What is the recommended dosage of escitalopram (Lexapro) for adults with major depressive disorder or generalized anxiety disorder?

Escitalopram Dosing for Major Depressive Disorder and Generalized Anxiety Disorder

Start escitalopram at 10 mg once daily for both major depressive disorder (MDD) and generalized anxiety disorder (GAD) in adults, which is the recommended and effective dose for most patients. 1

Initial Dosing

• Adults with MDD or GAD: Begin with 10 mg once daily, taken in the morning or evening, with or without food 1
• Adolescents with MDD: Use 10 mg once daily as the recommended dose 1
• Elderly patients: Limit to 10 mg/day as the maximum recommended dose 1
• Patients with hepatic impairment: Restrict to 10 mg/day 1

Dose Escalation Strategy

If considering dose increase to 20 mg daily, wait at least one week in adults with MDD or GAD before escalating. 1 For adolescents, wait a minimum of three weeks before increasing to 20 mg. 1

The evidence shows that 10 mg is often sufficient:

• Fixed-dose trials in MDD demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg 1
• In moderate depression specifically, 10 mg escitalopram achieved clinically significant response (effect size >0.40) while 20 mg did not show this advantage 2
• For GAD, patients maintained at 10 mg/day showed significantly greater improvement than placebo, with pooled analyses demonstrating efficacy at this dose 3

When to Use 20 mg Daily

Reserve the 20 mg dose for patients with severe depression (MADRS score ≥30) or inadequate response to 10 mg after appropriate trial duration. 2

• In severe MDD, 20 mg escitalopram showed superior efficacy with effect sizes above 0.40, while 10 mg did not reach this threshold in severely depressed patients 2
• The maximum recommended dose is 20 mg daily for adults 4
• Clinical response at 20 mg in severe depression typically occurs after 4 weeks of treatment 2

Onset of Action and Monitoring

Expect symptom improvement within 1-2 weeks of starting treatment, with escitalopram showing earlier separation from placebo than citalopram. 5

• Monitor patients closely during the first months of treatment and following any dosage adjustments 4
• Watch for behavioral activation or agitation, particularly in younger patients, which supports gradual up-titration when necessary 4
• Response rates in naturalistic settings reach approximately 68% on clinician assessment and 66% on patient self-report by 8 weeks 6

Maintenance Treatment

Continue escitalopram for several months or longer beyond acute response for MDD, as systematic evaluation demonstrates benefit of maintenance treatment. 1

• For MDD, maintenance therapy at 10 or 20 mg/day in responders significantly reduces relapse risk 1
• For GAD, while recognized as a chronic condition, efficacy beyond 8 weeks has not been systematically studied in the FDA label, though long-term trials up to 76 weeks show continued benefit with 4-fold reduction in relapse risk compared to placebo 7
• Periodically reassess the need for continued treatment 1

Discontinuation Protocol

When stopping escitalopram, taper the dose gradually rather than stopping abruptly to minimize discontinuation symptoms. 1

• If intolerable symptoms occur after dose reduction, resume the previous dose and decrease more slowly 1
• This gradual approach is critical as discontinuation symptoms are well-documented with SSRIs 4, 1

Special Populations and Precautions

• Severe renal impairment: Use with caution, though no adjustment needed for mild-moderate impairment 1
• Screen for bipolar disorder before initiating treatment to avoid precipitating mania 1
• MAOI interactions: Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1

Therapeutic Drug Monitoring

The therapeutic plasma concentration range for escitalopram is 15-80 ng/mL, though routine monitoring receives a level 4 recommendation ("probably useful") rather than being strongly recommended. 8 At 10 mg daily, expected plasma levels are approximately 27-28 ng/mL. 8

Tolerability Profile

Escitalopram demonstrates favorable tolerability compared to other antidepressants, making it a preferred first-line agent. 4 Common adverse events include nausea (typically mild and transient), ejaculatory problems, diarrhea, and insomnia, though most are no more frequent than placebo except for ejaculatory dysfunction and nausea. 5 Only 7-9% of patients discontinue due to adverse events in controlled trials. 7, 6