Escitalopram

Decreased libido, delayed orgasm, anorgasmia, erectile dysfunction. Affects a substantial percentage of patients (estimates vary widely, but rates of 30-50% are commonly cited though likely underreported). This is a class effect of all SSRIs, mediated through serotonergic stimulation of 5-HT2A and 5-HT2C receptors. It often does not improve with time. Management: dose reduction, switching to bupropion or mirtazapine, or adding bupropion.

GI serotonin receptor stimulation. Typically resolves within 1-2 weeks. Taking with food helps. If persistent, this is one of the symptoms mirtazapine augmentation can address (5-HT3 antagonism).

Some patients feel more anxious, jittery, or restless in the first 1-2 weeks before the antidepressant effect emerges. Anxiety symptoms can improve relatively early, but full mood benefit typically takes 2-6 weeks. The initial jitteriness is a front-loaded side effect that resolves as the antidepressant effect develops. Starting at 5mg for the first week mitigates this. Important to counsel patients in advance so they don't discontinue prematurely.

SSRIs reduce platelet serotonin content, impairing platelet aggregation. This increases GI bleeding risk, particularly when combined with NSAIDs, aspirin, or anticoagulants. Consider GI protection (PPI) in patients at high bleeding risk who require both an SSRI and an NSAID or antiplatelet agent.

Described as feeling "flat," "numb," or "robotic." Distinct from residual depression (neurovegetative symptoms are treated, but emotional range is compressed). More common at higher doses. Addressed through dose reduction, addition of bupropion, or medication switch.

Highest risk in elderly patients, those on diuretics, and those with low body weight. Monitor sodium if confusion, falls, or cognitive decline develop, particularly in the first few months.

Clinically relevant at 20mg and in patients with cardiac risk factors. Less restrictive than citalopram's warning but still warrants consideration. Check ECG in higher-risk patients.

Less weight gain than mirtazapine, olanzapine, or paroxetine. Some patients gain modestly over long-term use.

Half-life of approximately 27-32 hours. Taper over 2-4 weeks when discontinuing. Less severe than paroxetine or venlafaxine, more noticeable than fluoxetine (which self-tapers due to long half-life).

Both can occur. If insomnia develops, low-dose trazodone (50mg at bedtime) is the standard adjunct.

Usually resolves within the first few weeks.

Patients under 25 have a small increased risk of suicidal ideation early in SSRI treatment. This is a class effect, not specific to escitalopram, and does not mean SSRIs should be avoided in this population (untreated depression also increases suicide risk). Close follow-up after starting and after dose changes is standard practice, particularly in the first 1-2 months.