Escitalopram (Lexapro) Dosing for Depression and Generalized Anxiety Disorder
For adults with depression or generalized anxiety disorder, the recommended starting dose of escitalopram is 10 mg once daily, with a maximum recommended dose of 20 mg once daily. 1
Initial Dosing
Major Depressive Disorder
- Starting dose: 10 mg once daily
- Can be taken morning or evening, with or without food 1
- If dose increase is needed, increase to 20 mg after a minimum of one week 1
- A fixed-dose trial demonstrated effectiveness of both 10 mg and 20 mg doses, but failed to show greater benefit of 20 mg over 10 mg 1
Generalized Anxiety Disorder
- Starting dose: 10 mg once daily
- If dose increase is needed, increase to 20 mg after a minimum of one week 1
- Clinical trials have shown escitalopram to be effective for GAD at doses of 10-20 mg/day 2
- Significant improvement in anxiety symptoms can be seen as early as 1-2 weeks after starting treatment 2
Special Populations
Elderly Patients
- Recommended dose: 10 mg/day 1
- Elderly patients may be more sensitive to adverse effects and generally should not exceed 10 mg daily 3
- Escitalopram is considered a preferred agent for older adults due to its favorable adverse effect profile 3
Hepatic Impairment
- Recommended dose: 10 mg/day 1
- No further dose increases recommended in patients with hepatic impairment
Renal Impairment
- No dosage adjustment necessary for mild to moderate renal impairment
- Use with caution in severe renal impairment 1
Duration of Treatment
Acute Phase
- Treatment should continue for at least 4-8 weeks to determine full effectiveness 3
- Response should be evaluated regularly during this period
Maintenance Phase
- For depression, maintenance treatment should continue for 4-12 months after a first episode 3
- For recurrent depression, longer treatment may be beneficial 3
- For GAD, the efficacy beyond 8 weeks has been demonstrated in 24-week extension studies 4
- Periodic reassessment is recommended to determine the need for continued treatment 1
Monitoring and Adverse Effects
- Most common adverse effects: nausea (mild and transient), diarrhea, dizziness, dry mouth, fatigue, insomnia, and sexual dysfunction 5
- Monitor for signs of serotonin syndrome, QT prolongation, and increased suicidal thoughts, especially when initiating therapy
- Weight gain is possible but generally modest (mean increase of 3.0 lb in long-term studies) 4
Discontinuation
- Gradual dose reduction rather than abrupt cessation is recommended 1
- Monitor for discontinuation symptoms such as dizziness, sensory disturbances, anxiety, and sleep disturbances
- If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and decreasing more gradually 1
Clinical Pearls
- Screen for bipolar disorder prior to initiating treatment 1
- Allow at least 14 days between discontinuing MAOIs and starting escitalopram, and vice versa 1
- Escitalopram has demonstrated efficacy in both depression and anxiety disorders, making it particularly useful for patients with comorbid conditions 6
- Long-term studies show continued improvement in anxiety symptoms and quality of life with ongoing treatment 4