How is the dose of Lexapro (escitalopram) increased?

How to Increase Lexapro (Escitalopram) Dose

For adults with major depressive disorder or generalized anxiety disorder, increase escitalopram from 10 mg to 20 mg once daily after a minimum of one week at the initial dose; for adolescents with depression, wait a minimum of three weeks before increasing to 20 mg. 1

Standard Dosing Algorithm

Adults

• Start at 10 mg once daily (morning or evening, with or without food) 1
• Wait minimum 1 week before considering dose increase 1
• Increase to 20 mg once daily if additional therapeutic benefit is needed 1
• The 20 mg dose is the maximum FDA-approved dose for most patients 1

Adolescents (Depression)

• Start at 10 mg once daily 1
• Wait minimum 3 weeks before dose escalation 1
• Increase to 20 mg once daily only after this waiting period 1

Special Populations Requiring Lower Dosing

• Elderly patients: 10 mg/day is recommended as the maximum dose 1
• Hepatic impairment: 10 mg/day is recommended as the maximum dose 1
• Severe renal impairment: Use 10 mg/day with caution 1

Rationale for Gradual Titration

The waiting period before dose escalation minimizes early adverse effects such as behavioral activation, agitation, and anxiety, which are most common in the first few weeks of treatment, particularly in younger patients. 2

• Escitalopram reaches steady-state concentrations within 7-10 days of administration 3
• The elimination half-life is 27-33 hours, supporting once-daily dosing 3
• Plasma levels increase proportionately and predictably with dose increases due to linear pharmacokinetics 4, 3

Monitoring During Dose Escalation

Evaluate response every 2-4 weeks after dose increase, with particular attention to:

• Suicidality risk (especially in first months and after dosage adjustments) 2
• Emergence of behavioral activation or agitation 2
• Common adverse effects: nausea (most common, typically mild and transient), insomnia, ejaculatory problems, diarrhea, dry mouth 4, 5

When Standard Dosing Fails

If inadequate response after 8-12 weeks at 20 mg daily, consider these evidence-based alternatives rather than exceeding FDA-approved dosing:

First-Line Alternatives

• Add cognitive-behavioral therapy (CBT) to medication, which demonstrates superior efficacy compared to monotherapy 2
• Switch to an SNRI (venlafaxine or duloxetine), which shows greater efficacy in treatment-resistant cases 2, 6
• Switch to another SSRI (sertraline or paroxetine) 2

Higher Dose Considerations (Off-Label)

While doses up to 50 mg have been studied in treatment-resistant depression, this is off-label use with limited evidence:

• A pilot study found 35% remission rate with doses up to 50 mg in citalopram non-responders 7
• Tolerability declined above 40 mg, with 26% unable to tolerate 50 mg 7
• Median effective dose in responders was 30 mg 7

This approach should only be considered after exhausting standard alternatives including combination with psychotherapy and switching medication classes. 2

Key Clinical Pitfalls

• Do not increase dose before the minimum waiting period (1 week for adults, 3 weeks for adolescents), as steady-state has not been achieved 1, 3
• Do not abruptly discontinue if switching medications; use gradual dose reduction to minimize withdrawal symptoms 1
• Screen for bipolar disorder before initiating or increasing antidepressant therapy 1
• Monitor blood pressure if considering switch to SNRIs, as these can increase blood pressure and pulse 6