Selective serotonin reuptake inhibitors (SSRIs)
ATC code: N06AB10 (Escitalopram)
S-enantiomer of citalopram. The most selective SSRI – blocks the serotonin transporter with minimal effect on norepinephrine, dopamine, and other receptors. Two binding sites: primary (inhibits reuptake) and allosteric (stabilizes binding to the primary site). This provides more complete and rapid transporter blockade compared to racemic citalopram.
First line
Escitalopram is approved for generalized anxiety disorder. and recommend SSRIs as first-line therapy for GAD. Start at 10 mg, may increase to 20 mg. In anxious patients, consider starting at 5 mg for the first week to minimize paradoxical anxiety worsening at treatment initiation. Response develops over 4-8 weeks.
First line
Escitalopram is a first-line antidepressant per 2023 guidelines. Start at 10 mg once daily, increase to 20 mg after 3-4 weeks if needed. Maximum dose 20 mg daily. The Cipriani meta-analysis (2018, Lancet) ranked escitalopram among the top antidepressants for the balance of efficacy and tolerability out of 21 agents. Assess response at 4-6 weeks.
First line
Escitalopram is effective for social anxiety disorder. SSRIs are first-choice therapy per and recommendations. Dosage is the same as for depression – 10-20 mg daily. Treatment is long-term – continue for at least 12 months after remission. Early discontinuation frequently leads to relapse.
FDA category C. SSRIs in the third trimester may cause neonatal respiratory distress, jitteriness, and irritability (neonatal adaptation syndrome). First-trimester use does not increase the overall risk of congenital malformations. The decision to continue therapy is individualized, weighing the risk of depression relapse for the mother against potential fetal exposure.
Excreted in breast milk. Relative infant dose is low. Escitalopram and sertraline are preferred SSRIs during breastfeeding per LactMed.
escitalopram is evaluated for the following indications with varying evidence strength: Generalized anxiety disorder (evidence tier A), Social anxiety disorder (evidence tier A), Major depressive disorder (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of escitalopram (≥ 1 in 100): Nausea (especially in the first 1-2 weeks, then resolves), Headache, Insomnia or somnolence, Sexual dysfunction (decreased libido, anorgasmia, delayed ejaculation), Dry mouth, Sweating. See the Safety section for uncommon and serious reactions.
FDA category C. FDA category C. SSRIs in the third trimester may cause neonatal respiratory distress, jitteriness, and irritability (neonatal adaptation syndrome). First-trimester use does not increase the overall risk of congenital malformations. The decision to continue therapy is individualized, weighing the risk of depression relapse for the mother against potential fetal exposure.
Excreted in breast milk. Relative infant dose is low. Escitalopram and sertraline are preferred SSRIs during breastfeeding per LactMed.
escitalopram is contraindicated in: Concurrent use with MAO inhibitors (and within 14 days of their discontinuation); QT prolongation or congenital long QT syndrome; Concurrent use with pimozide or other drugs that significantly prolong QT; Hypersensitivity to escitalopram or citalopram. Full list in the Safety section.