Lexapro (Escitalopram) Dosage and Treatment Protocol
Start escitalopram at 10 mg once daily for both major depressive disorder and generalized anxiety disorder in adults and adolescents aged 12 years and older, with dose increases to 20 mg only after a minimum waiting period (3 weeks for adolescents, 1 week for adults). 1
Initial Dosing
Adults
- Starting dose: 10 mg once daily (morning or evening, with or without food) 1
- May increase to 20 mg daily after a minimum of 1 week if clinically indicated 1
- Maximum dose: 20 mg daily 2, 1
Adolescents (12 years and older)
- Starting dose: 10 mg once daily 2, 1
- May increase to 20 mg daily only after a minimum of 3 weeks 1
- Escitalopram is FDA-approved for adolescents with major depressive disorder starting at age 12 2
- Lower doses are generally effective in adolescents compared to adult guidelines 2
Special Populations
- Elderly patients: 10 mg daily (do not routinely increase) 1
- Hepatic impairment: 10 mg daily 1
- Severe renal impairment: Use with caution 1
Treatment Duration and Monitoring
Acute Phase
- Both 10 mg and 20 mg doses demonstrate effectiveness, though 20 mg did not show greater benefit than 10 mg in fixed-dose trials 1, 3
- Escitalopram separates from placebo as early as week 1-2 of treatment 4, 5
- Full response typically requires 4-8 weeks at therapeutic dose 6
Maintenance Treatment
- Major depressive disorder requires several months or longer of sustained pharmacological therapy beyond acute response 1
- Periodically reassess patients to determine continued need for maintenance treatment 1
- Long-term studies show continued improvement, with remission rates increasing from 46% at 8 weeks to 86% at 52 weeks 7
Monitoring Requirements
Initial Follow-up
- Contact patient (in-person or telephone) after treatment initiation to review understanding, adherence, and current status 2
- Monitor closely during first months of treatment and after dosage adjustments, particularly for suicidality risk 2, 6
- Evaluate response every 2-4 weeks after dose adjustments 6
Adverse Event Monitoring
- Screen for behavioral activation/agitation, especially in younger patients (supports slow up-titration) 6
- Monitor for switch to mania or development of suicide-related events 2
- Deliberate self-harm and suicide risk increase if starting at higher doses rather than normal starting doses 2
- Most adverse events are mild to moderate and emerge within first few weeks 6
Discontinuation Protocol
Never abruptly discontinue escitalopram—always taper gradually to minimize discontinuation syndrome. 8, 1
Tapering Strategy
- Gradual dose reduction is recommended over abrupt cessation 1
- Reduce from 20 mg to 10 mg gradually to minimize discontinuation symptoms 8
- If intolerable symptoms occur during taper, resume previous dose and decrease more gradually 1
Discontinuation Symptoms
- Common symptoms include: dizziness, fatigue, lethargy, headaches, nausea, insomnia, and anxiety 8, 9
- Critical to distinguish discontinuation symptoms from relapse of underlying condition 8
- Shorter-acting SSRIs like escitalopram are particularly prone to discontinuation syndrome 8
Important Clinical Considerations
Contraindications
- Absolute contraindication: MAOIs (monoamine oxidase inhibitors) 2
- Avoid combining with multiple serotonergic agents due to serotonin syndrome risk 6
Drug Interactions
- Escitalopram has favorable drug interaction profile with least effect on CYP450 isoenzymes among SSRIs 6
- This makes it safer for combination therapy when needed 6
Pre-Treatment Screening
- Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment 1