Escitalopram: A Comprehensive Pharmacological and Clinical Review

1. Introduction

Escitalopram, the (S)-enantiomer of the racemic bicyclic phthalane derivative citalopram, is a highly selective serotonin reuptake inhibitor (SSRI) widely utilized in the management of major depressive disorder (MDD) and generalized anxiety disorder (GAD).[1] Since its introduction, escitalopram has garnered significant attention due to its distinct pharmacological profile, characterized by high selectivity for the serotonin transporter (SERT) and a unique allosteric binding mechanism, which may contribute to its clinical efficacy and tolerability.[1] It is recognized as the most selective among currently available SSRIs.[1]

This report aims to provide a comprehensive review of escitalopram, encompassing its chemical and physical properties, detailed pharmacology including mechanism of action and pharmacokinetics, clinical applications and dosage guidelines across various populations, evidence from pivotal and comparative clinical trials, its safety and tolerability profile, and pertinent regulatory and market information. The objective is to consolidate current knowledge to inform both clinical practice and further research regarding this important psychotropic agent.

2. Chemical and Physical Properties

2.1. Identification and Nomenclature

Escitalopram is a small molecule drug, identified by DrugBank ID DB01175 and CAS Number 128196-01-0 for the base form [User Query]. It is the therapeutically active S-enantiomer of citalopram.[1] Common synonyms include (S)-Citalopram, S-(+)-Citalopram, and its widely recognized brand names Lexapro® and Cipralex®.[1] Marketed formulations typically contain escitalopram oxalate, the oxalate salt of the active base.[3] This distinction between the base and its salt form is important, as they possess different CAS numbers and molecular weights, although the tablet and oral solution dosage forms of escitalopram oxalate are reported to be bioequivalent to the base.[7] The physical properties, such as solubility, can differ between the base and its salt, potentially influencing drug formulation and dissolution. Escitalopram oxalate is described as a fine, white to slightly-yellow powder.[7]

Table 1: Key Chemical and Physical Properties of Escitalopram

Property	Value	Reference(s)
IUPAC Name (base)	(1S)-1-[3-(dimethylamino)propyl]-1-(4-fluorophenyl)-1,3-dihydro-2-benzofuran-5-carbonitrile	4
CAS Number (base)	128196-01-0	4
Molecular Formula (base)	C20​H21​FN2​O	4
Molecular Weight (base)	324.40 g/mol (approx. 324.399 Da)	4
PubChem CID (base)	146570	5
ChEMBL ID (base)	CHEMBL1508	9
SMILES (base)	CN(C)CCC[C@@H]1(c2ccc(C#N)cc2CO1)c3ccc(F)cc3 (Isomeric)	9
InChI (base)	InChI=1S/C20H21FN2O/c1-23(2)11-3-10-20(17-5-7-18(21)8-6-17)19-9-4-15(13-22)12-16(19)14-24-20/h4-9,12H,3,10-11,14H2,1-2H3/t20-/m0/s1	9
InChIKey (base)	WSEQXVZVJXJVFP-FQEVSTJZSA-N	9
ATC Code	N06AB10	14
Appearance (oxalate)	Fine, white to slightly-yellow powder	7
Solubility (oxalate)	Freely soluble in methanol anane	7
PubChem CID (oxalate)	146571	3
ChEMBL ID (oxalate)	CHEMBL1200322	5
CAS Number (oxalate)	219861-08-2	5
Molecular Formula (oxalate)	C22​H23​FN2​O5​	5
Molecular Weight (oxalate)	414.40 g/mol (approx. 414.433 Da)	[5 (414.4), 16 (414.433)]

3. Pharmacology

3.1. Mechanism of Action

Escitalopram's primary therapeutic action stems from its potent and highly selective inhibition of serotonin (5-hydroxytryptamine, 5-HT) reuptake into the presynaptic neuron.[1] This is achieved through binding to the primary, or orthosteric, binding site on the human serotonin transporter (SERT), the same site to which endogenous 5-HT binds.[1] By blocking this reuptake mechanism, escitalopram increases the concentration of 5-HT in the synaptic cleft, thereby enhancing and prolonging serotonergic neurotransmission.[1]

A distinguishing feature of escitalopram's pharmacology is its interaction with an allosteric binding site on the SERT molecule, in addition to the primary orthosteric site.[1] This dual binding mechanism, also noted for paroxetine, is thought to modulate the transporter's function in a unique way.[1] Binding to the allosteric site appears to stabilize the binding of escitalopram at the orthosteric site, prolonging the inhibition of 5-HT reuptake and potentially leading to a more robust and sustained increase in synaptic 5-HT levels compared to SSRIs that only bind orthosterically.[1] This unique allosteric interaction is hypothesized to contribute to escitalopram's observed superior efficacy and potentially faster onset of action compared to some other SSRIs, as suggested by some clinical data.[1]

The sustained elevation of synaptic 5-HT concentrations eventually leads to adaptive changes in the serotonergic system, including the desensitization of presynaptic 5-HT1A autoreceptors.[1] These autoreceptors normally exert negative feedback on 5-HT synthesis and release. Their desensitization effectively disinhibits serotonergic neurons, allowing for a more sustained firing rate and 5-HT release, which is believed to be crucial for the full manifestation of the antidepressant and anxiolytic effects of SSRIs.[1] This adaptive process may also contribute to the characteristic delay (typically several weeks) in the onset of full therapeutic benefits observed with SSRI treatment.

3.2. Pharmacodynamics (Receptor Binding Profile and Neurotransmitter System Effects)

Escitalopram is characterized by its high degree of selectivity for the serotonin transporter (SERT) over transporters for other monoamines, such as norepinephrine (NET) and dopamine (DAT).[1] It is often cited as the most selective SSRI available.[1] This high selectivity is a key factor in its generally favorable tolerability profile.

Furthermore, escitalopram exhibits minimal or no significant affinity for a wide range of other neurotransmitter receptors, including muscarinic acetylcholine receptors, histamine H1 receptors, alpha-1 and alpha-2 adrenergic receptors, beta-adrenergic receptors, dopamine D1-5 receptors, other serotonin receptor subtypes (beyond its primary interaction with SERT), and benzodiazepine receptors.[1] The low affinity for these receptors means that escitalopram is less likely to cause side effects commonly associated with less selective antidepressants, such as the anticholinergic effects (e.g., dry mouth, constipation, blurred vision), antihistaminic effects (e.g., sedation, weight gain), or cardiovascular effects (e.g., orthostatic hypotension) seen with tricyclic antidepressants (TCAs) or some other SSRIs with more off-target activity.[19]

While the primary and clinically relevant pharmacodynamic action of escitalopram is the potent and selective inhibition of SERT, comprehensive binding assays, such as those reported in DrugBank, may list inhibitory activity at other targets like Muscarinic M1, Histamine H1, 5-HT1A, 5-HT2A, Alpha-1 adrenergic, 5-HT2C, Alpha-2 adrenergic, D2 dopamine, NET, and DAT.[1] However, the affinity for these sites is substantially lower than for SERT, and these interactions are generally considered to have minimal contribution to the principal therapeutic effects or the common side effect profile of escitalopram at standard clinical doses.[1] Any minor activity at these off-targets might, in some instances, contribute to idiosyncratic reactions or very mild side effects.[1]

3.3. Pharmacokinetics (Absorption, Distribution, Metabolism, Elimination, and Special Populations)

The pharmacokinetic profile of escitalopram is well-characterized, supporting its clinical use.

Absorption: Following oral administration, escitalopram is rapidly and almost completely absorbed from the gastrointestinal tract.[1] Its absolute bioavailability is approximately 80%.[1] Peak plasma concentrations (Tmax) are typically reached within 3 to 5 hours post-dose.[1] Importantly, the absorption of escitalopram is not significantly affected by food intake, allowing for flexibility in administration relative to meals.[7] The pharmacokinetics are linear and dose-proportional over the usual clinical dose range of 10 to 30 mg/day.[7]

Distribution: Escitalopram distributes extensively into body tissues, with an apparent volume of distribution (Vd) of approximately 12-26 L/kg.[1] Plasma protein binding is relatively low, around 56%.[1] This low protein binding reduces the likelihood of drug interactions arising from displacement of or by other highly protein-bound drugs.[18]

Metabolism: Escitalopram undergoes extensive hepatic metabolism.[1] The primary metabolic pathways involve N-demethylation, mediated mainly by the cytochrome P450 (CYP) isoenzymes CYP2C19 and CYP3A4, with a lesser contribution from CYP2D6.[1] This process yields the principal metabolites S-desmethylcitalopram (S-DCT) and S-didesmethylcitalopram (S-DDCT).[1] These metabolites are pharmacologically much less active than the parent compound in terms of SERT inhibition and are present in plasma at lower concentrations (S-DCT at 28-31% and S-DDCT at <5% of parent drug levels at steady state), thus they do not contribute significantly to the overall clinical effect of escitalopram.[1] There is also some evidence suggesting metabolism to escitalopram propionic acid in the brain via monoamine oxidase A (MAO-A) and B (MAO-B).[1]

Elimination: The elimination of escitalopram and its metabolites occurs primarily through hepatic biotransformation, followed by renal excretion of the metabolites and a small fraction of unchanged drug. Approximately 8-10% of an oral dose is recovered in the urine as unchanged escitalopram and about 10% as S-DCT.[6] The mean terminal elimination half-life (t1/2) of escitalopram is approximately 27-33 hours.[1] This relatively long half-life supports once-daily dosing and implies that steady-state plasma concentrations are achieved within approximately one week of initiating therapy.[7] At steady state, plasma concentrations are about 2.2-2.5 times those observed after a single dose.[7] The oral clearance of escitalopram is approximately 600 mL/min, with renal clearance accounting for about 7% of this total; apparent hepatic clearance constitutes about 90% of the total dose.[1] The primary metabolite, S-DCT, has an even longer half-life of about 54 hours.[1]

Impact of Patient Factors / Special Populations:

• Age (Geriatric): In individuals aged 65 years and older, the area under the curve (AUC) and elimination half-life of escitalopram are increased by approximately 50%, while Cmax remains largely unchanged. A dosage of 10 mg once daily is generally recommended for this population.[1]
• Hepatic Impairment: Patients with hepatic impairment exhibit reduced clearance and a doubled half-life of escitalopram (similar to citalopram, where oral clearance was reduced by 37%). A dosage of 10 mg once daily is recommended.[1]
• Renal Impairment: No dosage adjustment is typically necessary for patients with mild to moderate renal impairment. However, escitalopram should be used with caution in patients with severe renal impairment (creatinine clearance < 20 mL/min), as its pharmacokinetics have not been extensively studied in this group and data for citalopram showed a 17% reduction in oral clearance.[7]
• CYP2C19 Polymorphisms: Genetic variations in the CYP2C19 enzyme significantly influence escitalopram metabolism. Individuals classified as CYP2C19 poor metabolizers (e.g., those with CYP2C19*2/*2 genotypes) may have substantially higher plasma concentrations of escitalopram, potentially increasing the risk of dose-dependent adverse effects. Dose reduction or selection of an alternative medication may be considered for known poor metabolizers.[1]
• Pediatric Patients: In adolescents (12-17 years), the AUC of escitalopram was found to be decreased by 19% and Cmax increased by 26% compared to adults; however, these differences do not typically necessitate a dosage adjustment based on pharmacokinetics alone.[18]

The pharmacokinetic properties, particularly its substantial metabolism by CYP2C19, underscore the potential for inter-individual variability in drug exposure due to genetic factors. The long half-life, while convenient for dosing, also means that if the drug is discontinued, it will take several days for complete elimination, which is relevant for washout periods when switching medications and for the duration of potential discontinuation symptoms.

Table 2: Summary of Escitalopram Pharmacokinetic Parameters

Parameter	Value	Reference(s)
Bioavailability (Absolute)	~80%	1
Time to Peak Plasma Conc. (Tmax)	~3-5 hours	1
Effect of Food on Absorption	Not significantly affected	7
Plasma Protein Binding	~56%	1
Volume of Distribution (Vd)	~12-26 L/kg	1
Metabolism - Primary Site	Hepatic	1
Metabolism - Key Enzymes	CYP2C19, CYP3A4 (major); CYP2D6 (minor)	1
Metabolism - Main Metabolites	S-desmethylcitalopram (S-DCT), S-didesmethylcitalopram (S-DDCT) (low activity)	1
Elimination Half-life (t1/2) - Parent	~27-33 hours	1
Elimination Half-life (t1/2) - S-DCT	~54 hours	1
Time to Steady State	~1 week	7
Excretion Routes	Primarily hepatic metabolism; metabolites and unchanged drug (~8-10%) in urine	6
Oral Clearance	~600 mL/min	7
Key Factors Influencing PK	Age (elderly: reduced clearance), Hepatic impairment (reduced clearance), CYP2C19 genotype (poor metabolizers: reduced clearance), Severe renal impairment (potential for reduced clearance)	1

4. Clinical Applications and Dosage

4.1. Approved Therapeutic Indications (FDA, EMA, Health Canada)

Escitalopram is approved for various psychiatric conditions, though specific indications vary by regulatory agency, reflecting differences in submitted data and regional review processes.

• Food and Drug Administration (FDA), USA:
• Major Depressive Disorder (MDD): For acute and maintenance treatment in adults and adolescents aged 12 years and older.[1]
• Generalized Anxiety Disorder (GAD): For acute treatment in adults and, more recently, pediatric patients aged 7 years and older.[1]
• European Medicines Agency (EMA), Europe:
• Depression (MDD): Approved for the treatment of major depressive episodes.[21]
• Anxiety Disorders: Approved for a broader range of anxiety disorders including GAD, Social Anxiety Disorder (SAD), Obsessive-Compulsive Disorder (OCD), and Panic Disorder with or without agoraphobia.[21]
• It is noteworthy that a 2005 CHMP opinion advised against the general use of SSRIs/SNRIs, including escitalopram, in children and adolescents for depression or anxiety outside of their specifically approved pediatric indications, due to an observed increased risk of suicidal behavior. However, the CHMP also acknowledged that physicians might decide to use these products off-label based on individual clinical needs, recommending careful monitoring in such cases.[31]
• Health Canada:
• Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD): Approved, aligning with FDA indications [[33] (implied)].
• Obsessive-Compulsive Disorder (OCD): Additionally approved for the symptomatic relief of OCD.[1]

The regional variations, particularly for OCD (approved in Canada and Europe but considered an off-label use in the US), underscore the importance for clinicians to be cognizant of the regulatory status within their specific jurisdiction.

Table 3: Approved Indications for Escitalopram by Regulatory Authority

Indication	FDA (USA) Approval Status	EMA (Europe) Approval Status	Health Canada Approval Status
Major Depressive Disorder (MDD)	Approved (Adults & Adolescents ≥12 yrs)	Approved	Approved
Generalized Anxiety Disorder (GAD)	Approved (Adults & Pediatrics ≥7 yrs)	Approved	Approved
Obsessive-Compulsive Disorder (OCD)	Off-label use	Approved	Approved
Social Anxiety Disorder (SAD)	Off-label use	Approved	Off-label use
Panic Disorder	Off-label use (APA guideline supported 33)	Approved	Off-label use

4.2. Off-Label Uses

Beyond its formally approved indications, escitalopram is frequently used off-label for a variety of other psychiatric conditions, often based on extrapolation from SSRI class effects, clinical experience, and emerging research. Common off-label applications include:

• Obsessive-Compulsive Disorder (OCD): In regions where it is not an approved indication, such as the United States.[5]
• Panic Disorder: Supported by some clinical guidelines, like those from the American Psychiatric Association.[18]
• Social Anxiety Disorder (Social Phobia):.[18]
• Posttraumatic Stress Disorder (PTSD):.[18]
• Premenstrual Dysphoric Disorder (PMDD): SSRIs as a class are effective.[18]
• Body Dysmorphic Disorder (BDD):.[5]
• Eating Disorders: Including binge eating disorder and bulimia nervosa.[5]
• Vasomotor Symptoms Associated with Menopause:.[18]
• Insomnia: When secondary to depression or panic disorder.[36]

The extensive range of off-label uses reflects the understanding that serotonergic dysregulation plays a role in these conditions. However, the evidence base for each off-label use can vary, and such prescribing necessitates careful clinical judgment, thorough patient discussion regarding the evidence, risks, and benefits, and appropriate documentation, particularly as these uses lack formal regulatory endorsement.[34]

4.3. Dosage and Administration

Escitalopram is administered orally, once daily, and can be taken in the morning or evening, with or without food.[26]

• Major Depressive Disorder (MDD):
• Adults: The usual initial and recommended dose is 10 mg once daily. The dose may be increased to a maximum of 20 mg once daily after a minimum of one week if clinically necessary. However, some fixed-dose trials have not demonstrated a greater benefit of 20 mg over 10 mg for MDD in adults, suggesting 10 mg/day may offer an optimal balance of efficacy and tolerability for many.[18]
• Adolescents (12-17 years): The recommended dose is 10 mg once daily. If an increase to 20 mg daily is required, it should occur after a minimum of three weeks.[18]
• Generalized Anxiety Disorder (GAD):
• Adults: The recommended starting dose is 10 mg once daily. This may be increased to a maximum of 20 mg once daily after a minimum of one week, based on clinical response.[18]
• Pediatric Patients (7 years and older): The recommended starting dose is 10 mg once daily. The dose may be increased to a maximum of 20 mg once daily after a minimum of two weeks if needed.[26]
• Obsessive-Compulsive Disorder (OCD) (Off-label in US; Approved in Canada/Europe):
• A typical starting dose is 10 mg once daily, which may be increased to 20 mg once daily after one week if required.[36]
• Dosage in Special Populations: Dosage adjustments are necessary for certain populations due to altered pharmacokinetics, aiming to maintain efficacy while minimizing adverse event risk.
• Geriatric Patients (≥65 years): The recommended dosage is 10 mg once daily. Higher doses (e.g., 20 mg/day) have not generally shown additional benefit in this age group and may increase side effect risk due to reduced clearance and increased half-life.[18]
• Hepatic Impairment: For patients with hepatic impairment, the recommended dosage is 10 mg once daily, reflecting reduced drug clearance and prolonged half-life.[18]
• Renal Impairment: No dosage adjustment is necessary for patients with mild or moderate renal impairment. For patients with severe renal impairment (creatinine clearance < 20 mL/min), escitalopram should be used with caution as pharmacokinetic data are limited, and dosage recommendations are not firmly established.[7]
• CYP2C19 Poor Metabolizers: Although not always explicitly stated in FDA labeling as a required adjustment, individuals known to be poor metabolizers of CYP2C19 may have significantly increased escitalopram exposure. Consideration should be given to initiating treatment at a lower dose (e.g., 5 mg/day) and titrating cautiously, with a potentially lower maximum dose (e.g., 10 mg/day).[1]
• Discontinuation of Treatment: To minimize the risk of withdrawal symptoms, a gradual reduction in dose is recommended when discontinuing escitalopram, rather than abrupt cessation.[5]
• Switching to or from a Monoamine Oxidase Inhibitor (MAOI): Specific washout periods are mandatory. Generally, at least 14 days should elapse between discontinuing an MAOI intended for psychiatric disorders and starting escitalopram, and vice versa.[26]

4.4. Pharmaceutical Preparations (Forms and Strengths)

Escitalopram is commercially available in the following forms, typically as the oxalate salt:

• Tablets (film-coated): Available in strengths equivalent to 5 mg, 10 mg, and 20 mg of escitalopram base. The 10 mg and 20 mg tablets are usually scored, which facilitates dose adjustments and gradual tapering.[5]
• Oral Solution: Available at a concentration of 1 mg/mL (escitalopram base equivalent).[5] This formulation can be beneficial for patients who have difficulty swallowing tablets or for whom very precise, smaller dose adjustments are needed. However, a recent FDA label (October 2023) indicated that the oral solution was "not currently being marketed" [26], so its availability should be verified.

The availability of scored tablets is a practical advantage, supporting flexible dosing strategies.

5. Clinical Efficacy and Comparative Studies

5.1. Pivotal Clinical Trials for Major Depressive Disorder (MDD)

The efficacy of escitalopram in the treatment of MDD is well-established through numerous randomized, controlled trials. FDA approval was based on data from four placebo-controlled, double-blind studies, three of which demonstrated a statistically significant superiority of escitalopram over placebo.[21] The primary outcome measure in these studies was typically the change from baseline in the Montgomery-Åsberg Depression Rating Scale (MADRS) total score.[2] Effective doses were generally in the range of 10-20 mg/day.[2] Furthermore, the efficacy of escitalopram in maintaining an antidepressant response in adult MDD patients for up to 36 weeks has been demonstrated in placebo-controlled maintenance trials.[7] A meta-analysis of 10 studies comparing escitalopram with other active controls (citalopram, fluoxetine, paroxetine, sertraline, and venlafaxine XR) found that escitalopram was superior in overall treatment effect, as well as in response and remission rates in patients with MDD.[2] This body of evidence supports its role as a first-line treatment option for MDD.

5.2. Pivotal Clinical Trials for Generalized Anxiety Disorder (GAD)

Escitalopram's efficacy in GAD has also been confirmed in robust clinical trials. FDA approval for GAD was supported by three 8-week, flexible-dose, placebo-controlled studies in adult outpatients.[7] The primary efficacy endpoint in these trials was often the change from baseline in the Hamilton Anxiety Rating Scale (HAMA) total score.[42] Escitalopram, at doses of 10-20 mg/day, demonstrated statistically significant and clinically relevant improvements in GAD symptoms compared to placebo.[42] Notably, significant improvements in both the HAMA total score and the HAMA psychic anxiety subscale score were observed as early as Week 1 of treatment and were maintained throughout the study duration.[42] Response rates (e.g., 68% for escitalopram vs. 41% for placebo in study completers) further substantiated its efficacy.[42] Pooled analyses of GAD trials also indicated that escitalopram is effective in patients with GAD irrespective of the severity of baseline depressive symptoms and leads to improvements in quality of life.[43] This early and sustained efficacy across various GAD symptom domains underscores its utility in this often chronic condition.

5.3. Comparative Efficacy and Tolerability

Comparative studies and meta-analyses provide valuable context for escitalopram's position relative to other antidepressants.

Table 5: Summary of Comparative Efficacy and Tolerability Data for Escitalopram

Comparator	Key Efficacy Outcomes (vs. Escitalopram)	Key Tolerability Differences (vs. Escitalopram)	Onset of Action Notes	Reference(s)
Citalopram	Escitalopram superior: MADRS mean diff. ~1.13-1.7 pts; Response rate diff. ~7-8.3%; Remission rate diff. ~5.1-17.6%. Superiority may be more pronounced in severe MDD.	Similar or favorable for escitalopram.	Escitalopram may have faster onset.	2
Fluoxetine	Escitalopram superior on SMD at endpoint in one meta-analysis; no difference in response/remission.	Escitalopram generally has a cleaner CYP profile. Fluoxetine associated with more agitation, weight loss in some comparisons.	Escitalopram potentially faster.	22
Paroxetine	Escitalopram superior in efficacy (MADRS, remission), relapse prevention, especially in severe MDD/high anxiety.	Paroxetine: higher rates of sexual dysfunction, discontinuation symptoms, weight gain, anticholinergic effects (muscarinic antagonism), potent CYP2D6 inhibition. Escitalopram better tolerated.	Escitalopram potentially faster.	2
Sertraline	Efficacy often comparable in head-to-head trials. Some meta-analyses favor escitalopram/sertraline over paroxetine.	Sertraline: higher rates of diarrhea, potentially more sexual dysfunction. Sertraline inhibits DAT, moderate CYP interactions. Escitalopram generally has fewer such issues.	Escitalopram potentially faster.	2
Venlafaxine XR (SNRI)	Escitalopram at least as effective in head-to-head MDD study (20mg esc vs 225mg ven XR). Meta-analyses: comparable efficacy.	Escitalopram significantly better tolerated than venlafaxine XR in direct comparison (fewer AEs, lower discontinuation due to AEs).	Escitalopram potentially faster than venlafaxine XR.	2

5.3.1. Escitalopram vs. Citalopram

The comparison between escitalopram (the S-enantiomer) and its racemic parent, citalopram, is of particular interest. Multiple meta-analyses have consistently indicated that escitalopram offers a statistically significant and, by some interpretations, clinically relevant efficacy advantage over citalopram in MDD.2 This superiority is observed in mean changes on the MADRS (differences typically ranging from 1.13 to 1.7 points), as well as in higher response and remission rates (response rate differences of approximately 7-8.3%, remission rate differences varying more widely from 5.1% to 17.6%).44 The therapeutic advantage of escitalopram may be even more pronounced in patients with severe depression.2 This consistent finding supports the hypothesis that the R-enantiomer of citalopram might not be inert and could potentially interfere with the action of the S-enantiomer, or that the unique allosteric properties of escitalopram itself confer this benefit.1 Tolerability profiles are generally similar, though some analyses suggest escitalopram might be slightly favored or at least not worse.44

5.3.2. Escitalopram vs. Other SSRIs (Fluoxetine, Paroxetine, Sertraline)

When compared to other commonly prescribed SSRIs:

• Fluoxetine: Direct comparative data are less abundant. One meta-analysis suggested escitalopram was superior based on standardized mean difference at endpoint, but not in response or remission rates.[44] Fluoxetine has a longer half-life and different CYP interaction profile.[22]
• Paroxetine: Escitalopram generally demonstrates superior efficacy and/or better tolerability compared to paroxetine.[2] Studies have shown lower relapse rates, greater improvement in severe depression and anxiety, and fewer discontinuations with escitalopram.[19] Paroxetine is associated with a higher incidence of sexual dysfunction, weight gain, discontinuation symptoms, and anticholinergic side effects (due to its muscarinic receptor antagonism), as well as a potent inhibition of CYP2D6, leading to a higher potential for drug interactions.[19]
• Sertraline: Head-to-head trials often show comparable efficacy between escitalopram and sertraline, although study design nuances (e.g., dosing flexibility) could influence outcomes.[19] Meta-analyses tend to group escitalopram and sertraline as having favorable efficacy and tolerability profiles, often superior to paroxetine.[19] Sertraline is associated with higher rates of gastrointestinal side effects like diarrhea and also has a notable incidence of sexual dysfunction. Unlike escitalopram's high selectivity, sertraline also inhibits the dopamine transporter (DAT) to some extent and has a moderate potential for CYP enzyme interactions.[19] Overall, escitalopram's high selectivity for SERT and cleaner profile regarding off-target receptor binding and CYP enzyme inhibition often translate into a favorable balance of robust efficacy and good tolerability within the SSRI class.

5.3.3. Escitalopram vs. SNRIs (Venlafaxine)

Comparisons with serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine are important, as SNRIs are sometimes considered for more severe or treatment-resistant depression. A key head-to-head, fixed-dose study found escitalopram (20 mg/day) to be at least as effective as venlafaxine XR (225 mg/day) in treating MDD, but escitalopram was significantly better tolerated, with lower rates of overall adverse events and discontinuations due to adverse events.49 Meta-analyses comparing escitalopram specifically to venlafaxine or SNRIs as a class have yielded results suggesting comparable efficacy.2 While some broader meta-analyses indicate that SNRIs as a class might offer a slight efficacy advantage over SSRIs as a class 50, the direct comparative data for escitalopram suggest it performs well against venlafaxine, particularly when tolerability is factored in. This challenges a generalized assumption of SNRI superiority over all individual SSRIs.

5.4. Onset of Action

A potential clinical advantage of escitalopram is its purportedly faster onset of action compared to some other antidepressants. This is hypothesized to be linked to its unique allosteric binding at SERT, which may lead to a more rapid and robust increase in synaptic serotonin.[1] A pooled analysis of controlled clinical trials by Wade et al. (2006) reported that escitalopram-treated patients showed a significantly greater improvement in MADRS total scores compared to those treated with other SSRIs and venlafaxine XR as early as day 7 of treatment, a difference that was sustained throughout the studies. Secondary outcomes, including Clinical Global Impression (CGI) scales and early improvement metrics, also supported a faster onset for escitalopram.[51] However, a more recent meta-analysis by Liu et al. (2023) found no significant difference between escitalopram and other antidepressants in "early response" rates.[45] This discrepancy may be due to differences in study pooling, comparator drugs, or the specific definitions and statistical methods used to assess "early response" versus continuous improvement from an early timepoint. Further research with standardized definitions may be needed to definitively clarify this aspect.

6. Safety and Tolerability Profile

6.1. Adverse Effects (Common, Serious, and by System Organ Class)

Escitalopram is generally considered to have a favorable tolerability profile among antidepressants, largely attributed to its high selectivity for the serotonin transporter.[1] However, like all SSRIs, it is associated with a range of potential adverse effects.

Table 6: Common and Serious Adverse Effects of Escitalopram

Category	Adverse Effect	Approximate Incidence / Key Clinical Considerations	Reference(s)
Common Adverse Effects	Nausea	15-18% (often transient)	18
	Headache	Reported, can be transient	36
	Insomnia	9-12%	18
	Somnolence / Drowsiness	6-13%	18
	Dizziness	5%	30
	Diarrhea	8%	30
	Dry Mouth	6-9%	30
	Increased Sweating	4-5%	30
	Fatigue	5-8%	18
	Ejaculation Disorder (primarily delay)	9-14% (in males)	18
	Decreased Libido	3-7%	18
	Anorgasmia	2-6% (higher in females)	18
	Constipation	3-5%	30
	Appetite Decreased	3%	30
Serious Adverse Effects	Serotonin Syndrome	Potentially life-threatening; risk increased with co-administered serotonergic agents. Symptoms: mental status changes, autonomic instability, neuromuscular hyperactivity, GI symptoms.	18
	QT Prolongation / Torsades de Pointes	Dose-dependent risk; caution with pre-existing cardiac conditions or concomitant QT-prolonging drugs.	6
	Suicidal Thoughts/Behavior	See Black Box Warning (Section 6.2).	5
	Hyponatremia	Often due to SIADH, especially in elderly or volume-depleted patients. Symptoms: headache, confusion, weakness, unsteadiness, seizures.	18
	Abnormal Bleeding	Increased risk, especially with NSAIDs, aspirin, anticoagulants due to effects on platelet function.	26
	Seizures	Rare; use with caution in patients with seizure history.	26
	Activation of Mania/Hypomania	Screen for bipolar disorder prior to treatment.	6
	Angle-Closure Glaucoma	May be precipitated in susceptible individuals.	26
	Severe Allergic Reactions / Anaphylaxis	Rare; symptoms include swelling, breathing difficulty, rash.	26
	Priapism	Painful erections lasting >2 hours; medical emergency.	26

Many common side effects, such as nausea and headache, are often transient and may improve within the first week or two of treatment.[34] Sexual dysfunction (including decreased libido, anorgasmia, and ejaculatory delay) is a common and often distressing side effect of SSRIs, including escitalopram. While these symptoms may diminish over time for some, they can persist and, in rare cases, may continue even after discontinuing the medication.[18] Weight changes with escitalopram are variable; some studies report minimal change or even weight loss (particularly in conditions like binge eating disorder), while others note potential for weight gain with long-term use.[12] Post-marketing surveillance has identified a wide array of other adverse reactions across various body systems, though their frequency is often not reliably estimable.[26] Patient education regarding common and potential serious adverse effects is crucial for adherence and prompt management.

6.2. Black Box Warnings

The U.S. Food and Drug Administration (FDA) has mandated a boxed warning for escitalopram, similar to other antidepressant medications:

• Suicidal Thoughts and Behaviors: Antidepressants, including escitalopram, increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (ages 18-24) in short-term studies of MDD and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes (increases or decreases).[5] Escitalopram is not approved for use in pediatric patients younger than 12 years for MDD or younger than 7 years for GAD.[26] This warning underscores the need for careful risk-benefit assessment and vigilant monitoring when prescribing escitalopram to younger populations.

6.3. Contraindications

Escitalopram is contraindicated in the following situations:

• Concomitant use with Monoamine Oxidase Inhibitors (MAOIs): Taking escitalopram with MAOIs (including those intended to treat psychiatric disorders, as well as other MAOIs such as linezolid or intravenous methylene blue) or within 14 days of stopping an MAOI (and vice versa for escitalopram) is contraindicated due to the risk of serotonin syndrome, a potentially life-threatening condition.[18]
• Concomitant use with Pimozide: This is contraindicated due to the risk of QT interval prolongation.[17]
• Known Hypersensitivity: Patients with a known hypersensitivity to escitalopram, citalopram, or any of the inactive ingredients in the formulation should not take escitalopram.[18]
• Congenital Long QT Syndrome or Known Pre-existing QT Prolongation: While sometimes listed as a strong warning rather than an absolute contraindication, use in these patients is generally discouraged or requires extreme caution due to escitalopram's potential to prolong the QT interval.[12]

6.4. Warnings and Precautions

A number of warnings and precautions are associated with escitalopram use:

• Serotonin Syndrome: This potentially life-threatening condition can occur with serotonergic agents like escitalopram, particularly when used concomitantly with other drugs that increase serotonin levels (e.g., triptans, other SSRIs/SNRIs, TCAs, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, St. John’s Wort) or drugs that impair serotonin metabolism (e.g., MAOIs). Symptoms include mental status changes (agitation, hallucinations, delirium, coma), autonomic instability (tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (nausea, vomiting, diarrhea). If serotonin syndrome occurs, escitalopram and any concomitant serotonergic agents should be discontinued immediately, and supportive symptomatic treatment initiated.[17]
• Discontinuation Syndrome: Abrupt discontinuation of escitalopram can lead to withdrawal symptoms, including dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible.[5]
• Seizures: Escitalopram should be used with caution in patients with a history of seizure disorder, as convulsions have been reported with its use. It should be discontinued in any patient who develops seizures.[26]
• Activation of Mania/Hypomania: In patients with bipolar disorder, treatment with an antidepressant may precipitate a mixed/manic episode. Therefore, patients should be adequately screened for a personal or family history of bipolar disorder, mania, or hypomania prior to initiating treatment with escitalopram.[6]
• Hyponatremia: Clinically significant hyponatremia can occur with SSRI treatment, including escitalopram, and appears to be reversible upon discontinuation. It is often the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Elderly patients, those taking diuretics, or those who are otherwise volume depleted may be at greater risk. Symptoms can range from headache and difficulty concentrating to more severe manifestations like confusion, weakness, unsteadiness (leading to falls), hallucinations, syncope, seizures, coma, and respiratory arrest.[18]
• Increased Risk of Bleeding: Drugs that interfere with serotonin reuptake, including escitalopram, have been associated with an increased risk of bleeding events. These can range from ecchymoses, hematomas, epistaxis, and petechiae to more serious gastrointestinal or life-threatening hemorrhages. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, and other anticoagulants or antiplatelet drugs may potentiate this risk.[6]
• Angle-Closure Glaucoma: The pupillary dilation that can occur following use of many antidepressant drugs, including escitalopram, may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy. An eye examination prior to starting treatment may be advisable for patients at risk.[26]
• QT Prolongation and Torsades de Pointes (TdP): Escitalopram (and its parent citalopram) are associated with dose-dependent QT interval prolongation. This can increase the risk of TdP, a potentially fatal ventricular arrhythmia. Caution is advised when prescribing escitalopram to patients with known underlying QT prolongation, congenital long QT syndrome, a family history of such conditions, electrolyte imbalances (hypokalemia, hypomagnesemia), bradycardia, recent myocardial infarction, uncompensated heart failure, or those taking other medications known to prolong the QT interval.[6]
• Use in Patients with Concomitant Illness: Clinical experience with escitalopram in patients with certain concomitant systemic illnesses is limited. Caution is advised in using escitalopram in patients with diseases or conditions that produce altered metabolism or hemodynamic responses, such as recent myocardial infarction or unstable heart disease.[26]
• Sexual Dysfunction: Escitalopram may cause symptoms of sexual dysfunction in both male (e.g., ejaculatory delay or failure, decreased libido, erectile dysfunction) and female (e.g., decreased libido, delayed or absent orgasm) patients. It is advisable for prescribers to inquire about sexual function prior to initiation and during treatment.[18]
• Cognitive and Motor Performance: Like other psychotropic drugs, escitalopram may impair judgment, thinking, or motor skills. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that escitalopram therapy does not affect their ability to engage in such activities.[26]
• Pregnancy: Escitalopram is classified under the older FDA system as Pregnancy Category C. Exposure during the third trimester may be associated with an increased risk of persistent pulmonary hypertension of the newborn (PPHN) and poor neonatal adaptation syndrome (including respiratory distress, feeding difficulties, and neurological symptoms, potentially consistent with a direct toxic effect or a drug discontinuation syndrome). Untreated depression during pregnancy also carries risks. A pregnancy exposure registry monitors outcomes in women exposed to antidepressants during pregnancy. The decision to use escitalopram during pregnancy requires careful consideration of potential risks and benefits.[18]
• Lactation: Escitalopram and its metabolite S-DCT are excreted in human breast milk. There have been reports of adverse effects in breastfed infants, including excessive sedation, restlessness, agitation, poor feeding, and poor weight gain. Infants exposed through breast milk should be monitored for such signs. The decision to continue or discontinue either breastfeeding or escitalopram therapy should take into account the risk of infant exposure, the benefits of breastfeeding, and the benefits of treatment to the mother.[18]

6.5. Drug Interactions

Escitalopram has several clinically significant drug interactions that necessitate careful management.

Table 7: Clinically Significant Drug Interactions with Escitalopram

Interacting Drug/Class	Potential Consequence	Clinical Recommendation/Management Strategy	Reference(s)
Monoamine Oxidase Inhibitors (MAOIs) (e.g., phenelzine, tranylcypromine, isocarboxazid, selegiline, linezolid, IV methylene blue)	Serotonin Syndrome (potentially life-threatening)	Contraindicated. Allow at least 14-day washout period when switching.	17
Pimozide	Increased risk of QT prolongation and ventricular arrhythmias	Contraindicated.	17
Other Serotonergic Agents (e.g., other SSRIs, SNRIs, triptans, TCAs, lithium, tramadol, buspirone, fentanyl, St. John's Wort, amphetamines)	Increased risk of Serotonin Syndrome	Use with caution; monitor closely for symptoms, especially during initiation and dosage increases. Avoid combination if possible.	6
QT Prolonging Drugs (e.g., certain antiarrhythmics Class IA/III, antipsychotics, macrolide antibiotics, fluoroquinolones)	Increased risk of QT prolongation and Torsades de Pointes	Use with caution or avoid. Monitor ECG if concomitant use is necessary and risk factors are present.	6
Drugs that Interfere with Hemostasis (e.g., NSAIDs, aspirin, warfarin, other anticoagulants/antiplatelet drugs)	Increased risk of bleeding (e.g., GI bleeding, ecchymosis)	Use with caution. Inform patients of risk. Monitor INR for patients on warfarin.	6
CYP2C19 Inhibitors (e.g., omeprazole, cimetidine, fluconazole)	May increase plasma concentrations of escitalopram	Use with caution. Consider escitalopram dose reduction if strong CYP2C19 inhibitor co-administered. (Cimetidine increased citalopram levels).	6
CYP2D6 Substrates (e.g., desipramine, metoprolol, aripiprazole, risperidone, TCAs)	Escitalopram is a weak inhibitor of CYP2D6; may increase plasma concentrations of these substrates	Use with caution. Dosage adjustment of the CYP2D6 substrate may be needed.	6
Alcohol	Additive CNS depressant effects, impaired judgment/motor skills	Concomitant use is not recommended.	17
Carbamazepine (CYP3A4 inducer)	May increase escitalopram clearance, potentially reducing efficacy	Monitor for clinical response; dosage adjustment of escitalopram may be needed.	17
Triptans (e.g., sumatriptan)	Increased risk of Serotonin Syndrome; reports of weakness, hyperreflexia, incoordination	Observe carefully if used concomitantly, particularly during treatment initiation and dosage increases.	17

Escitalopram itself has negligible inhibitory effects on P-glycoprotein, making interactions via this transporter unlikely.[25] A thorough medication review is critical before initiating escitalopram.

6.6. Food Interactions

• General Food Effect: Escitalopram can be taken with or without food, as food does not significantly affect its absorption.[7] This offers flexibility in administration.
• Grapefruit Juice: Some non-regulatory sources suggest that grapefruit juice might worsen side effects of escitalopram, potentially through inhibition of CYP3A4 (a minor metabolic pathway for escitalopram).[59] However, official FDA labeling for escitalopram does not specifically mention an interaction with grapefruit juice.[26] Given that CYP2C19 is the primary metabolizing enzyme, the clinical significance of a grapefruit interaction is likely low for most patients.
• Alcohol: Although clinical trials did not show escitalopram potentiating the cognitive and motor effects of alcohol, concomitant use of alcohol with escitalopram (and other psychotropic medications) is generally not recommended.[17]

6.7. Overdose Management

Overdose with escitalopram can occur, particularly with large ingestions or when co-ingested with other substances.

• Symptoms: Common symptoms of escitalopram overdose include central nervous system effects (dizziness, convulsions, somnolence, altered mental status, potentially progressing to coma), gastrointestinal distress (nausea, vomiting), and cardiovascular abnormalities (hypotension, tachycardia, ECG changes including QRS and QT interval prolongation, which can lead to Torsades de Pointes and other arrhythmias).[1] Serotonin syndrome is a significant risk, especially if other serotonergic drugs are involved in the overdose.[26]
• Risks: Severe overdose can be life-threatening, with risks including refractory seizures, severe cardiac arrhythmias (TdP), and, rarely, acute renal failure.[5] Post-marketing data suggest overdose events have occurred at dosages exceeding 1000 mg.[61]
• Management:
• There is no specific antidote for escitalopram overdose.[1]
• Management is primarily supportive and symptomatic. This includes maintaining an adequate airway, ensuring oxygenation and ventilation, and continuous monitoring of cardiac function (prolonged ECG monitoring, e.g., for at least 12 hours, is recommended for significant ingestions, such as >300 mg) and vital signs.[1]
• Gastrointestinal decontamination with activated charcoal may be considered, especially if the patient presents early after a large ingestion. Gastric lavage may also be considered in some cases.[5]
• Enhanced elimination techniques such as forced diuresis, dialysis, hemoperfusion, and exchange transfusion are unlikely to be beneficial due to escitalopram's large volume of distribution.[1]
• If serotonin syndrome is present, offending agents should be discontinued, and supportive care (including temperature control, benzodiazepines for agitation/rigidity) should be initiated. Cyproheptadine may be considered in refractory cases.[18]
• Torsades de Pointes, if it occurs, should be treated according to standard cardiac protocols, which may include magnesium sulfate and, if hemodynamically unstable, electrical cardioversion/defibrillation.[18]
• Consultation with a Poison Control Center or a medical toxicologist is recommended for guidance in managing overdose cases.[18]

Early recognition of overdose, assessment for co-ingestants, and prompt initiation of supportive care with a focus on cardiovascular monitoring are crucial for optimizing outcomes.

7. Regulatory Status and Market Information

7.1. Regulatory Approval History

• Food and Drug Administration (FDA), USA: Escitalopram (as Lexapro®) received initial FDA approval for Major Depressive Disorder (MDD) in August 2002, followed by approval for Generalized Anxiety Disorder (GAD) in December 2003.[3] The development of escitalopram was notably rapid, attributed to the extensive prior experience of the manufacturers with its racemic parent, citalopram.[21] The first generic version of escitalopram was approved by the FDA in May 2006 (Teva Pharmaceuticals).[6]
• European Medicines Agency (EMA), Europe: Escitalopram (as Cipralex®) was approved in European countries around 2001-2002. A significant review by the EMA's Committee for Medicinal Products for Human Use (CHMP) in April 2005 addressed the use of SSRIs and SNRIs in children and adolescents. The CHMP concluded that these antidepressants should not be used in this age group except for their specifically approved indications, due to an increased risk of suicidal thoughts and behavior. However, the committee acknowledged that physicians might, based on clinical need, use these products off-label for depression or anxiety in children and adolescents, but stressed the importance of careful monitoring for suicidality in such cases.[31]
• Health Canada: Escitalopram is approved in Canada for MDD, GAD, and OCD.[1] Specific approval dates were not detailed in the provided materials but its availability for these indications is established.

7.2. Generic Availability

Escitalopram is widely available in generic formulations in many countries, including the United States since 2006.[6] The availability of generic escitalopram has significantly reduced its cost compared to the brand-name product (Lexapro®), making it a more accessible treatment option for many patients.[64] Generic escitalopram is generally covered by most Medicare and insurance plans, and various pharmacy discount programs can further lower the out-of-pocket expense.[65] This improved affordability has likely contributed to its widespread use.

7.3. International Brand Names

Escitalopram is marketed under various brand names globally. The most common international brand names include:

• Lexapro®: Widely used in the United States, Canada, and other regions.[1]
• Cipralex®: Common in Europe, Canada, Australia, and other international markets.[1]

Other reported brand names or synonyms include Esertia®, Esitol®, Seroplex®, and the development code LU-26-054.[1] The existence of multiple brand names necessitates careful attention to the active pharmaceutical ingredient (escitalopram) to avoid confusion for patients and healthcare providers, especially in international contexts or when reviewing patient medication histories from different regions.

7.4. Prescription Status

Escitalopram is a prescription-only medication in major regulatory regions, including the United States, Canada, and European countries [[8] ("Rx Only" for Lexapro), [67] (implying prescription status for travel with medications)]. Patients require a prescription from a licensed healthcare practitioner to obtain this medication. Travelers carrying escitalopram internationally should ensure they comply with the regulations of their destination country regarding prescription medications, often requiring a copy of the prescription and a doctor's note.[67]

8. Conclusion

Escitalopram, the S-enantiomer of citalopram, stands as a highly selective serotonin reuptake inhibitor (SSRI) with a distinct pharmacological profile, including a unique allosteric binding mechanism at the serotonin transporter (SERT). This profile is thought to contribute to its efficacy and tolerability. Clinical evidence robustly supports its use for Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) in adults and specified pediatric populations, with approvals varying slightly across major regulatory agencies like the FDA, EMA, and Health Canada.

Comparative studies and meta-analyses frequently position escitalopram favorably against its racemic parent, citalopram, often demonstrating superior efficacy. When compared to other SSRIs and some SNRIs (like venlafaxine XR), escitalopram generally exhibits comparable or, in some analyses, superior efficacy, coupled with a potentially better tolerability profile, particularly concerning certain side effects like anticholinergic symptoms or significant CYP enzyme inhibition. Some evidence also suggests a potentially faster onset of action, although this is not universally confirmed across all studies and definitions of early response.

The safety profile of escitalopram is characteristic of the SSRI class, with common adverse effects including nausea, headache, insomnia/somnolence, and sexual dysfunction. Clinicians must remain vigilant for serious but less common risks, such as the potential for QT interval prolongation, serotonin syndrome (especially with concomitant serotonergic medications), hyponatremia, and increased bleeding risk. The FDA-mandated black box warning regarding an increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults necessitates careful patient selection and close monitoring in these age groups. Discontinuation of therapy should be gradual to minimize withdrawal symptoms.

Effective and safe use of escitalopram requires careful consideration of patient-specific factors, including age, co-existing medical conditions (particularly cardiac, hepatic, and renal status), genetic factors (such as CYP2C19 metabolizer status), and a thorough review of concomitant medications to mitigate the risk of clinically significant drug interactions.

In summary, escitalopram represents a significant therapeutic option in psychiatric pharmacotherapy, offering a well-documented balance of efficacy and tolerability for its approved indications. Its widespread generic availability has further enhanced its accessibility. Ongoing research and pharmacovigilance continue to refine understanding of its long-term effects and optimal use in diverse patient populations.

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