Lexapro

(escitalopram)

Lexapro (escitalopram); not controlled

Summary

Lexapro is a selective serotonin reuptake inhibitor approved for major depressive disorder from 12 years of age and for generalized anxiety disorder from 7 years of age. It is not an ADHD medication, and appears here because depression and anxiety so often accompany ADHD. Its advantage over its SSRI siblings is a flat ladder: a single 10 mg start and a 20 mg ceiling at every approved age. Not controlled; brand and generic.

Forms & Strengths

• Tablets, film-coated: 5 mg, 10 mg, 20 mg
• Oral solution: 5 mg/5 mL
• Capsules: 15 mg

Dosing

• Age:
  • Major depressive disorder: 12 y/o and older, and adults
  • Generalized anxiety disorder: 7 y/o and older, and adults
  • Not approved below 7 y/o for any indication
• Onset: 1 to 2 weeks for early effect; 8 weeks at target dose for full response
• Duration: continuous with once-daily dosing; steady state in about one week
• Initial Dose: 10 mg once daily at every approved age and for both indications
• Titration:
  • MDD, 12 to 17 y/o: to 20 mg once daily, interval no less than 3 weeks
  • GAD, 7 to 17 y/o: to 20 mg once daily, interval no less than 2 weeks
  • Adults, either indication: to 20 mg once daily, interval no less than 1 week
• Max Dose: 20 mg/day at every approved age
• Considerations: Cap at 10 mg daily in hepatic impairment and in elderly patients. Screen for personal and family history of bipolar disorder before the first dose. Taper on stopping; do not stop abruptly.

Pharmacology

• Mechanism: inhibits neuronal 5-HT reuptake; the S-enantiomer of citalopram, over 100-fold more potent than the R-enantiomer
• Delivery / Release: immediate-release tablet, bioequivalent oral solution; half-life 27 to 32 hours, hepatic via CYP3A4 and 2C19
• Class Positioning: the only SSRI whose label quantifies a dose-related QTcF rise: 4.5 msec at 10 mg, 6.6 msec predicted at 20 mg, 10.7 msec at 30 mg
• Versus siblings: citalopram carries an explicit QT dose cap, escitalopram does not. Weaker CYP inhibitor than fluvoxamine; shorter half-life than fluoxetine. Alternative: Cymbalta.

Indications

• Major depressive disorder (ICD-10: F32.x, F33.x): 12 y/o and older, and adults; not established below 12 y/o
• Generalized anxiety disorder (ICD-10: F41.1): 7 y/o and older, and adults. This pediatric floor is on the brand label only; generic labels present GAD as adult-only.

Off-Label Uses

• Anxiety other than GAD (ICD-10: F93.0, F40.1, F41.0): supported at CLASS level only; AHRQ graded SSRIs and SNRIs moderate to high. (AHRQ 2017)
• MDD below 12 y/o (ICD-10: F32.x): insufficient; efficacy not established, and the boxed warning applies fully
• Pediatric OCD (ICD-10: F42.x): limited data; no OCD indication at any age, and better-studied agents exist
• Adjunctive Abilify (ICD-10: F32.x, F33.x): approved augmentation in adult MDD only; insufficient in youth
• ADHD itself (ICD-10: F90.x): insufficient; no indication and no efficacy claim at any age

Contraindications & Warnings

• Boxed Warning: Suicidal thoughts and behaviors. Antidepressants increased this risk in children, adolescents and young adults. Monitor closely for clinical worsening and emergent suicidality during the initial few months and at every dose change; counsel caregivers to watch for behaviour change and alert the prescriber; consider stopping if suicidality emerges. Not approved below 7 y/o.
• Contraindicated:
  • MAOI use, current or within 14 days in either direction, including linezolid and intravenous methylene blue.
  • Concurrent pimozide, which risks QT prolongation and ventricular arrhythmia.
  • Known hypersensitivity to escitalopram, citalopram, or any inactive ingredient.
• Use with caution:
  • Known or suspected bipolar disorder; an antidepressant alone can precipitate a manic or mixed episode.
  • Seizure disorder; convulsions are reported on treatment.
  • Hyponatremia risk, notably diuretics or volume depletion; sodium below 110 mmol/L reported as SIADH.
  • Aspirin, NSAIDs, antiplatelets or anticoagulants: added bleeding risk.
  • Untreated narrow anterior chamber angles.
  • Hepatic impairment, elderly patients and CYP2C19 poor metabolizers: cap at 10 mg daily.
• Screen before starting:
  • Personal and family history of bipolar disorder, mania or hypomania, plus a baseline suicidality assessment.
  • Medication list checked for MAOIs, pimozide, serotonergic agents and drugs affecting hemostasis.
  • Baseline height, weight, hepatic function, and sexual function history in adolescents.

Drug Interactions

• MAOIs (phenelzine, tranylcypromine, linezolid, methylene blue): contraindicated; allow 14 days in each direction.
• Pimozide: contraindicated; QT prolongation and ventricular arrhythmia.
• Other serotonergic drugs (SNRIs, triptans, tricyclics, opioids, lithium, buspirone, amphetamines, St John's Wort): additive serotonin syndrome risk, live in an ADHD clinic.
• Drugs affecting hemostasis (aspirin, NSAIDs, antiplatelets, warfarin): added bleeding risk; monitor INR closely.
• Carbamazepine: may increase escitalopram clearance; suspect it before concluding the drug failed.
• CYP2D6 substrates (desipramine, metoprolol): escitalopram 20 mg doubled desipramine AUC; reduce the substrate if toxicity appears.

Administration

• Give once daily at a fixed time, with or without food; morning for insomnia, evening for somnolence.
• The 10 mg and 20 mg tablets are scored; the 5 mg is not. Step down with the 5 mg tablet or the solution.
• If the child cannot swallow tablets, use the bioequivalent 5 mg/5 mL oral solution.
• The 15 mg capsule is single-strength; its label bars initiation, titration and discontinuation.
• Missed dose: give it when remembered the same day; do not double up.
• Do not stop abruptly; see Discontinuation & Taper.

Side Effects

• Common: headache, nausea, insomnia, somnolence, fatigue, dry mouth, diarrhea, dizziness, sweating; in children also irritability and anger, the activation signal
• Serious:
  • Suicidal thoughts and behaviors: the boxed warning. Reassess early and after any dose change.
  • Serotonin syndrome: stop escitalopram and every serotonergic drug immediately; treat supportively.
  • Activation of mania or a mixed episode: reconsider the diagnosis and stop rather than titrating through.
  • Hyponatremia, often SIADH; seizures; bleeding from bruising to life-threatening haemorrhage.
  • Angle closure glaucoma in untreated narrow angles: an ophthalmological emergency.
  • Sexual dysfunction, decreased appetite and weight loss: ask directly and plot growth.

Monitoring & Labs

• Suicidality: assess ideation, agitation and behaviour change at every contact for the first 3 months and at every dose change, then each visit.
• Activation and mania: ask during titration and at least every 3 months once stable about reduced sleep need, pressured speech and new anger.
• Growth: height and weight charted at baseline, every 3 months for the first year, then every 6 months; investigate a fall over one percentile line.
• Serum sodium: check within days of new headache, confusion or unsteadiness; baseline and 4 weeks on a diuretic.
• QT: no routine ECG at 10 or 20 mg in a normal heart. Baseline ECG, repeated 1 to 2 weeks after the target dose, if long QT, sudden cardiac death history, electrolyte disturbance or a QT-prolonging co-drug.
• Bleeding and sexual function: ask about bruising, epistaxis and new NSAIDs each visit; sexual function every 6 months.
• Response: reassess with the same rating instrument at 4 and 8 weeks.

Discontinuation & Taper

• Do not stop abruptly; reduce gradually and monitor for discontinuation symptoms.
• Discontinuation syndrome: dysphoric mood, irritability, agitation, dizziness, electric shock sensations, headache, insomnia, hypomania. Usually self-limiting.
• Matters more than for fluoxetine, whose metabolite self-tapers; this half-life clears in days.
• If intolerable symptoms follow a decrease, resume the previous dose and go slower.
• Drug holidays are not appropriate; a weekend off buys a discontinuation syndrome.

Pregnancy & Lactation

• Pregnancy: no established increase in major birth defects or miscarriage. Risks: persistent pulmonary hypertension of the newborn, poor neonatal adaptation, and a less than 2-fold increase in postpartum hemorrhage.
• Weighing it: set these against the relapse risk of untreated illness.
• Lactation: relative infant dose roughly 2.6% to 3.9%; maternal doses up to 20 mg daily are not expected to cause adverse effects, and are not a reason to stop breastfeeding. (LactMed 2026)
• Infant monitoring: watch for excess sedation, restlessness, agitation, poor feeding and poor weight gain. (LactMed 2026)
• Exposure Registry: National Pregnancy Registry for Antidepressants, 1-844-405-6185, womensmentalhealth.org.

Counseling Points

• Counsel the family on:

  • Little happening for two to four weeks; the decision point is 8 weeks.
  • The pediatric ladder being deliberately slow: 3 weeks before 20 mg in MDD at 12 to 17, 2 weeks in GAD at 7 to 17.
  • 20 mg being the ceiling at every age; more is not better, and the QT signal is dose-related.
  • Watching daily early and after dose changes for agitation, anger or self-harm talk.
  • Never stopping abruptly, including when a prescription lapses over a holiday.
  • Ibuprofen and aspirin adding to bleeding risk; tell the adolescent directly.

• Advise them to call for:

  • Any new or worsening talk of self-harm, or sudden change in mood or behaviour.
  • Agitation with fever, shivering, twitching or stiffness; a same-day call.
  • Several nights of almost no sleep, pressured speech, or grandiose plans.
  • Headache with confusion, memory trouble or unsteadiness, which can be low sodium.
  • Nosebleeds that will not stop, unusual bruising, or blood in vomit or stool.
  • A seizure of any kind.

References

1. DailyMed. Lexapro (escitalopram) tablets and oral solution, Allergan, Inc. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=13bb8267-1cab-43e5-acae-55a4d957630a
2. DailyMed. Escitalopram capsules, Almatica Pharma (NDA219130). 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c0401570-a3b0-bef2-7365-c23dc952b8b6
3. LactMed. Escitalopram. Drugs and Lactation Database, NICHD. 2026. https://www.ncbi.nlm.nih.gov/books/NBK501275/
4. AHRQ. Anxiety in Children. Comparative Effectiveness Review 192. 2017. https://www.ncbi.nlm.nih.gov/books/NBK476277/
5. FDA. National Drug Code Directory, openFDA; generic name escitalopram. 2026. https://api.fda.gov/drug/ndc.json?search=generic_name:%22escitalopram%22&limit=1000