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

Starting Dose of Escitalopram

The starting dose of escitalopram is 10 mg once daily for both major depressive disorder and generalized anxiety disorder in adults. 1

Standard Dosing Protocol

• Administer 10 mg once daily, in the morning or evening, with or without food 1
• This 10 mg starting dose applies to both major depressive disorder and generalized anxiety disorder 1
• The dose may be increased to 20 mg daily after a minimum of one week if clinically indicated 1

Dose Escalation Considerations

• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg in major depressive disorder 1
• For generalized anxiety disorder, pooled analysis showed that patients maintained at 10 mg/day had significantly greater improvement than placebo, suggesting the starting dose is often sufficient 2
• In clinical trials, the mean dose used was approximately 10-15 mg/day, with many patients achieving remission without dose escalation 3, 2

Special Population Adjustments

• For elderly patients (>65 years) and those with hepatic impairment, 10 mg/day is the maximum recommended dose, not just the starting dose 1
• No dosage adjustment is necessary for patients with mild to moderate renal impairment 1
• Use with caution in patients with severe renal impairment 1

Onset and Titration Strategy

• Symptom improvement may begin within 1-2 weeks of starting treatment 3
• Gradual up-titration is recommended to minimize early adverse effects like agitation or behavioral activation, particularly in younger patients 4
• Some clinicians may start with a subtherapeutic "test" dose in anxiety-prone patients, then titrate to 10 mg 5

Maximum Dosing Limits

• The maximum recommended daily dose is 20 mg for adults 4
• Higher doses are associated with QT prolongation and cardiac risks without additional therapeutic benefit 5

Common Pitfalls to Avoid

• Do not start below 10 mg in standard adult patients, as this delays therapeutic response without meaningful reduction in side effects 1
• Do not exceed 10 mg in elderly patients or those with hepatic impairment, as they have altered pharmacokinetics 1
• Allow adequate trial duration (6-8 weeks at therapeutic dose) before declaring treatment failure 5