What are the equivalent dosages of sertraline (Zoloft) and escitalopram (Lexapro) for a typical adult patient with depression or anxiety?

Equivalent Dosages of Sertraline and Escitalopram

Based on guideline recommendations and comparative trials, escitalopram 10 mg daily is approximately equivalent to sertraline 50-100 mg daily, while escitalopram 20 mg daily (the maximum recommended dose) is approximately equivalent to sertraline 100-150 mg daily. 1, 2, 3

Standard Therapeutic Dose Ranges

• Escitalopram (Lexapro): 10-20 mg per day 1
• Sertraline (Zoloft): 50-200 mg per day 1

The starting dose of escitalopram is typically 10 mg daily, which represents a fully therapeutic dose for most patients, whereas sertraline is initiated at 50 mg daily and commonly requires titration to 100-200 mg for optimal effect. 1, 4

Evidence-Based Dose Equivalency

A head-to-head randomized controlled trial directly comparing these medications found that fixed-dose escitalopram 10 mg daily demonstrated equivalent efficacy to flexibly-dosed sertraline (mean dose 144 mg/day, median 150 mg/day) in treating major depressive disorder. 2 Both achieved similar response rates (75% vs 70%) and mean MADRS score reductions (-19.1 vs -18.4 points). 2

Another comparative trial in Indian patients showed:

• Escitalopram 10 mg daily achieved 58% response at 2 weeks and 90% at 4 weeks 3
• Sertraline 50-100 mg daily achieved 52% response at 2 weeks, with most patients requiring dose escalation to 100-150 mg to achieve 97% response at 4 weeks 3

This suggests that escitalopram 10 mg provides therapeutic effects comparable to sertraline at higher doses (100-150 mg), likely due to escitalopram's greater selectivity and potency at the serotonin transporter. 5

Practical Dosing Algorithm

For initial treatment:

• Start escitalopram at 10 mg daily (fully therapeutic dose) 1, 6
• Start sertraline at 50 mg daily, with expectation of titration 1, 4

For dose optimization:

• Escitalopram can be increased to maximum 20 mg daily after 1+ weeks if needed 6
• Sertraline should be titrated in 50 mg increments at weekly intervals to 100-200 mg based on response 1, 4

Approximate equivalencies:

• Escitalopram 10 mg ≈ Sertraline 100-150 mg 2, 3
• Escitalopram 20 mg ≈ Sertraline 150-200 mg 1, 3

Important Clinical Considerations

Tolerability differences: Escitalopram generally demonstrates superior tolerability with fewer adverse events (45% vs 56-58%) and lower discontinuation rates (2% vs 4%) compared to sertraline. 2, 3 Escitalopram requires less frequent dose escalation, making it easier to achieve therapeutic effect at the starting dose. 3

Drug interactions: Sertraline has significantly less effect on cytochrome P450 metabolism compared to other SSRIs, making it safer when multiple medications are involved. 1, 7 However, escitalopram has the most favorable drug interaction profile overall due to minimal CYP450 inhibition. 6

QTc prolongation risk: The maximum recommended dose of escitalopram is 20 mg daily due to dose-dependent QTc prolongation at higher doses, whereas sertraline can be safely titrated to 200 mg daily without this cardiac concern. 1, 6

Time to response: Both medications require 4-8 weeks at therapeutic doses to assess full efficacy, though escitalopram may have a relatively faster onset of action. 1, 5