What are the side effects of escitalopram (SSRI - Selective Serotonin Reuptake Inhibitor)?

Side Effects of Escitalopram

Escitalopram is generally well-tolerated with mostly mild and transient adverse effects, but clinicians must monitor for potentially serious complications including suicidal ideation (especially in patients under 24 years), serotonin syndrome, sexual dysfunction, and discontinuation symptoms. 1

Common Side Effects

The most frequently reported adverse effects with escitalopram include:

Gastrointestinal Effects

• Nausea (15% vs 7% placebo) is the most common side effect, typically mild and transient 1
• Diarrhea (8% vs 5% placebo) 1
• Constipation (3% vs 1% placebo) 1
• Dry mouth 2
• Indigestion and abdominal pain 1

Neurological Effects

• Headache, dizziness (5% vs 3% placebo) 1
• Somnolence (6% vs 2% placebo) and insomnia (9% vs 4% placebo) 1
• Vivid dreams 2
• Fatigue (5% vs 2% placebo) 1

Sexual Dysfunction

• Ejaculatory delay (9% in males vs <1% placebo) is a prominent side effect 1
• Decreased libido (3% vs 1% placebo) 1
• Impotence (3% in males vs <1% placebo) and anorgasmia (2% in females vs <1% placebo) 1

Other Common Effects

• Increased sweating (diaphoresis) 2, 1
• Tremor, nervousness, bruxism 2
• Changes in appetite and weight 2

Serious and Potentially Life-Threatening Side Effects

Suicidal Ideation and Behavior

• All SSRIs including escitalopram carry an FDA boxed warning for increased suicidal thinking and behavior in patients up to age 24 years 2, 1
• Pooled absolute risk: 1% with antidepressants vs 0.2% with placebo (risk difference 0.7%, NNH=143) 2
• Close monitoring is mandatory, especially during the first months of treatment and following dose adjustments 1

Serotonin Syndrome

• A potentially life-threatening condition characterized by mental status changes, autonomic instability, and neuromuscular symptoms 1, 3
• Risk increases dramatically with concomitant use of other serotonergic drugs (triptans, tramadol, MAOIs, St. John's Wort, amphetamines) 1
• Escitalopram must be discontinued immediately if serotonin syndrome is suspected 1
• Case reports document serotonin syndrome even with escitalopram monotherapy at higher doses (30 mg/day) 3

Behavioral Activation/Agitation

• Motor or mental restlessness, insomnia, impulsiveness, disinhibited behavior, aggression 2
• More common in younger children than adolescents 2
• Typically occurs early in treatment or with dose increases 2
• Supports the need for slow up-titration and close monitoring, particularly in pediatric patients 2

Mania/Hypomania

• Can occur in patients with undiagnosed bipolar disorder 2, 1
• Screen all patients for personal or family history of bipolar disorder before initiating escitalopram 1
• Unlike behavioral activation, mania may appear later in treatment and persist after discontinuation 2

Hyponatremia/SIADH

• Can occur with all SSRIs including escitalopram 1
• Cases with serum sodium <110 mmol/L have been reported 1
• Elderly patients and those taking diuretics are at higher risk 1

Other Serious Effects

• Seizures (use cautiously in patients with seizure history) 2, 1
• Abnormal bleeding, especially with concomitant NSAIDs or aspirin 2
• QT prolongation (though less commonly reported with escitalopram than other SSRIs) 4

Discontinuation Syndrome

Abrupt cessation of escitalopram can cause withdrawal symptoms including dysphoric mood, irritability, dizziness, sensory disturbances (electric shock sensations), anxiety, confusion, and insomnia 1

• Symptoms are generally self-limiting but can be serious 1
• Gradual dose reduction is recommended rather than abrupt cessation 1
• If intolerable symptoms occur, resume the previous dose and taper more slowly 1

Pediatric-Specific Considerations

In children and adolescents, additional side effects include:

• Increased thirst 1
• Abnormal increase in muscle movement or agitation 1
• Nosebleed 1
• Difficult urination 1
• Heavy menstrual periods 1
• Possible slowed growth rate and weight changes requiring monitoring 1

Clinical Monitoring Recommendations

Monitor patients for:

• Emergence of suicidal thoughts or behaviors, especially in the first few months 1
• Signs of serotonin syndrome when combining with other serotonergic agents 1
• Behavioral activation in the first weeks of treatment 2
• Sexual dysfunction (may require dose adjustment or medication change) 1
• Sodium levels in elderly patients or those on diuretics 1

Comparative Tolerability

• Escitalopram demonstrates better tolerability than sertraline with lower gastrointestinal side effects 5
• Discontinuation symptoms are milder with escitalopram than with paroxetine 6
• Escitalopram has fewer effects on CYP450 enzymes, resulting in lower drug interaction potential 5
• Most adverse effects emerge within the first few weeks and are generally mild and transient 2, 7