How to Start Lexapro (Escitalopram)
Start Lexapro at 10 mg once daily, taken at the same time each day (morning or evening), with or without food. 1
Critical Pre-Treatment Screening
Before prescribing Lexapro, you must screen for bipolar disorder by obtaining a personal and family history of bipolar disorder, mania, or hypomania 1. This is essential because escitalopram can trigger treatment-emergent mania/hypomania, particularly at higher doses, even in patients without prior bipolar history 2.
Starting Dosage by Indication
For Major Depressive Disorder (Adults)
- Initial dose: 10 mg once daily 1
- This 10 mg dose is effective for moderate depression and demonstrates superiority to placebo as early as week 1-2 3, 4, 5
- May increase to 20 mg daily after at least 1 week if needed 1
- The 20 mg dose is more appropriate for severe depression (MADRS ≥30) 5
For Generalized Anxiety Disorder (Adults)
- Initial dose: 10 mg once daily 1
- Fixed at 10 mg for the first 4 weeks
- May increase to 20 mg after 4 weeks based on response 6
Special Populations Requiring Lower Dosing
- Elderly patients: Maximum 10 mg once daily 1
- Hepatic impairment: Maximum 10 mg once daily 1
- Preferred SSRI for older adults due to favorable tolerability profile 7
Dose Escalation Strategy
If patients don't achieve remission at 10 mg:
- Wait at least 1 week before increasing to 20 mg in adults with depression 1
- For non-responders at standard doses (10-20 mg), escalation to 30 mg may provide additional benefit, though this is off-label 8
- Caution: Dose escalation increases risk of treatment-emergent mania/hypomania—manic symptoms typically emerge within 1 month of increasing to 20 mg 2
Common Side Effects
Most frequent adverse effects (occurring more than placebo) 1, 9, 3:
- Nausea (most common, but typically transient and occurs in <10% of patients at 10 mg)
- Insomnia
- Ejaculation disorder/sexual dysfunction
- Diarrhea
- Dry mouth
- Somnolence
- Dizziness
- Fatigue
- Headache
- Sweating
Key tolerability points:
- Discontinuation rates due to adverse events at 10 mg are similar to placebo (3-4%) 4
- About 63% of patients on SSRIs experience at least one adverse effect during treatment 7
- Nausea and vomiting are the most common reasons for discontinuation across all SSRIs 7
Serious Adverse Effects to Monitor
Black Box Warning
Increased risk of suicidal thoughts and behaviors in pediatric and young adult patients 1. Closely monitor all patients, especially during:
- Initial treatment period
- Dose changes
- First few months of therapy
Other Serious Risks
- Serotonin syndrome (14-16% of SSRI overdoses): Watch for tremor, diarrhea, delirium, neuromuscular rigidity, hyperthermia 7
- QT prolongation: While less concerning than with citalopram, monitor in patients taking other QT-prolonging medications 10
- Discontinuation syndrome: Taper gradually rather than stopping abruptly 1
MAOI Interactions
Absolute contraindication: Allow at least 14 days between discontinuing an MAOI and starting Lexapro, and vice versa 1. Do not start Lexapro in patients receiving linezolid or IV methylene blue.
When to Expect Response
- Week 1: Improvement in Clinical Global Impression scores 3
- Week 2: Significant improvement in depression rating scales 3, 4
- Week 4: Full therapeutic effect typically evident 5
- For moderate depression at 10 mg: response by week 2
- For severe depression at 20 mg: response by week 4 5
Duration of Treatment
- First episode of major depression: Minimum 4 months after symptom resolution 7
- Recurrent depression: Consider prolonged/indefinite treatment 7
Discontinuation Protocol
When stopping Lexapro, taper gradually rather than stopping abruptly 1. If intolerable withdrawal symptoms occur, resume the previous dose and taper more slowly. Monitor for discontinuation symptoms including dizziness, sensory disturbances, anxiety, and mood changes.