What are the potential causes of insomnia in a patient taking Lexapro (escitalopram) 20mg daily at night?

From the Guidelines

I strongly recommend that patients with insomnia related to Lexapro (escitalopram) 20mg daily discuss cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment approach with their healthcare provider, as it is a strongly recommended treatment with moderate-quality evidence. Insomnia is a known side effect of Lexapro, especially at higher doses like 20mg, as it affects serotonin levels which play a role in regulating sleep-wake cycles 1. According to the American College of Physicians, CBT-I is the recommended initial treatment for chronic insomnia disorder, with a strong recommendation and moderate-quality evidence 1.

Some key points to consider:

• Lexapro can cause sleep disturbances due to its effects on serotonin levels, which regulate sleep-wake cycles 1.
• CBT-I is a non-pharmacological approach that can help improve sleep quality without the need for additional medications 1.
• Practicing good sleep hygiene, such as avoiding caffeine after noon, establishing a regular bedtime routine, and keeping the bedroom dark and cool, may also help improve sleep quality while continuing treatment.
• If sleep problems persist, the healthcare provider might consider reducing the dose temporarily to 10mg daily, then gradually increasing it back to 20mg as the body adjusts, or recommend a short-term sleep aid or consider switching to another antidepressant with less impact on sleep, such as mirtazapine or trazodone 1.
• It is essential not to stop taking Lexapro suddenly, as this can cause withdrawal symptoms.

The benefits of CBT-I include improved sleep quality, reduced symptoms of insomnia, and enhanced overall quality of life, with moderate-quality evidence supporting its effectiveness 1. By prioritizing CBT-I as the initial treatment approach, patients with insomnia related to Lexapro can experience significant improvements in their sleep quality and overall well-being.

From the FDA Drug Label

The most commonly observed adverse reactions in Escitalopram patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating increased, fatigue, and somnolence Insomnia 9% 4% TABLE 4 shows common adverse reactions that occurred in the 20 mg/day Escitalopram group with an incidence that was approximately twice that of the 10 mg/day Escitalopram group and approximately twice that of the placebo group Insomnia 4% 7% 14%

Insomnia is a common side effect of escitalopram, and the incidence of insomnia is dose-dependent, with a higher incidence at 20 mg/day compared to 10 mg/day.

• The incidence of insomnia in patients taking 20 mg/day of escitalopram is 14%, compared to 7% in patients taking 10 mg/day and 4% in patients taking placebo 2.
• Given that the patient is taking 20 mg/day of escitalopram and is experiencing difficulty sleeping, it is possible that the insomnia is related to the medication.
• Consider reducing the dose or switching to a different medication if the insomnia persists and is causing significant distress to the patient 2.

From the Research

Patient Unable to Sleep Well on Lexapro 20mg Daily at Night

• The patient is taking Lexapro (escitalopram) 20mg daily at night and is experiencing sleep disturbances.
• According to a study published in 2011 3, escitalopram was found to be beneficial for the treatment of sleep problems in patients with major depressive disorder (MDD) and generalized anxiety disorder (GAD).
• The study compared escitalopram with other SSRIs, SNRIs, and placebo, and found that escitalopram was significantly more effective in improving sleep symptoms in patients with MDD and GAD.
• Another study published in 2019 4 found that the lower range of the licensed dose of SSRIs, including escitalopram, achieves the optimal balance between efficacy, tolerability, and acceptability in the acute treatment of major depression.
• The study suggested that doses of SSRIs between 20mg and 40mg fluoxetine equivalents may be optimal for treating depression, including sleep disturbances.
• However, it is essential to note that individual responses to medication can vary, and the patient's sleep disturbances may be related to other factors, such as underlying medical conditions or lifestyle habits.
• Further evaluation and consultation with a healthcare professional may be necessary to determine the best course of treatment for the patient's sleep disturbances while taking Lexapro.