Is it normal for a 38-year-old female to experience panic attacks lasting 1-10 minutes, feeling stuck in a negative loop, and low self-esteem after starting 5mg Lexapro (escitalopram) a few days ago?

From the Guidelines

It's normal to experience increased anxiety or panic symptoms when starting Lexapro (escitalopram), especially in the first few days to weeks of treatment. I would recommend continuing the medication for at least 2-4 weeks before considering a switch, as these initial side effects often resolve as your body adjusts to the medication 1. Lexapro and other SSRIs can temporarily worsen anxiety symptoms before they improve, which is why many doctors sometimes prescribe a short-term benzodiazepine like lorazepam (0.5mg as needed) during the initial adjustment period. The negative thought loops and feeling down are also common initial reactions that typically improve with time. If the panic attacks become severe or unbearable, contact your doctor promptly as they might adjust your dosing schedule (possibly starting at 2.5mg and gradually increasing) or add a temporary supportive medication. Most patients see these initial side effects subside within 1-2 weeks, with therapeutic benefits beginning around 2-4 weeks and full effects by 6-8 weeks 1. Practicing relaxation techniques, maintaining regular sleep patterns, and avoiding caffeine and alcohol can help manage these temporary symptoms during the adjustment period. Some key points to consider:

• The American College of Physicians recommends assessing patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy 1.
• A conservative medication trial for mild to moderate anxiety presentations may entail increasing the dose as tolerated within the therapeutic dosage range in the smallest available increments at approximately 1- to 2-week intervals when prescribing shorter half-life SSRIs (eg, sertraline, citalopram) 1.
• Because an initial adverse effect of SSRIs can be anxiety or agitation, it may be advisable to start with a subtherapeutic dose as a “test” dose 1.

From the FDA Drug Label

Monitor all antidepressant-treated patients for any indication for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes. The patient's symptoms of panic, feeling stuck in a negative loop, and feeling down on herself are not explicitly addressed in the drug label as normal or expected side effects. Key considerations:

• The patient has just started on escitalopram (Lexapro) and is experiencing these symptoms after only a few days.
• The drug label warns of the risk of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of treatment.
• The patient denies suicidal or harm feelings, but it is still important to monitor her closely. Given the uncertainty and potential risks, it is prudent to closely monitor the patient's symptoms and consider consulting with a healthcare provider to determine the best course of action, which may include adjusting the treatment regimen 2.

From the Research

Patient Complaints and Medication Side Effects

• The patient, a 38-year-old female, has just started taking 5 mg of Lexapro (escitalopram) and is experiencing panic attacks that last 1-10 minutes, feeling stuck in a negative loop, and feeling down on herself 3, 4.
• These symptoms are common side effects of selective serotonin reuptake inhibitors (SSRIs), which escitalopram is a part of 3, 4.
• The patient denies having suicidal or harm feelings, which is a crucial consideration when prescribing antidepressant medications 3, 4.

Efficacy and Safety of Escitalopram

• Escitalopram has been shown to be an effective and generally well-tolerated treatment for moderate to severe major depressive disorder (MDD) 3, 4.
• Studies have demonstrated that escitalopram is at least as effective as other SSRIs, such as citalopram, paroxetine, and sertraline, in reducing symptoms of depression 3, 4.
• Escitalopram has also been found to have a predictable tolerability profile, with generally mild to moderate and transient adverse events 3, 4.

Comparison to Other Treatments

• Mindfulness-based stress reduction (MBSR) has been shown to be a viable option for the treatment of anxiety disorders, with comparable effectiveness to escitalopram 5, 6.
• MBSR was found to have a lower rate of study-related adverse events compared to escitalopram, with 15.4% of participants in the MBSR group experiencing adverse events compared to 78.6% in the escitalopram group 6.
• Other studies have compared the efficacy of escitalopram to other antidepressant medications, such as sertraline and fluoxetine, and found that they are all effective in reducing symptoms of depression, but with some differences in terms of side effects and patient acceptability 7.