What is the recommended dosing for Lexapro (escitalopram) in adults with depression or generalized anxiety disorder?

Recommended Dosing for Lexapro (Escitalopram) in Adults with Depression or Generalized Anxiety Disorder

For adults with depression or generalized anxiety disorder, the recommended dosing of escitalopram is 10 mg once daily initially, which may be increased to 20 mg once daily after a minimum of one week if clinical response is inadequate. 1, 2

Initial Dosing

• Major Depressive Disorder (MDD):

  • Start with 10 mg once daily (morning or evening, with or without food) 2
  • May increase to 20 mg once daily after a minimum of one week if needed 2
  • Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg for most patients 2

• Generalized Anxiety Disorder (GAD):

  • Start with 10 mg once daily 2
  • May increase to 20 mg once daily after a minimum of one week if needed 2

Special Populations

• Elderly patients (≥65 years):

  • Recommended dose is 10 mg/day 2
  • No dose adjustment required, but lower doses may be better tolerated 1

• Hepatic impairment:

  • Recommended dose is 10 mg/day 2
  • No dose adjustment is required in mild to moderate hepatic impairment 1

• Renal impairment:

  • No dosage adjustment necessary for mild or moderate renal impairment
  • Use with caution in severe renal impairment 2

Monitoring and Assessment

• Assess for initial response within 1-2 weeks of starting treatment 1
• Evaluate for therapeutic response at 4-6 weeks 1
• Consider switching to another antidepressant or augmentation strategies if inadequate response after 6-8 weeks at maximum tolerated dose 1

Treatment Duration

• For first episode of depression:

  • Continue treatment for 4-12 months after achieving remission 1
  • Discontinuing treatment too early significantly increases relapse risk 1

• For recurrent depression:

  • Consider maintenance treatment for 1+ years 1
  • Risk of recurrence increases with each episode (50% after first, 70% after second, 90% after third) 1

• For GAD:

  • Efficacy beyond 8 weeks has been demonstrated in controlled studies 3, 4
  • Long-term studies show continued improvement in anxiety symptoms and quality of life with ongoing treatment 3
  • In relapse prevention studies, the risk of relapse was 4.04 times higher for placebo-treated patients than for escitalopram-treated patients 4

Discontinuation

• Gradual dose reduction rather than abrupt cessation is recommended 2
• Monitor for discontinuation symptoms (dizziness, nervousness, insomnia) 4
• If intolerable symptoms occur during discontinuation, resume previously prescribed dose and decrease more gradually 2

Efficacy Considerations

• Escitalopram has demonstrated efficacy in both depression and anxiety disorders 5, 6
• In GAD, escitalopram has shown continued efficacy in long-term treatment with 75.9% of patients responding after 24 weeks 3
• In relapse prevention studies for GAD, only 19% of escitalopram-treated patients relapsed compared to 56% on placebo 4

Common Pitfalls to Avoid

1. Inadequate trial duration: Ensure at least 4-6 weeks at therapeutic dose before concluding treatment is ineffective
2. Premature discontinuation: Continuing treatment for several months after symptom resolution reduces relapse risk
3. Abrupt discontinuation: Always taper gradually to minimize withdrawal symptoms
4. Failure to screen for bipolar disorder: Always screen for personal/family history of bipolar disorder before starting treatment 2
5. Inadequate dose adjustment in special populations: Use 10 mg/day in elderly patients and those with hepatic impairment 2