Most Common Side Effects of Lexapro (Escitalopram)
The most common side effects of Lexapro include nausea (15-18%), insomnia (9-12%), ejaculation disorder (9-14% in males), diarrhea (8%), fatigue (5-8%), decreased libido (3-7%), somnolence (6-13%), dizziness (5%), increased sweating, and headache. 1
Most Frequently Reported Side Effects by Indication
Major Depressive Disorder
According to FDA labeling data, the most commonly observed adverse reactions in adult patients with depression (occurring in ≥5% and approximately twice the rate of placebo) include: 1
- Nausea (15%) - the most common gastrointestinal side effect
- Insomnia (9%)
- Ejaculation disorder (9% in males) - primarily ejaculatory delay
- Diarrhea (8%)
- Fatigue (5%)
- Increased sweating (5%)
- Somnolence (6%)
- Dizziness (5%)
Generalized Anxiety Disorder
In GAD patients, the side effect profile is similar but with some variations in frequency: 1
- Nausea (18%) - notably higher than in depression trials
- Somnolence (13%)
- Insomnia (12%)
- Ejaculation disorder (14% in males)
- Fatigue (8%)
- Decreased libido (7%)
- Anorgasmia (6% in females)
- Diarrhea (8%)
Gastrointestinal Side Effects
Nausea and vomiting are the most common reasons for treatment discontinuation across all second-generation antidepressants, including SSRIs. 2 The American Family Physician guidelines note that about 63% of patients receiving second-generation antidepressants experience at least one adverse effect during treatment. 2
Additional gastrointestinal effects include: 1
- Constipation (3-5%)
- Indigestion (3%)
- Abdominal pain (2%)
- Flatulence (2%)
Sexual Dysfunction
Sexual side effects are commonly reported but often underestimated, as patients and physicians may be reluctant to discuss them. 1 The FDA label acknowledges that reliable estimates are difficult to obtain due to this reluctance. 1
Sexual dysfunction includes: 1
- Ejaculation disorder in males (9-14%) - primarily ejaculatory delay
- Decreased libido (3-7%)
- Anorgasmia (2-6% in females)
- Impotence (3% in males)
Central Nervous System Effects
Common CNS side effects include: 2, 1
- Dizziness (5%)
- Headache
- Tremors
- Somnolence (6-13%)
- Insomnia (9-12%)
Other Common Side Effects
Additional frequently reported effects include: 2, 1
- Dry mouth
- Increased sweating
- Weight gain
- Fatigue (5-8%)
- Decreased appetite (3%)
- Yawning (2%)
- Influenza-like symptoms (5%)
- Rhinitis (5%)
Dose-Dependent Effects
Higher doses of escitalopram (20 mg/day) are associated with significantly higher rates of adverse effects compared to 10 mg/day. 1 The overall incidence of adverse events at 20 mg/day (86%) was substantially higher than at 10 mg/day (66%) or placebo (61%). 1
Common adverse reactions with approximately twice the incidence at 20 mg/day versus 10 mg/day include: 1
- Insomnia (14% vs 7%)
- Diarrhea (14% vs 6%)
- Dry mouth (9% vs 4%)
- Somnolence (9% vs 4%)
- Dizziness (7% vs 4%)
- Increased sweating (8% vs 3%)
Discontinuation Rates
Among adults with depression, 6% discontinued escitalopram due to adverse events compared to 2% on placebo. 1 The most common adverse events leading to discontinuation (≥1% and at least twice placebo rate) were nausea (2%) and ejaculation disorder (2% in males). 1
In GAD patients, 8% discontinued treatment due to adverse events versus 4% on placebo, with nausea (2%), insomnia (1%), and fatigue (1%) being the primary reasons. 1
Pediatric Considerations
In pediatric patients (ages 6-17), the side effect profile is generally similar to adults, with additional effects including: 1
- Back pain
- Urinary tract infection
- Vomiting
- Nasal congestion
- Increased thirst
- Abnormal increase in muscle movement or agitation
- Nosebleed
Important Clinical Caveats
While escitalopram is generally well-tolerated compared to other SSRIs, the American Family Physician guidelines note that SSRIs as a class have a number needed to harm for discontinuation ranging from 20 to 90 in primary care settings. 2 This compares favorably to tricyclic antidepressants (4 to 30). 2
Patients should be counseled that most side effects are mild to moderate, transient, and typically occur within the first 2 weeks of treatment, with 60-65% resolving within the first month. 2 This information is extrapolated from similar SSRI data and helps set appropriate expectations for tolerability.