Lexapro for Depression

Escitalopram, also known as Lexapro, is a type of antidepressant medication that belongs to a class of drugs called selective serotonin reuptake inhibitors (SSRIs). Lexapro, like other SSRIs, helps regulate moods by increasing serotonin levels in the brain, which is believed to positively impact mood and emotional well-being. It is commonly prescribed to treat major depressive disorder and generalized anxiety disorder, but it is also used off-label to treat many other conditions. This article provides an overview of Lexapro for depression, how it works, other conditions it treats, potential side effects and interactions, and some alternative treatments, including its use with therapies like Spravato and TMS.

While Lexapro and other SSRIs can be effective in treating depression and anxiety for many people, they may not work well or be suitable for everyone. Fortunately, several medications and other alternative treatments can be used alone or in combination with Lexapro, such as transcranial magnetic stimulation (TMS).

What is Lexapro?

Lexapro (escitalopram) is a type of antidepressant that belongs to a group of medications known as highly selective serotonin reuptake inhibitors (SSRIs) [8]. SSRIs like escitalopram are drugs approved by the U.S. Food and Drug Administration (FDA) for short-term and long-term treatment of major depressive disorder (MDD) in adults and teenagers (ages 12-17) and also for use in treating generalized anxiety disorder (GD) in adults and children ages seven and older [8].

Escitalopram comes in liquid and tablet forms, with strengths of 5 mg, 10 mg, or 20 mg [8]. Usually, people start with 10 mg once daily, and the dose can be raised after a week if needed [8]. The drug works consistently within a certain dose range (10 to 30 mg per day), reaching its highest concentration in the blood about 5 hours after taking it [8].

Lexapro is also used off-label to treat many other conditions, such as [8, 15]:

 How Lexapro Works

Selective serotonin reuptake inhibitors (SSRIs), such as escitalopram (Lexapro), are one of the most prescribed types of antidepressants used to treat a range of depression and anxiety conditions. These medications interfere with the brain’s serotonin reuptake process [8].

The brain uses neurotransmitters, like serotonin, to facilitate communication between nerve cells. Serotonin is essential for mood regulation and also influences memory, stress response, appetite, addiction, and sexuality [8]. Imbalances in serotonin levels are linked to conditions like depression and anxiety [8]. That’s where medications like Lexapro come in – they disrupt the brain’s serotonin reuptake process [8].

Usually, serotonin is released into the synapse (the space between nerve cells), binds to receptors on the receiving nerve cell, and sends its signal [8]. Lexapro interferes with this reuptake process by blocking the protein responsible for reabsorbing serotonin into the presynaptic cell [8]. Consequently, Lexapro increases the concentration of serotonin in the synapse, making more of it available for communication between nerve cells [8]. This increased presence of serotonin in the synapse is believed to improve mood and alleviate symptoms of depression and anxiety over time [8].

 Side Effects

Like any medication, Lexapro may cause side effects, as reported in approximately 10% of patients [15]. Common side effects of this antidepressant include [8,15]:

  • Drowsiness or sleepiness (Somnolence)
  • Insomnia (trouble sleeping)
  • Dizziness
  • Headache
  • Diaphoresis (excessive and abnormal sweating)
  • Nausea
  • Vomiting
  • Dry mouth (xerostomia)
  • Constipation
  • Diarrhea
  • Sexual problems

Less common or more severe side effects may occur, such as:

  • Suicidal Thoughts: Antidepressants, including Lexapro, may increase the risk of suicidal thoughts, especially in young adults and teenagers.
  • Serotonin Syndrome and Hyponatremia: While escitalopram generally has a lower toxicity profile, rare but severe side effects include serotonin syndrome and syndrome of inappropriate antidiuretic hormone secretion (SIADH), potentially leading to hyponatremia, especially in older patients [8,15]. Symptoms of hyponatremia range from mild, such as nausea and fatigue, to severe conditions like altered mental status, seizures, and coma [8,15].
  •  QT Prolongation: Prolonged corrected QT interval on an electrocardiogram, potentially leading to fatal cardiac arrhythmias, including torsades de pointes [8,15].
  •  Allergic Reactions: Some people may be allergic to Lexapro, with symptoms such as rash, itching, swelling, severe dizziness, or difficulty breathing.
  • Worsening Depression:

It is important to take Lexapro only under the guidance of a healthcare provider, and individuals should not stop taking it without consulting with their physician or medical provider.

 Contraindications

While Lexapro can be effective for many individuals, it may not suit everyone. Key considerations include [8,15]:

Hypersensitivity or Reaction History: Individuals with a history of hypersensitivity, and an unusual or allergic reaction to escitalopram or citalopram should avoid Lexapro. Allergic reactions may manifest as rash, itching, swelling, severe dizziness, or difficulty breathing. In severe cases, contact a poison control center, immediate medical attention is necessary if these symptoms occur.

Medication Interactions: Lexapro may cause significant drug interactions, so it is important to discuss other medications you are taking, including prescription drugs, over-the-counter medications such as nonsteroidal anti-inflammatory drugs, and supplements. This information can help your healthcare provider determine whether any of your medications could interact with each other or cause adverse effects.

Discussing your complete medical history with your healthcare provider is important to ensure that any underlying health conditions or risk factors are considered when making treatment decisions. By providing a full picture of your medication use and health history, you can help your healthcare provider make informed decisions about your care.

It is generally not advised to take Lexapro in the following cases [8,15]:

  • Individuals with a history of hypersensitivity to escitalopram or citalopram.
  • Family history of long QT syndrome or sudden cardiac death.
  • Taking Monoamine Oxidase Inhibitors (MAOIs), as combining them with Lexapro may increase the risk of serotonin syndrome.
  • Women who are planning to become pregnant or may be pregnant.

Caution is urged for adults aged 65 and older, as Lexapro may cause or worsen hyponatremia (SIADH) [15]. Specific considerations in dosing are required for patients with hepatic impairment, renal impairment, and pregnant or breastfeeding individuals. Escitalopram is classified as a pregnancy category C medicine, and caution is advised in breastfeeding mothers [8].

How Long Can Someone Remain on Lexapro?

The duration for taking medications like Lexapro, among other SSRIs or various antidepressants, varies individually. Collaborating closely with your healthcare provider helps determine the right timeline based on your unique situation.

Extended use of antidepressants may lead to tolerance, diminishing their effectiveness. Research suggests this tolerance can develop in 9%-57% of patients [7]. In such cases, healthcare providers might adjust the dosage, switch to a different antidepressant, or combine treatments like medications and psychotherapy [7].

Additionally, about 10% to 30% of individuals do not respond positively to antidepressant treatments, which may be associated with a condition called treatment-resistant depression (TRD) [1]. Individuals should monitor their symptoms and contact their physician or healthcare provider if they experience an increase in side effects or their severity or if they feel that their antidepressant is not working.

Getting Off of Lexapro

At times, individuals may decide to stop taking Lexapro due to adverse side effects, ineffectiveness, worsening symptoms, or deciding to try a different treatment. If you decide to make any changes to your medication, make sure you tell your doctor and follow their guidance.

If you decide to stop taking Lexapro, your doctor may start tapering your medication. It is common for individuals to experience uncomfortable SSRI withdrawal symptoms which include physical, emotional, and psychological symptoms. Stopping Lexapro abruptly may lead to SSRI discontinuation syndrome which comes along with more severe withdrawal symptoms that can become serious. Be sure to follow your doctor’s instructions to avoid

Alternatives to Lexapro for Depression

Medications

SSRIs, like Lexapro, are often the first choice for treating depression. They work by increasing serotonin levels in the brain, a neurotransmitter related to mood. Sertraline, for instance, is usually started just below its minimum therapeutic dose (MTD), like 50 mg, to minimize side effects [14]. In addition to SSRIs, there exists a wide range of psychiatric medications used to treat depression and other mental health conditions.

If well-tolerated, the dose is increased to the MTD over a few days, and patients are reassessed after 4-6 weeks. SSRIs are commonly preferred due to their safety and tolerability profiles, making them a go-to option for many clinicians [14].

Lexapro (escitalopram) is just one among various SSRIs used for treating conditions and their associated symptoms. However, the effectiveness can vary from person to person. Other SSRIs, like Zoloft (sertraline), Celexa (citalopram), Prozac (fluoxetine), Luvox (fluvoxamine), Paxil (paroxetine), Viibryd (vilazodone)offer alternative options [3].

Selective Serotonin Reuptake Inhibitors (SSRIs)

Newer SNRIs such as duloxetine (Cymbalta) or desvenlafaxine (Pristiq) are considered when there’s a suspicion of norepinephrine imbalance or specific patient preferences. These drugs affect both serotonin and norepinephrine levels in the brain [14].

The initial approach involves starting below the MTD to minimize side effects, then increasing to the MTD after a few days. The patient is reassessed at 4-6 weeks. SNRIs might be chosen for slight differences in side-effect profiles, but the decision is usually based on individual patient needs and responses [14].

Atypical ADTs (Antidepressants):

Atypical antidepressants, such as Merative (mirtazapine), Desyrel(trazodone), and Wellbutrin (bupropion), don’t fit neatly into traditional categories. Mirtazapine is known as a “sedating antidepressant,” which means it works by preventing norepinephrine alpha-2 auto receptors and blocking 5-HT2A/2C receptors, resulting in increased neurotransmitter levels [14].

Trazodone, with a complex mechanism, is often used for its anxiolytic (anxiety-relieving) and sedative effects. Bupropion, a norepinephrine-dopamine reuptake inhibitor (NDRI), stands out for its unique profile, promoting weight loss and lacking sexual side effects [14]. These atypical options offer diverse choices for patients with specific needs or preferences [14].

Lexapro in Conjunction with Other Treatments

Lexapro and TMS (Repetitive Transcranial Magnetic Stimulation)

Repetitive Transcranial Magnetic Stimulation (rTMS) is a noninvasive medical procedure that uses magnetic fields to target specific brain regions associated with the treated disorder [10]. Researchers have explored it as a complementary therapy alongside escitalopram (Lexapro) for the treatment of major depressive disorder (MDD).

  •  One study [9] reviewed the efficacy, acceptability, and tolerability of rTMS combined with antidepressants, including citalopram (a similar drug to escitalopram). The findings indicated that the combination of rTMS with antidepressants showed greater mean-endpoint scores on the Hamilton Depression Rating Scale (HAMD) compared to sham plus antidepressants.
  •  Another study [2] investigated the combination of high-frequency rTMS over the left cortex with escitalopram in patients with major depression resistant to non-tricyclic antidepressants. The study concluded that high-frequency rTMS over the left cortex is a clinically significant add-on strategy in combination with escitalopram for such patients.
  •  In addition, a consensus recommendation [11] for the clinical application of rTMS in the treatment of depression acknowledges the clinical need for additional antidepressant treatments. It suggests that rTMS is a safe, noninvasive neuromodulation technique.
  •  Furthermore, a double-blind, randomized, sham-controlled trial [12] found that rTMS hastened the response to escitalopram, sertraline, or venlafaxine in patients with major depressive disorder. The study supported the efficacy of rTMS in accelerating the response to antidepressant drugs in such patients.

Lexapro and Spravato

Spravato (esketamine) is an FDA-approved prescription nasal spray designed to address depression in adults with treatment-resistant depression (TRD) who haven’t found relief with other antidepressants. Administered in combination with an oral antidepressant, Spravato offers a novel approach to tackle TRD [6].

Several clinical studies have demonstrated the effectiveness of Spravato in treating TRD when used in combination with an SSRI or SNRI medication.

  •  Studies involving approximately 1,800 patients revealed that Spravato, taken with an SSRI or SNRI, alleviated symptoms of TRD, as measured using a standard scoring system known as MADRS [5].
  •  In a longer-term study, Spravato demonstrated efficacy in preventing depression relapse, with a 27% relapse rate for patients on Spravato (plus an SSRI or SNRI) compared to 45% in the placebo group (also on an SSRI or SNRI) [5].
  •  Furthermore, a study [4] published in JAMA Psychiatry indicated that the combination of esketamine and an antidepressant reduced relapse risk by 51% in patients achieving stable remission or response after 16 weeks of treatment. Continued treatment with esketamine plus an antidepressant demonstrated significant, clinically meaningful superiority compared to an antidepressant plus placebo.
  •  Limited phase III trials have also illustrated the efficacy and safety of intranasal esketamine in reducing depressive symptoms [13].

 Find Out if Lexapro is Right for You

In conclusion, Lexapro (escitalopram) stands as one of a list of valuable SSRI medications, offering potential benefits for many individuals, either as a standalone treatment or in conjunction with other therapeutic options like psychotherapy, Spravato, or TMS. It’s important to remember that Lexapro is just one type of antidepressant medication, and various alternatives exist. As responses to medications can vary individually, close collaboration with healthcare providers is essential for crafting tailored and effective treatment plans.

If you’re dealing with depression, anxiety, or another mental illness, Neuro Wellness Spa is here to support you. Reach out today to explore personalized treatment options designed to bring relief and empower you on the path to emotional well-being. Our expert team is ready and available to guide you through identifying the best treatment option for you. Contact us today to learn more about our psychiatry and medication management to find out if Lexapro is right for you or explore alternative treatments such as TMS therapy and take the first step toward a brighter tomorrow.

 References

  1.  Al-Harbi K. S. (2012). Treatment-resistant depression: therapeutic trends, challenges, and future directions. Patient preference and adherence, 6, 369–388. https://doi.org/10.2147/PPA.S29716
  2. Bretlau, L. G., Lunde, M., Lindberg, L., Undén, M., Dissing, S., & Bech, P. (2008). Repetitive transcranial magnetic stimulation (rTMS) in combination with escitalopram in patients with treatment-resistant major depression: a double-blind, randomised, sham-controlled trial. Pharmacopsychiatry, 41(2), 41–47. https://doi.org/10.1055/s-2007-993210
  3. Chu A, Wadhwa R. Selective Serotonin Reuptake Inhibitors. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554406/
  4. Daly, E. J., Singh, J. B., Fedgchin, M., Cooper, K., Lim, P., Shelton, R. C., Thase, M. E., Winokur, A., Van Nueten, L., Manji, H., & Drevets, W. C. (2018). Efficacy and Safety of Intranasal Esketamine Adjunctive to Oral Antidepressant Therapy in Treatment-Resistant Depression: A Randomized Clinical Trial. JAMA psychiatry, 75(2), 139–148. https://doi.org/10.1001/jamapsychiatry.2017.3739
  5. European Medicines Agency (2019, December 18). Spravato. https://www.ema.europa.eu/en/medicines/human/EPAR/spravato
  6. Food and Drug Administration (2019, March 5). FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor’s office or clinic. https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified
  7. Kinrys, G., Gold, A. K., Pisano, V. D., Freeman, M. P., Papakostas, G. I., Mischoulon, D., Nierenberg, A. A., & Fava, M. (2019). Tachyphylaxis in major depressive disorder: A review of the current state of research. Journal of affective disorders, 245, 488–497. https://doi.org/10.1016/j.jad.2018.10.357
  8. Landy K, Rosani A, Estevez R. Escitalopram. [Updated 2023 Nov 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557734/
  9. Maneeton, B., Maneeton, N., Woottiluk, P., & Likhitsathian, S. (2020). Repetitive Transcranial Magnetic Stimulation Combined with Antidepressants for the First Episode of Major Depressive Disorder. Current neuropharmacology, 18(9), 852–860. https://doi.org/10.2174/1570159X18666200221113134
  10. Mann SK, Malhi NK. Repetitive Transcranial Magnetic Stimulation. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568715/
  11. McClintock, S. M., Reti, I. M., Carpenter, L. L., McDonald, W. M., Dubin, M., Taylor, S. F., Cook, I. A., O’Reardon, J., Husain, M. M., Wall, C., Krystal, A. D., Sampson, S. M., Morales, O., Nelson, B. G., Latoussakis, V., George, M. S., Lisanby, S. H., National Network of Depression Centers rTMS Task Group, & American Psychiatric Association Council on Research Task Force on Novel Biomarkers and Treatments (2018). Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. The Journal of clinical psychiatry, 79(1), 16cs10905. https://doi.org/10.4088/JCP.16cs10905
  12. Rossini, D., Magri, L., Lucca, A., Giordani, S., Smeraldi, E., & Zanardi, R. (2005). Does rTMS hasten the response to escitalopram, sertraline, or venlafaxine in patients with major depressive disorder? A double-blind, randomized, sham-controlled trial. The Journal of clinical psychiatry, 66(12), 1569–1575. https://doi.org/10.4088/jcp.v66n1212
  13. Salahudeen, M. S., Wright, C. M., & Peterson, G. M. (2020). Esketamine: new hope for the treatment of treatment-resistant depression? A narrative review. Therapeutic advances in drug safety, 11, 2042098620937899. https://doi.org/10.1177/2042098620937899
  14. Santarsieri, D., & Schwartz, T. L. (2015). Antidepressant efficacy and side-effect burden: a quick guide for clinicians. Drugs in context, 4, 212290. https://doi.org/10.7573/dic.212290
  15. Sharbaf Shoar N, Fariba KA, Padhy RK. Citalopram. [Updated 2023 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482222/
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