Does Lexapro (escitalopram) cause weight gain?

Does Lexapro (Escitalopram) Cause Weight Gain?

Lexapro (escitalopram) causes minimal weight change in most patients, with an average gain of only 0.14 kg (0.05 BMI points) over 12 weeks of treatment, making it one of the more weight-neutral SSRI options available. 1

Weight Profile of Escitalopram

Escitalopram demonstrates minimal impact on body weight compared to other antidepressants:

• In controlled trials, patients treated with escitalopram showed no clinically important difference in body weight compared to placebo-treated patients 2
• Direct comparison studies found escitalopram caused significantly less weight gain than the tricyclic antidepressant nortriptyline, which produced 1.2 kg gain at 12 weeks 1
• A large electronic health records study of 183,118 patients found escitalopram was associated with 0.41 kg more weight gain than sertraline at 6 months, though this difference is clinically modest 3

Comparative Positioning Among SSRIs

When comparing escitalopram to other SSRIs, it falls in the middle range for weight effects:

• Paroxetine has the highest risk of weight gain among all SSRIs and should be avoided when weight is a concern 4, 5
• Fluoxetine and sertraline typically cause initial weight loss followed by weight neutrality with long-term use 4, 5
• Escitalopram shows higher weight gain than citalopram, though the difference is small 4
• Cross-sectional studies found that escitalopram, along with citalopram, sertraline, paroxetine, venlafaxine, duloxetine, and mirtazapine (but not fluoxetine) were all associated with significant weight gain when used for 6-36 months 6

Best Alternative if Weight is a Primary Concern

If weight gain is a significant concern, bupropion is the superior choice:

• Bupropion is the only antidepressant consistently associated with weight loss rather than weight gain, with 23% of patients losing ≥5 lbs compared to only 11% on placebo 5
• In the large comparative study, bupropion showed 0.22 kg less weight gain than sertraline at 6 months, and 15% reduced risk of gaining ≥5% of baseline weight 3
• However, bupropion is contraindicated in patients with seizure disorders or eating disorders, and is activating which may exacerbate anxiety 4, 5

Clinical Decision Algorithm

When prescribing antidepressants with weight considerations:

1. First-line choice: Bupropion (if no seizure disorder, eating disorder, or significant anxiety) 5
2. Second-line choices: Fluoxetine or sertraline for weight-neutral profiles 5, 7
3. Acceptable option: Escitalopram for minimal weight impact 1
4. Avoid entirely: Paroxetine (highest SSRI risk), mirtazapine, amitriptyline, and MAOIs 5, 7

Monitoring Recommendations

Regular weight monitoring is essential during escitalopram treatment:

• Check weight at baseline, monthly for the first 3 months, then quarterly during continued treatment 7
• For patients experiencing significant weight gain on escitalopram, consider switching to fluoxetine or bupropion if clinically appropriate 4

Important Clinical Caveats

• Weight gain with escitalopram is less pronounced than with antipsychotics, mood stabilizers, and tricyclic antidepressants 4
• Predictors of weight gain include lower education status, lower baseline BMI, and family history of obesity 6
• Long-term studies (beyond 12 months) show that short-term investigations may be insufficient to fully characterize weight gain risk 8
• The FDA label confirms no clinically important weight changes in controlled trials, though metabolic effects note "increased weight" as a reported adverse event 2