What is the recommended dose of Lexapro (escitalopram) for an adult with Major Depressive Disorder (MDD)?

Recommended Dose of Lexapro (Escitalopram) for Adults with Major Depressive Disorder

The recommended starting dose of escitalopram for adults with MDD is 10 mg once daily, which can be increased to 20 mg daily after a minimum of one week if needed. 1

Initial Dosing

• Start with 10 mg once daily (morning or evening, with or without food) for all adult patients with MDD 1
• The FDA-approved label establishes 10 mg as the standard initial dose, with fixed-dose trials demonstrating effectiveness at both 10 mg and 20 mg 1
• Wait at least one week before increasing to 20 mg if the initial dose is insufficient 1

Dose Selection Based on Depression Severity

The optimal dose appears to vary by depression severity:

• For moderate depression (MADRS 22-29): 10 mg daily is the optimal dose, showing clinically significant response (effect size >0.40) within 2 weeks 2
• For severe depression (MADRS ≥30): 20 mg daily is more effective, achieving clinically significant response after 4 weeks 2
• The 20 mg dose failed to show greater benefit than 10 mg in the overall population but demonstrated superiority in severe depression specifically 1, 2

Dose Escalation Strategy

If inadequate response after 4 weeks at 10 mg:

• Patients showing <30% improvement in depressive symptoms at 4 weeks have a 70-85% probability of non-response/non-remission at 8 weeks 3
• This should prompt consideration of dose increase to 20 mg or switching treatment strategies 3
• The FDA label supports increasing to 20 mg after one week minimum, though clinical judgment may warrant waiting longer to assess response 1

Special Population Dosing

Elderly patients (≥60 years):

• Maximum dose is 10 mg daily due to QT prolongation risk 4, 1
• Start at approximately 50% of standard adult dose (5 mg) and increase cautiously 5, 4

Hepatic impairment:

• 10 mg daily is the recommended maximum dose 1

Renal impairment:

• No adjustment needed for mild-moderate impairment 1
• Use with caution in severe renal impairment 1

Maintenance Treatment Duration

• Continue treatment for 4-12 months after achieving remission for first episode of MDD 5, 1
• Longer maintenance treatment is beneficial for recurrent depression 5
• Systematic evaluation demonstrated benefit of maintenance treatment at 10-20 mg daily in responders 1

Discontinuation Protocol

Never stop abruptly—always taper gradually:

• Taper over a minimum of 10-14 days to limit withdrawal symptoms (irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania) 4, 1
• If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 4, 1

Critical Safety Considerations

• Screen for bipolar disorder before initiating treatment, as antidepressants can precipitate manic episodes 1
• QT prolongation risk: Limit maximum dose in elderly patients and those with cardiac risk factors; consider baseline ECG 4
• Avoid MAOIs: Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1

Common Pitfalls to Avoid

• Don't exceed 10 mg in elderly patients (>60 years)—this violates FDA safety guidelines for QT prolongation 4, 1
• Don't increase dose before one week in adults or three weeks in adolescents 1
• Don't stop abruptly—withdrawal symptoms are common and can be severe 4, 1
• Don't assume 20 mg is always better—moderate depression responds optimally to 10 mg 2