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

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

For adults with major depressive disorder or generalized anxiety disorder, start escitalopram at 10 mg once daily, which is the recommended therapeutic dose; if needed, increase to a maximum of 20 mg daily after at least one week at 10 mg. 1

Standard Adult Dosing

• Initial dose: 10 mg once daily (morning or evening, with or without food) for both major depressive disorder and generalized anxiety disorder 1
• Maximum dose: 20 mg daily for most adults 2, 1
• Timing of dose increase: Wait a minimum of one week before increasing from 10 mg to 20 mg 1
• The 10 mg dose is fully therapeutic—fixed-dose trials showed that 10 mg was as effective as 20 mg for depression, though both doses separated from placebo 1, 3

Special Populations

Elderly patients (≥65 years):

• Maximum recommended dose: 10 mg daily 1
• Lower doses minimize adverse effects like agitation or dizziness, and escitalopram is preferred over paroxetine and fluoxetine due to fewer anticholinergic effects 2

Hepatic impairment:

• Maximum recommended dose: 10 mg daily 1

Renal impairment:

• No dose adjustment needed for mild to moderate renal impairment 2, 1
• Use with caution in severe renal impairment 1

Treatment Duration and Maintenance

Acute treatment phase:

• Allow 4-8 weeks for full therapeutic effect 4, 2
• Significant improvement may be observed within 1-2 weeks, but full response requires longer treatment 5, 3

Maintenance treatment:

• First episode: Continue for 4-12 months after achieving remission 2
• Recurrent depression or GAD: Long-term treatment significantly reduces relapse risk—the risk of relapse is approximately 4 times higher with placebo than with continued escitalopram 2, 6

Dose Optimization Strategy

When to consider increasing to 20 mg:

• If inadequate response after 4-8 weeks at 10 mg 2
• For adolescents with depression, wait a minimum of three weeks before increasing to 20 mg 1
• Monitor closely during the first 2-4 weeks after dose increase for behavioral activation or agitation, particularly in younger patients 2

Therapeutic plasma levels:

• Target range: 15-80 ng/mL 2
• At 10 mg daily, expected plasma levels are approximately 27-28 ng/mL 2

Discontinuation Protocol

Never stop abruptly—gradual dose reduction is essential to minimize discontinuation symptoms 2, 1

• Taper over 10-14 days at minimum 4
• If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 1

Common Pitfalls to Avoid

• Don't increase too quickly: Rushing to 20 mg before allowing adequate time at 10 mg may increase side effects without additional benefit, as 10 mg is fully therapeutic for many patients 3
• Don't underdose elderly patients indefinitely: While 10 mg is the recommended maximum for elderly patients, this is appropriate as it provides full therapeutic effect in this population 1
• Don't discontinue prematurely: Full response requires 8-12 weeks; early discontinuation due to perceived lack of efficacy at 2-3 weeks is a common error 2
• Don't combine with MAOIs: Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1

Tolerability Profile

• Escitalopram has a favorable adverse effect profile compared to other antidepressants, making it a preferred first-line agent 2
• Most common adverse events (11-17% incidence): headache, back pain, upper respiratory tract infection, rhinitis, and nausea 7
• Adverse events are typically mild to moderate, emerge within the first few weeks, and decline with continued treatment 7, 6
• Discontinuation rate due to adverse events at 10 mg is similar to placebo (4.2% vs 2.5%) 3