Escitalopram

Is escitalopram safe?

For most adults with depression or anxiety, yes. Escitalopram, sold as Lexapro in the US and Cipralex in the UK and Europe, is a selective serotonin reuptake inhibitor (SSRI) with a reputation for being one of the easier antidepressants to take. It is not addictive, overdoses on it alone are rarely fatal, and its dose range is simple: 10 mg for most people, 20 mg at most.

It does share the class risks, and it adds one of its own: a small, dose-related effect on heart rhythm. We score it 71, between sertraline at 72 and fluoxetine at 70. The three are close; the differences lie in the details below.

How well people tolerate it

The Lexapro label pools 715 people with depression on escitalopram and 592 on placebo:

Side effect	Escitalopram	Placebo
Nausea	15%	7%
Insomnia	9%	4%
Ejaculation disorder (men)	9%	under 1%
Diarrhoea	8%	5%
Somnolence	6%	2%
Fatigue	5%	2%

Six per cent stopped because of side effects, against 2% on placebo, and at 10 mg the dropout rate was not significantly different from placebo. Those are low numbers for an antidepressant. Sexual side effects are the ones most likely to persist, and they are often not mentioned unless the prescriber asks.

The heart rhythm question

Escitalopram is the active half of citalopram, an older SSRI. In 2011 a Europe-wide review found both lengthen the QT intervalQT prolongationA delay in the heart's electrical recovery between beats, seen on an ECG. Some medicines cause it, and in rare cases it leads to a serious heart rhythm problem.More in the glossary on an ECG in proportion to dose. For escitalopram the average increase was about 4.3 milliseconds at 10 mg and 10.7 milliseconds at 30 mg, above the licensed maximum. Reports of torsade de pointes, a dangerous rhythm, came mainly from women and people with low potassium or existing heart disease.

The MHRA's response was to cap escitalopram at 10 mg a day for people over 65 and those with liver problems, and to contraindicate it in people with congenital long QT syndrome or with other QT-prolonging medicines. The US label is less strict: it recommends 10 mg for older adults and liver impairment but has no QT section. For a healthy adult on 10 or 20 mg, the effect is small. It matters if you have a heart condition, take several QT drugs, or have taken an overdose.

The boxed warning

Escitalopram carries the boxed warningBoxed warningThe strongest safety warning the US FDA puts on a medicine's label, printed inside a black border at the top.More in the glossary shared by all US antidepressants: in short-term trials pooling about 77,000 adults and 4,500 children, antidepressants raised suicidal thoughts and behaviour in people aged 24 and under. It is approved in the US for depression from age 12 and generalised anxiety from age 7. Families should watch closely for agitation, worsening mood or talk of self-harm in the first months and after any dose change, and report it to the prescriber the same day.

Interactions to check

The label contraindicates MAOI antidepressants (within 14 days either way), linezolid, intravenous methylene blue and pimozide. Tramadol, triptans, other antidepressants, lithium and St John's wort add serotonin syndromeSerotonin syndromeA reaction caused by too much serotonin in the body, usually from combining medicines that raise it. Symptoms range from shivering to high fever.More in the glossary risk. Our 5-HTP page covers the same risk with that supplement. Like other SSRIs it raises bleeding risk with aspirin, ibuprofen, warfarin and newer anticoagulants.

Escitalopram has fewer liver-enzyme interactions than fluoxetine, but some drugs raise its levels. The MHRA names cimetidine and omeprazole, which may call for a lower dose given the QT findings. Mention escitalopram whenever you are prescribed an antibiotic, antipsychotic or heart drug.

Overdose and stopping

In trials, overdoses of up to 600 mg caused no deaths, and fatal cases after much larger doses are rare. The current label still warns of delayed seizures and arrhythmias and recommends prolonged heart monitoring, so any overdose needs hospital assessment. In the US call Poison Help on 1-800-222-1222; in the UK call 111 or 999.

With a half-life of 27 to 32 hours, escitalopram leaves the body faster than fluoxetine. Stopping suddenly can bring dizziness, irritability, sleep problems and electric-shock sensations. The label advises a gradual reduction and going back to the previous dose if symptoms are hard to bear.

Who should be careful

Talk to your doctor or pharmacist before starting escitalopram, or before adding anything to it, if you:

• are under 25, or have had thoughts of suicide or self-harm
• have a heart rhythm problem, a slow heart rate, heart failure or low potassium or magnesium
• take an antipsychotic, antiarrhythmic, certain antibiotics or another antidepressant
• are over 65 or have liver disease
• have bipolar disorder, epilepsy or narrow-angle glaucoma
• take a blood thinner or regular anti-inflammatories
• are pregnant or breastfeeding

How we scored it

Track record (88) and overdose marginOverdose marginHow far a normal dose is from a harmful one. A wide margin means an accidental extra dose is unlikely to cause serious harm.More in the glossary (80) are strong. Regulatory warnings (48) reflect the boxed warningBoxed warningThe strongest safety warning the US FDA puts on a medicine's label, printed inside a black border at the top.More in the glossary plus the European QT restrictions, and interactions (58) the serotonin, bleeding and QT combinations. Serious side effects (70) are a touch better than for most SSRIs because fewer people stop treatment.