What is the recommended dosage and treatment regimen for Lexapro (escitalopram) in patients with major depressive disorder or generalized anxiety disorder?

Escitalopram (Lexapro) Dosing and Treatment Regimen

For both major depressive disorder and generalized anxiety disorder, start escitalopram at 10 mg once daily, which is effective for most patients, with the option to increase to a maximum of 20 mg daily after at least one week if needed. 1

Initial Dosing

Adults

• Start at 10 mg once daily (morning or evening, with or without food) 1
• The 10 mg dose is effective as monotherapy and demonstrated clear efficacy in controlled trials 2, 3
• If increasing to 20 mg, wait a minimum of one week for major depressive disorder or generalized anxiety disorder 1
• Fixed-dose trials show 10 mg is as effective as 20 mg for many patients, with 20 mg failing to demonstrate consistent additional benefit over 10 mg 2

Adolescents (Major Depressive Disorder Only)

• Start at 10 mg once daily 1
• If increasing to 20 mg, wait a minimum of three weeks 1

Special Populations

• Elderly patients: 10 mg/day maximum is recommended 1
• Hepatic impairment: 10 mg/day maximum 1
• Renal impairment (mild to moderate): No dose adjustment needed 4, 1
• Severe renal impairment: Use with caution 1

Timeline for Response Assessment

• Begin monitoring within 1-2 weeks of treatment initiation for adverse effects and suicidality risk 5
• Escitalopram shows separation from placebo as early as week 1-2 for both depression and anxiety 6, 3
• Allow 6-8 weeks at therapeutic dose before declaring treatment failure 5, 4
• Full therapeutic response may require 4-8 weeks at the target dose 7

Maintenance Treatment Duration

First Episode

• Continue for 4-9 months after achieving satisfactory response 5, 1
• Some guidelines recommend 4-12 months after remission 4

Recurrent Episodes (≥2 episodes)

• Consider years to lifelong maintenance therapy 5, 7
• Long-term treatment significantly reduces relapse risk in recurrent cases 4

Treatment Modifications for Inadequate Response

If no adequate response after 6-8 weeks at therapeutic dose 5:

1. First step: Optimize to 20 mg daily if currently on 10 mg (do not exceed 20 mg due to QT prolongation risk) 4, 7
2. Second step: Switch to SNRI (venlafaxine or duloxetine), which demonstrates statistically significantly better response rates than SSRIs in treatment-resistant cases 7
3. Third step: Consider augmentation with bupropion or cognitive-behavioral therapy, which shows superior efficacy to medication alone 7

Discontinuation Protocol

• Never stop abruptly - always taper gradually 4, 8, 1
• Gradual dose reduction minimizes discontinuation syndrome (dizziness, fatigue, headaches, nausea, insomnia, anxiety) 8
• If intolerable symptoms occur during taper, resume previous dose and decrease more slowly 1
• Escitalopram has lower discontinuation syndrome risk compared to paroxetine or sertraline, but monitoring remains essential 7

Monitoring Requirements

• Assess every 2-4 weeks after initiation or dose changes using standardized scales 4, 7
• Monitor specifically for suicidality during first 1-2 months, when risk is highest 5, 7
• Watch for behavioral activation/agitation, particularly in younger patients 4, 7
• Screen for personal or family history of bipolar disorder before initiating treatment 1

Key Safety Considerations

• Maximum dose is 20 mg daily - higher doses increase QT prolongation risk without additional benefit 4, 7
• Avoid MAOIs: Allow 14 days between discontinuing MAOI and starting escitalopram, and vice versa 1
• Avoid combining with other serotonergic agents due to serotonin syndrome risk 7
• Escitalopram has the least effect on CYP450 enzymes, making it safer for combination therapy and patients on multiple medications 7, 9

Therapeutic Drug Monitoring

• Therapeutic plasma concentration range: 15-80 ng/mL 4
• Expected plasma level at 10 mg daily: approximately 27-28 ng/mL 4
• Routine monitoring receives a level 4 recommendation (optional) 4

Common Pitfalls to Avoid

• Do not switch medications prematurely - allow full 6-8 weeks at therapeutic dose before declaring failure 7
• Do not exceed 20 mg daily - no additional efficacy and increased cardiac risk 4, 7
• Do not combine with buspirone or other augmentation before ensuring adequate SSRI trial duration and dose 7
• Do not use trazodone 25 mg for depression - this dose is only appropriate for sleep; antidepressant doses are 50-400 mg daily 7