What is the recommended dosage of escitalopram (Lexapro) for adults and adolescents with major depressive disorder or generalized anxiety disorder?

Escitalopram Dosage Recommendations

For adults with major depressive disorder or generalized anxiety disorder, start escitalopram at 10 mg once daily, which is the effective dose for most patients; increase to 20 mg daily only after a minimum of one week if needed, though 10 mg is often sufficient. 1

Adult Dosing for Major Depressive Disorder

• Start at 10 mg once daily (morning or evening, with or without food) 1
• Increase to 20 mg daily only after a minimum of one week if clinically indicated 1
• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg 1
• For moderate depression (MADRS 22-29), 10 mg daily is the optimal dose with clinically significant response within 2 weeks 2
• For severe depression (MADRS ≥30), 20 mg daily may be needed with response typically occurring after 4 weeks 2
• Maximum dose is 20 mg daily for adults 3, 1

Adult Dosing for Generalized Anxiety Disorder

• Start at 10 mg once daily 1
• Increase to 20 mg daily after a minimum of one week if needed 1
• Pooled trial data showed 10 mg daily was effective, with dose increases to 20 mg permitted after 4 weeks 4
• Mean effective dose in clinical trials was approximately 11.6 mg daily 5

Adolescent Dosing (Ages 12-17)

• Start at 10 mg once daily for major depressive disorder 6, 1
• Increase to 20 mg daily only after a minimum of three weeks (note the longer waiting period compared to adults) 6, 1
• Maximum dose is 20 mg daily 6, 3
• Effective dosages for adolescents are generally lower than adult guidelines 6
• Only escitalopram and fluoxetine are FDA-approved for adolescents with depression (escitalopram approved for ages 12 and older) 6

Special Populations

Elderly Patients (>60 years)

• Use 10 mg daily as the recommended dose for most elderly patients 1
• Start at approximately 50% of the adult starting dose due to greater risk of adverse drug reactions 7
• Maximum dose should be reduced due to QT prolongation concerns 7, 3
• Dose increases should be made cautiously 7

Hepatic Impairment

• 10 mg daily is the recommended dose 1

Renal Impairment

• No dosage adjustment necessary for mild or moderate renal impairment 1
• Use with caution in severe renal impairment 7, 1

Maintenance Treatment

• Continue treatment for 4-12 months after remission for first episode of major depressive disorder 7
• Longer maintenance treatment may be beneficial for recurrent depression 7
• Controlled trials demonstrated sustained response and reduced relapse rates with continued escitalopram 10-20 mg daily 1, 8
• Periodically reassess the need for continued treatment 1

Discontinuation Protocol

• Taper gradually over a minimum of 10-14 days to limit withdrawal symptoms 7
• Never stop abruptly due to risk of withdrawal effects including irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania 6, 7
• If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 7, 1

Critical Safety Considerations

QT Prolongation

• Maximum dose limited to 20 mg daily due to QT-interval prolongation concerns 7, 3
• Risk increases with doses above 20 mg 3
• Use caution in patients with pre-existing QT interval prolongation 7
• Further dose reduction recommended for patients older than 60 years 7, 3

Contraindications

• Contraindicated with MAOIs - allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 6, 1
• Do not start in patients receiving linezolid or intravenous methylene blue due to serotonin syndrome risk 1

Monitoring

• Screen for bipolar disorder, mania, or hypomania before initiating treatment 1
• Monitor for behavioral activation, switch to mania, or suicide-related events, especially in adolescents 6
• Deliberate self-harm and suicide risk is more likely if starting at higher doses rather than normal starting doses 6
• Contact patients after initiation to review adherence and current status 6

Common Pitfalls to Avoid

• Do not start adolescents at doses higher than 10 mg - this increases suicide risk 6
• Do not wait less than 3 weeks before increasing dose in adolescents (versus 1 week in adults) 6, 1
• Do not exceed 20 mg daily due to QT prolongation risk without additional efficacy benefit 3, 1
• Do not abruptly discontinue - always taper gradually 6, 7