Lexapro (Escitalopram) Treatment Guidelines
Recommended Dosing for Major Depressive Disorder
Start escitalopram at 10 mg once daily (morning or evening, with or without food) for both adolescents and adults with major depressive disorder. 1
Dose escalation to 20 mg should occur after a minimum of 1 week in adults and 3 weeks in adolescents, though clinical trials show 10 mg is sufficient for most patients and 20 mg failed to demonstrate greater benefit over 10 mg in fixed-dose studies. 1
For elderly patients and those with hepatic impairment, maintain the dose at 10 mg daily as this is the recommended maximum for these populations. 1
No dosage adjustment is necessary for mild-to-moderate renal impairment, but use caution in severe renal impairment. 1
Recommended Dosing for Generalized Anxiety Disorder
Initiate escitalopram at 10 mg once daily for GAD, with dose increases to 20 mg permitted after a minimum of 1 week if needed. 1
Pooled analysis of three randomized controlled trials demonstrates that escitalopram 10 mg/day is effective for GAD, with significant improvement beginning at week 1-2 and continuing through week 8, and patients maintained at 10 mg/day showed significant benefit without requiring dose escalation. 2
Escitalopram 20 mg daily significantly reduces relapse risk in GAD (19% relapse rate vs 56% with placebo), with the risk of relapse being 4.04 times higher for placebo-treated patients. 3
Treatment Duration and Maintenance
Continue escitalopram for 4-9 months after satisfactory response in first-episode major depressive disorder; for patients with 2 or more episodes, longer duration therapy is beneficial. 4
Systematic evaluation demonstrates clear benefit of maintenance treatment at 10-20 mg/day in adults who responded during acute treatment. 1
For GAD, long-term treatment with escitalopram 20 mg/day for 24-76 weeks is effective in preventing relapse and well-tolerated. 3
Monitoring and Treatment Modification
Assess patient status, therapeutic response, and adverse effects within 1-2 weeks of initiation, then regularly throughout treatment. 4
Modify treatment if inadequate response occurs within 6-8 weeks of initiation for major depressive disorder. 4
Screen all patients for personal or family history of bipolar disorder, mania, or hypomania prior to initiating escitalopram. 1
Discontinuation Protocol
Taper escitalopram gradually rather than stopping abruptly to minimize discontinuation syndrome (dizziness, nausea, sensory disturbances, nervousness, insomnia). 5, 1, 3
During tapered withdrawal, discontinuation symptoms occur in 10-12% (dizziness), 2-6% (nervousness), and 2-6% (insomnia) of patients. 3
If intolerable symptoms occur during dose reduction, resume the previous dose and decrease more gradually. 1
Comparative Effectiveness and Selection Rationale
Select escitalopram based on its superior tolerability profile, minimal drug interactions, and cost-effectiveness compared to other second-generation antidepressants. 4
Escitalopram is the most selective SSRI with almost no significant affinity to other receptors and has the least effect on CYP450 isoenzymes, making it safer for combination therapy. 5, 6
Escitalopram demonstrates at least equivalent efficacy to other SSRIs (fluoxetine, paroxetine, sertraline), SNRIs (venlafaxine, duloxetine), and bupropion, with generally better tolerability and relatively fast onset of action. 6, 7
All second-generation antidepressants show similar efficacy for treating depression; selection should be based on adverse effect profiles, cost, and patient preferences. 4
Critical Safety Considerations
Avoid combining escitalopram with MAOIs or multiple serotonergic agents due to serotonin syndrome risk. 5
Sexual dysfunction with escitalopram occurs at similar or lower rates compared to paroxetine, similar or greater rates compared to duloxetine, and greater rates than bupropion. 7
Common adverse events are generally mild to moderate and transient. 7
Augmentation Strategies for Treatment-Resistant Cases
If inadequate response to escitalopram monotherapy, consider adding cognitive behavioral therapy (CBT) rather than immediately switching medications, as combination CBT plus SSRI demonstrates superior outcomes to medication alone. 5, 8
Switching from one second-generation antidepressant to another shows no difference in response rates based on moderate-quality evidence. 4
Augmentation with bupropion decreases depression severity more than augmentation with buspirone in patients not responding to citalopram (escitalopram's racemic parent compound). 4