What is the recommended treatment and dosage for Lexapro (escitalopram) in patients with major depressive disorder or generalized anxiety disorder?

Escitalopram (Lexapro) Treatment for Major Depressive Disorder and Generalized Anxiety Disorder

For patients with major depressive disorder (MDD) or generalized anxiety disorder (GAD), escitalopram (Lexapro) should be initiated at 10 mg once daily, with the option to increase to 20 mg daily after 1-4 weeks if needed based on response. 1

Dosing Recommendations

Major Depressive Disorder

• Adults:

  • Starting dose: 10 mg once daily
  • May increase to 20 mg after minimum of one week if needed
  • Take in morning or evening, with or without food
  • Duration: Continue for 4-9 months after satisfactory response for first episode; longer treatment for recurrent episodes 2, 1

• Adolescents:

  • Starting dose: 10 mg once daily
  • May increase to 20 mg after minimum of three weeks if needed 1

Generalized Anxiety Disorder

• Adults:
  • Starting dose: 10 mg once daily
  • May increase to 20 mg after minimum of one week if needed
  • Efficacy demonstrated in multiple placebo-controlled trials 3, 4

Special Populations

• Elderly patients: Recommended dose is 10 mg/day 1
• Hepatic impairment: Recommended dose is 10 mg/day 1
• Renal impairment:
  • Mild to moderate: No dosage adjustment needed
  • Severe: Use with caution 1

Efficacy

Escitalopram has demonstrated efficacy in:

• MDD: Comparable or superior efficacy to other SSRIs and SNRIs 5, 6
• GAD: Significant improvement in anxiety symptoms beginning as early as week 1-2 3, 4

The 10 mg dose is often sufficient for therapeutic effect, with studies showing:

• Significant improvement over placebo at 10 mg/day for both MDD and GAD 1, 3
• Rapid onset of action compared to other antidepressants 6

Monitoring and Follow-up

• Assess therapeutic response and adverse effects within 1-2 weeks of starting therapy 2
• If inadequate response after 6-8 weeks, consider modifying treatment 2
• For MDD, continue treatment for 4-9 months after satisfactory response for first episode 2
• For recurrent depression (≥2 episodes), longer maintenance treatment is beneficial 2

Discontinuation

• Gradual dose reduction rather than abrupt cessation is recommended
• Monitor for discontinuation symptoms (dizziness, sensory disturbances, anxiety, etc.)
• If intolerable symptoms occur during discontinuation, resume previous dose and taper more gradually 1

Common Side Effects

• Nausea (most common)
• Insomnia or somnolence
• Dizziness
• Sexual dysfunction
• Headache

Important Precautions

• Screen for bipolar disorder before initiating treatment 1
• Allow at least 14 days between MAOI discontinuation and escitalopram initiation (and vice versa) 1
• Monitor for worsening of depression or emergence of suicidal thoughts, especially early in treatment

Clinical Pearls

• Escitalopram is the S-enantiomer of citalopram with higher selectivity for serotonin reuptake inhibition
• Taking with food may reduce nausea, which is often transient
• Sexual dysfunction may occur but appears to be less frequent than with some other SSRIs 5
• Cost-effectiveness analyses have generally favored escitalopram over other antidepressants 5

Escitalopram represents an effective first-line option for both MDD and GAD with a favorable tolerability profile and relatively rapid onset of action compared to other antidepressants.