitalopram (Lexapro) side effects include14:

  • nausea
  • diarrhea
  • headaches
  • agitation and slight tremor
  • insomnia
  • dry mouth
  • sweating
  • weight gain/loss
  • decreased libido
  • taste disturbances

Many of these will eventually go away or reduce substantially. If they don’t after several weeks, speak to your doctor about trying another medication.

Serious Side Effects

Escitalopram can have side effects.17 If you experience any of the following, see your doctor immediately17:

  • jaundice (yellowing of the skin)
  • eye pain or pressure in the eye
  • severe abdominal pain
  • frequent or excessive bruising
  • nose bleeds
  • excessive dizziness or fainting
  • palpitations or fast heart rate

 

Warnings for Escitalopram Use

General Warnings

Escitalopram is generally very safe to use but it must be used with care. It can interact with several medications and herbal medicines to develop something called serotonin syndrome (sometimes called serotonin toxicity).

Serotonin syndrome is a temporary and sometimes dangerous condition which can happen when you take too many medications that increase the level of serotonin in the brain.10 Although this is rare, it is very important that you always check with your doctor or pharmacist before taking a new medication or herbal supplement with escitalopram (or any other SSRI/SNRI medication such as venlafaxine, sertraline or citalopram).

Some of the symptoms of serotonin syndrome include17:

  • confusion
  • excess sweating
  • tremor and agitation
  • rapid heart rate
  • nausea and vomiting

Escitalopram should not be stopped suddenly. Stopping an SSRI or SNRI medication all of a sudden will probably cause withdrawal symptoms such as anxiety, dizziness, fatigue and flu-like symptoms.14 If you want to stop taking escitalopram, your doctor will slowly lower the dose over a few weeks to reduce your chances of having these nasty symptoms.

Escitalopram can take several weeks to begin working.14 It generally works much faster to reduce anxiety than it does to treat depression. It is also common in the first few weeks of using escitalopram and other SSRI/SNRI medications to have an increase in suicidal thoughts and feelings. Seek help or speak to your doctor if these feelings become overwhelming.14

 

Warnings for Special Groups

Sometimes pregnant women need to take something to treat their anxiety or depression. Although no medication has been proven to be a 100% safe during pregnancy, your doctor will try to choose a medication that is least likely to cause harm.

Some researchers have found that there is a possibility that using escitalopram can slightly increase the chance of heart problems in the baby so it will rarely be the first medication of choice in pregnancy. Your doctor will only use it if he/she feels it is necessary. It is pregnancy category C.14

Escitalopram is generally considered safe to use while breastfeeding; however the medication is excreted in breast milk and there have been reports of relatively mild side effects.11

If you have (or have had) a history of any of the following, ask your doctor before using escitalopram as it may not be suitable for you14:

  • bipolar disorder
  • suicide attempts
  • liver conditions
  • low levels of sodium, magnesium or potassium in the blood
  • heart problems
  • gastrointestinal bleeding or ulcers

 

Older people may experience more side effects with escitalopram. If you are older, you are more likely to experience heart problems with this medication (such as palpitations or arrhythmia) and to be on other medications which can interact with escitalopram. If you experience any heart symptoms whilst on this medication, see your doctor immediately.12

 

Escitalopram (Lexapro) Compared to Other Similar Drugs

Sertraline vs Lexapro

Sertraline and escitalopram (Lexapro) are both SSRIs that are used in depression and anxiety disorders. A comparative review showed both sertraline and escitalopram to be effective; however escitalopram is considered more effective than many antidepressant.15 The FDA notes that sertraline is generally considered to be safe for babies, while there is no data for  escitalopram.11 Both medicines are usually avoided during pregnancy unless necessary.

Citalopram vs Lexapro

Escitalopram is closely related to the drug citalopram. Both are SSRIs and citalopram is an older version of the drug escitalopram. Escitalopram (Lexapro) is less dangerous in overdose than citalopram, generally has fewer side effects and fewer drug interactions. Lexapro tends to be used more commonly for anxiety disorders while citalopram is used for treating depression.3

Clonazepam vs Lexapro

Clonazepam belongs to a family of medications called benzodiazepines which are used to reduce anxiety and often to help people sleep. Low doses of clonazepam are used in people with social anxiety disorder (and anxiety disorders generally) to help calm them down in situations where they know they will be very anxious. However, it is also more likely to make you feel drowsy, hence Lexapro is often used as a daily and longer-term solution.13

Lexapro vs Xanax

Like clonazepam, Xanax (alprazolam) also belongs to the family of benzodiazepines. Also like clonazepam, it is usually only used by patients for stressful situations or prescribed along with Lexapro to help reduce anxiety immediately while the Lexapro begins to work.

 

Drug Interactions with Escitalopram

There are several ways that escitalopram can interact with other medications.

It can block an enzyme in the liver called CYP2D6 which is responsible for breaking certain medications down such as metoprolol, tramadol and codeine, amongst others. This enzyme acts like a trash compressor for medications in the body- it begins to break them down so they can eventually be removed from the body altogether.14

When escitalopram blocks this enzyme, medications that are usually broken down by CYP2D6 begin to build up in the body. This buildup can cause an increase in side-effects and toxicity which can be dangerous.14

Escitalopram can also interact with other medications to increase the level of serotonin in the brain causing serotonin syndrome. Some medicines which can interact with escitalopram to cause serotonin syndrome include10:

  • SSRIs such as citalopram (Celexa), sertraline (Zoloft) and fluoxetine (Prozac)
  • SNRIs such as venlafaxine (Efexor)
  • Pain medications such as tramadol and codeine
  • Anti-nausea medications such as metoclopramide
  • Migraine medications (triptans)
  • Cough medicines such as Robitussin
  • Herbal medicines such as St John’s Wort and ginseng

If you are taking any of these medications, please speak to your doctor or pharmacist before using escitalopram and vice versa. The chances of a drug interaction with escitalopram are fairly low but it is always a good idea to stay on the lookout just in case.

 

Abuses of escitalopram

Some people believe that since SSRIs (and antidepressants generally) can improve your mood, that taking lots of it should give you a “high”. This is untrue. According to the US National Library of Medicine, animal studies suggest the abuse potential of racemic citalopram is low.19 Escitalopram oxalate has not been systematically studied in humans for its potential for abuse, tolerance, or physical dependence.19 However, if the amount taken of escitalopram is too high, it can lead to an overdose and serotonin syndrome which can be fatal.10

 

Good to Know

Some important points to remember when taking escitalopram9:

  • Take it in the morning. Escitalopram can cause insomnia so the earlier you take it during the day, the better. Avoid taking it at night unless instructed by your doctor.
  • Do not drive, operate machinery or do anything that requires sustained concentration before you know how escitalopram affects you.
  • Let your doctor or pharmacist know that you are taking escitalopram before taking any other new medication or herbal supplement. Escitalopram can interact with herbal medicines such as St John’s Wort so it is important that you ask a health professional before taking something new.10
  • Do not stop taking escitalopram suddenly. If you miss your dose, take it as soon as you remember. If it’s later than 12 hours after your dose was due, wait until the following day to take your next dose.
  • Escitalopram may take a few weeks to work and may cause suicidal thoughts in that time. Let someone close to you know about this risk and please seek help if you begin having thoughts about harming yourself or others.14

 

Escitalopram FAQs

●     Can Lexapro cause depression?

Lexapro is very unlikely to cause depression. It is used to treat depression. In the first few weeks of taking Lexapro, you may find that you are having thoughts of suicide or harming yourself.14 If this happens, please get some help. If you are currently taking Lexapro and your doctor begins to lower your dose, there is a possibility that your depression may return. If this happens, let your doctor know and he/she may increase it again.

●     What happens if you stop taking escitalopram?

If you stop taking escitalopram all of a sudden, you will probably experience some Lexapro withdrawal symptoms. Some symptoms include insomnia, anxiety, tearfulness and agitation. If you want to stop taking escitalopram, your doctor will slowly lower your dose over a period of weeks so you don’t get these nasty symptoms.14

●     Is 5mg Lexapro therapeutic?

This depends on your body! Your doctor will often start you on 5mg of Lexapro and slowly increase your dose. Some people respond well to 5mg of Lexapro but the most common therapeutic dose is 10mg. Starting at 5mg and slowly making your way up to 10mg will reduce the chances of you having any unwanted side-effects.7,14

●     How long do I have to wait until Lexapro works?

For most people, Lexapro begins to work 2-4 weeks after starting the medication. It often reduces anxiety faster than it reduces symptoms of depression. If you find that you are not noticing any difference in your mood after a couple of months of starting the Lexapro, see your doctor about increasing your dose or trying a new medication.7,14

 

References

  1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
  2. Hyttel J. Pharmacological characterization of selective serotonin reuptake inhibitors (SSRIs). Int Clin Psychopharmacol. 1994;9 Suppl 1:19-26.
  3. Moore N, Verdoux H, Fantino B. Prospective, multicentre, randomized, double-blind study of the efficacy of escitalopram versus citalopram in outpatient treatment of major depressive disorder.Int Clin Psychopharmacol. 2005;20(3):131-137.
  4. Kariuki CM, Stein DJ. Social anxiety disorder.Anxiety disorders: A guide for integrating psychopharmacology and psychotherapy 2013:221-239.
  5. Schimmenti A, Bifulco A. Linking lack of care in childhood to anxiety disorders in emerging adulthood: the role of attachment styles.Child Adolesc Ment Health. 2015;20(1):41-48.
  6. Kasper S, Stein DJ, Loft H, Nil R. Escitalopram in the treatment of social anxiety disorder.Br J Psychiatry. 2005;186(3):222-226.
  7. Lepola UM, Loft H, Reines EH. Escitalopram (10–20 mg/day) is effective and well tolerated in a placebo‐controlled study in depression in primary care. Int Clin Psychopharmacol. 2003;18(4):211.
  8. Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380-387.
  9. Handbook AM. AUSTRALIAN MEDICINES HANDBOOK 2017. AUSTRALIAN MEDICINES HAND; 2017.
  10. Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014;348:g1626.
  11. Gentile S. The safety of newer antidepressants in pregnancy and breastfeeding. Drug Saf. 2005;28(2):137-152.
  12. Kasper S, de Swart H, Friis Andersen H. Escitalopram in the treatment of depressed elderly patients. Am J Geriatr Psychiatry. 2005;13(10):884-891.
  13. Mayo-Wilson E, Dias S, Mavranezouli I, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2014;1(5):368-376.
  14. US Food and Drug Administration. Lexapro. https://www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4065b1-22-tab11C-Lexapro-Tabs-SLR015.pdf. Last revision: 04/04 (year not provided). Accessed August 29, 2017.
  15. Sanchez, C; Reines E; Montgomery S. A comparative review of escitalopram, paroxetine, and sertraline: are they all alike? Int Clin Psychopharmacol. 2014 Jul; 29(4):185–196.
  16. Northwestern University. Women’s Health Research Institute. Menopause Overview – Off Label Use. Available at: http://menopause.northwestern.edu/content/label-use. Accessed August 27, 2017.
  17. US National Library of Medicine. MedlinePlus. Escitalopram. Available at: https://medlineplus.gov/druginfo/meds/a603005.html. Accessed August 29, 2017.
  18. US National Library of Medicine. MedlinePlus. Serotonin Syndrome. Available at: https://medlineplus.gov/ency/article/007272.htm. Accessed August 29, 2017.
  19. US National Library of Medicine. DailyMed. ESCITALOPRAM OXALATE- escitalopram solution. Available at: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=09894a38-4e3a-475d-96cd-c6c8ed87869a. Accessed August 27, 2017.
  20. US National Institutes of Health. NCI Dictionary of Cancer Terms. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=335511. Accessed August 29, 2017.

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