Escitalopram is FDA approved for major depressive disorder in adolescents ages 12+ and generalized anxiety disorder (GAD) in children ages 7+. But how effective is it? Below, we will review the evidence and rationale for using escitalopram in children and adolescents across multiple conditions.

Depression

Efficacy

The effect size for escitalopram is generally small (0.27, p=0.022) and there may be some difference in how children versus adolescents respond, with adolescents showing more benefit (Emslie GJ et al, J Am Acad Child Adolesc Psychiatry 2009;48(7):721–729). Fluoxetine has firmer research and a bigger effect size than escitalopram, at -0.51 vs -0.17 (Zhou X et al, Lancet Psychiatry 2020;7(7):581–601). 

Tolerability

Tolerability between escitalopram and fluoxetine is similar. See “Common Uses for Escitalopram in Children and Teens” table for more information.

When to consider

Consider escitalopram after trials of fluoxetine or sertraline (which also has better data than escitalopram for this use). Escitalopram is an option for those on other medications to augment depression treatment or stabilize mood.

Anxiety 

For most types of anxiety, selective serotonin reuptake inhibitors (SSRIs) show a medium effect size compared to placebo. This is better than depression outcomes, possibly due to lower placebo response. Still, many children remain symptomatic with SSRI treatment alone (Strawn JR et al, Depress Anxiety 2015;32(3):149–157).

Evidence

• Approval for GAD in children is based on two RCTs, only one of which studied younger children ages 7–17 given flexibly dosed escitalopram (10–20 mg) for eight weeks (Strawn JR et al, J Child Adolesc Psychopharmacol 2023;33(3):91–100). For GAD, escitalopram treatment outcomes are comparable to other first-line medications. 
• SSRIs targeting GAD also help social and separation anxiety. One small study of escitalopram for social anxiety disorder (SAD) in children and adolescents ages 10–17 showed a large effect size (0.9–1.9), with 65% responding to treatment (Isolan L et al, J Child Adolesc Psychopharmacol 2007;17(6):751–760). Most subjects (60%) had co-occurring anxiety disorders. 

When to consider

• Escitalopram may work for GAD and SAD as soon as two weeks after initiation and with good ­tolerability. 
• More research is needed on obsessive-compulsive disorder (OCD), but the caution related to QT interval prolongation restricts its use at the higher dosages of SSRIs often employed in OCD (see “Tolerability and safety” section for more).

Off-label use

Escitalopram has been used off-label to treat borderline personality disorder (BPD) and OCD, but research is limited. 

Evidence

• For OCD, escitalopram may be as good or better than other SSRIs and clomipramine, and it has better tolerability than clomipramine (Tao Y et al, J Psychiatr Res 2022;148:95–102).
• Escitalopram may have utility for anxiety and depression co-occurring with other conditions. See “Additional Off-Label Escitalopram Uses” table or more. 

Tolerability and safety 

Escitalopram has minimal impact on CYP450 enzymes and may be a good choice for patients who are taking medications with potential for CYP450 interactions or who have genetic P450 polymorphisms. However, it has limitations related to cardiac risk, especially when used with medications that prolong the QT interval (eg, ondansetron, many antibiotics, other psychotropic medications; www.tinyurl.com/4rv74fdk).

Side effects and risks

Common (>10%) side effects include: 

• Abdominal pain 
• Headache
• Insomnia
• Nausea
• Irritability and activation (mania not reported in children and ­adolescents) 

Risks include: 

• Serotonin syndrome
• Discontinuation symptoms
• QT prolongation (doses >20 mg daily)
• Manic switch
• New-onset suicidal thinking (est. 1%)

Avoid escitalopram in patients with prolonged QT or with medications that prolong the QT interval. With all SSRIs, informed consent includes a discussion about monitoring for bipolar symptoms and suicidality (see CCPR Oct/Nov/Dec 2020). 

Psychoeducation

Talk to families about:

• Risk factors for seizures and QT prolongation 
• Your rationale for prescribing if using off-label
• Timeline (many patients who benefit do so in the first four weeks)
• Side effects (can be transient and may not require discontinuation)

Discuss mood/behavioral changes

Explain activation and disinhibition in simple terms. Alert families to the ­theoretical risk for hypomania/mania, especially if there is concern or risk for bipolar disorder. Ask families and patients to contact the prescriber in the event of worsening mood, suicidal thoughts or behaviors, behavioral concerns, sleep changes, or other persistent side effects that impact functioning. Review the black box warning and the need to monitor for suicidal thoughts or behaviors, which occur in about 1% of patients. Make sure parents know to watch for agitation, irritability, impulsivity, insomnia, and other changes in mood or behavior. Include kids and teens in these conversations in a developmentally appropriate way.

Dosing 

Minimize early discontinuation by following dosing guidelines and monitoring:

Younger children (ages 6–9)

• Start at 2.5 mg/day
• Increase weekly to a maximum of 20 mg/day

Older children (ages 10–17)

• Start at 5 mg/day
• Increase weekly to a maximum of 20 mg/day

Endpoints

Track symptoms and side effects throughout treatment. For the first two weeks, monitor for any reduction of symptoms. If there are no improvements in 4–6 weeks, try another SSRI. The goal is a 35%–50% reduction in symptoms in the first 1–2 months and a sustained period of few to no symptoms for 6–12 months. Make sure to check weight and growth as part of routine follow-up (Calarge C et al, J Clin Psychopharmacol 2024; Epub ahead of print). For severe, recurrent depression or anxiety, continue treatment during remission for at least a year. Monitor for several months after discontinuation and collaborate with families for gradual tapering over several months (Walter HJ et al, J Am Acad Child Adolesc Psychiatry 2023;62(5):479–502).

Carlat Verdict 

For children and teens with most kinds of anxiety disorders or OCD, start with therapy and consider escitalopram after other first-line SSRIs. For depression and other mental health conditions, escitalopram is a third-line medication due to issues with efficacy and cardiac risks.