Can Lexapro (escitalopram), a selective serotonin reuptake inhibitor (SSRI), cause sleep issues in patients?

Can Lexapro Cause Sleep Issues?

Yes, Lexapro (escitalopram) commonly causes sleep disturbances, with insomnia occurring in 9-12% of patients compared to 4-6% with placebo, though paradoxically it may also improve sleep problems in some patients with depression or anxiety. 1

Sleep-Related Side Effects from FDA Label Data

The FDA-approved prescribing information clearly documents that insomnia is one of the most common adverse reactions with escitalopram:

• Insomnia occurs in 9% of patients with major depressive disorder (MDD) treated with escitalopram versus 4% with placebo 1
• Insomnia occurs in 12% of patients with generalized anxiety disorder (GAD) treated with escitalopram versus 6% with placebo 1
• Insomnia is dose-dependent, occurring in 7% at 10 mg/day but increasing to 14% at 20 mg/day 1
• Insomnia led to treatment discontinuation in 1% of patients with both MDD and GAD, making it one of the few side effects causing medication cessation 1

Conversely, somnolence (excessive sleepiness) also occurs:

• Somnolence affects 6% of MDD patients on escitalopram versus 2% on placebo 1
• Somnolence affects 13% of GAD patients on escitalopram versus 7% on placebo 1

Paradoxical Effects on Sleep Quality

Despite causing insomnia as a side effect, escitalopram may actually improve sleep problems when they are symptoms of the underlying depression or anxiety disorder:

• In patients with MDD who had baseline sleep problems, escitalopram significantly improved sleep symptoms compared to placebo, other SSRIs, and SNRIs 2
• In patients with GAD, escitalopram significantly improved insomnia symptoms compared to placebo 2
• Escitalopram may be the exception among SSRIs in that it appears less likely to derange sleep architecture compared to other selective serotonin reuptake inhibitors 3

Mechanism and Clinical Implications

The sleep disturbances with escitalopram likely result from:

• Increased serotonergic neurotransmission, which can suppress REM sleep and alter sleep architecture 3, 4
• Activating effects that may interfere with sleep initiation when taken at bedtime 1

Rare but Serious Sleep-Related Parasomnias

SSRIs including escitalopram have been associated with REM sleep behavior disorders and parasomnias in case reports:

• Escitalopram has been linked to sexsomnia (sexual behavior during sleep) in at least one documented case that resolved upon discontinuation 4
• Other SSRIs have caused sleep paralysis, though escitalopram has also been used successfully to treat recurrent isolated sleep paralysis in two case reports 5, 6
• The American Academy of Sleep Medicine notes that SSRIs can induce or exacerbate REM-related parasomnias in some individuals 7

Practical Management Recommendations

If insomnia develops on escitalopram:

• Consider timing of administration—taking escitalopram in the morning rather than evening may reduce insomnia 1
• Evaluate whether insomnia represents a treatment-emergent side effect versus inadequate treatment of underlying depression/anxiety 2
• Implement sleep hygiene measures including consistent bedtimes, avoiding daytime napping, and limiting caffeine 8
• Consider dose reduction if patient is on 20 mg/day, as insomnia doubles at higher doses 1

If somnolence develops:

• Consider taking escitalopram at bedtime to leverage sedating effects 1
• Avoid driving or operating machinery until effects are known 1
• Evaluate for other contributing medications or medical conditions 8

Critical Caveats

• The relationship between escitalopram and sleep is bidirectional—it can both cause and improve sleep problems depending on whether sleep disturbance is a medication side effect or a symptom of the underlying psychiatric disorder 2
• Sleep problems that emerge or worsen after starting escitalopram warrant clinical reassessment, as they may indicate inadequate treatment response, medication side effects, or development of a parasomnia 7, 5
• Combining escitalopram with other sedating medications (benzodiazepines, sedating antidepressants, antipsychotics) increases risk of excessive sedation and should be done cautiously 8, 1