Lexapro. What diseases does it treat?

Use Lexapro (escitalopram) for adults with generalized anxiety disorder (GAD) and for major depressive disorder (MDD) in adults and adolescents aged 12–17 (FDA-approved). Begin treatment at 10 mg once daily for most adults; use 5 mg for older adults or those with significant hepatic impairment. If response is inadequate after 1–2 weeks, increase to 20 mg once daily while monitoring tolerability and adverse effects.

Approved indications: Major depressive disorder – adults and adolescents 12–17; generalized anxiety disorder – adults. Escitalopram is also prescribed off-label for panic disorder, social anxiety disorder and other anxiety-related conditions; check current guidelines and trial data when considering off-label use.

Expect anxiety symptom reduction within 1–2 weeks and a measurable antidepressant response by 4–6 weeks; use standardized rating scales at baseline and during follow-up (every 2–4 weeks during titration). Monitor patients younger than 25 for new or worsening suicidal thoughts throughout treatment. When discontinuing, taper gradually (for example over 2–4 weeks) to minimize withdrawal symptoms and adjust plans for pregnancy, breastfeeding or hepatic impairment in consultation with the prescriber.

Contraindications: concurrent monoamine oxidase inhibitors and known hypersensitivity to escitalopram. Key interactions include other serotonergic agents (risk of serotonin syndrome), anticoagulants/NSAIDs (increased bleeding risk) and strong CYP2C19/CYP3A4 inhibitors. Common adverse reactions include nausea, headache, insomnia or somnolence and sexual dysfunction; reassess dose or switch medication if side effects persist. Do not exceed 20 mg/day.

FDA-approved uses: adult major depressive disorder (MDD) and generalized anxiety disorder (GAD)

Begin treatment for adults with MDD or GAD at 10 mg escitalopram once daily; consider 5 mg daily for frail patients, those ≥65 years, hepatic impairment, or confirmed CYP2C19 poor metabolizers.

If symptoms persist after 4 weeks at 10 mg, increase to 20 mg once daily for inadequate response; reassess clinical benefit and tolerability at 4–6 weeks after dose change. Maintain therapy for a minimum of 6–12 months following a first depressive episode; extend maintenance for recurrent depression or chronic anxiety based on relapse history and functional recovery.

Monitor for worsening mood, emergent suicidal ideation (black box risk in patients under 24), agitation, or unusual behavioral changes; instruct patients and caregivers to report these promptly. Expect some anxiolytic improvement within 1–2 weeks and fuller antidepressant response by 4–6 weeks in many patients.

Watch for common adverse effects: sexual dysfunction, nausea, insomnia or somnolence, and potential weight change. Screen older adults for hyponatremia and falls. Use caution at 20 mg daily because escitalopram prolongs QT interval in a dose-related manner; obtain baseline ECG and avoid high-dose use with existing QT prolongation, electrolyte disturbances, or other QT-prolonging drugs.

Avoid concurrent MAOI therapy; allow at least a 14-day washout between escitalopram and MAOIs (longer washout is required after certain SSRIs). Antidepressant combinations that increase serotonergic tone (other SSRIs, SNRIs, triptans, tramadol, certain illicit drugs) raise serotonin syndrome risk. Co-prescribing NSAIDs, aspirin, or anticoagulants increases bleeding risk; monitor closely.

Adjust dosing for hepatic impairment (limit to 10 mg/day) and consider dose reduction when patients take strong CYP2C19 inhibitors (e.g., omeprazole) due to higher escitalopram exposure. For pregnancy or breastfeeding, discuss potential neonatal adaptation and developmental data with the treating clinician when weighing maternal benefit versus fetal/infant risk.

Taper escitalopram gradually rather than stopping abruptly to reduce discontinuation symptoms; if withdrawal effects occur, slow the taper over several weeks and reassess treatment options with the prescriber.

Adolescent approval and recommended dosing for pediatric MDD (ages 12–17)

Use escitalopram (Lexapro) for adolescents aged 12–17 with a diagnosis of major depressive disorder at a starting dose of 10 mg once daily; maximum recommended dose is 20 mg once daily.

• Initiation: Begin with 10 mg orally once daily. Take with or without food; if nausea occurs, taking with food can help.
• Titration: If partial clinical response after at least 3 weeks and the 10 mg dose is well tolerated, consider increasing to 20 mg once daily. Reassess benefit and tolerability before escalating.
• Maximum dose: Do not exceed 20 mg/day for adolescents.
• Dose reductions and hepatic impairment: For moderate to severe hepatic impairment, reduce dose and slow titration; consider a maximum of 10 mg/day depending on clinical judgment and specialist input.
• Formulations: Use available tablet strengths (e.g., 5 mg, 10 mg) to adjust dosing precisely for down-titration or temporary dose changes.

Monitor and safety measures:

• Assess suicidality frequently during initiation and dose changes (weekly during the first month, then regularly), and counsel families about warning signs of worsening mood, behavioral activation, or suicidal thoughts.
• Screen for bipolar disorder or family history of bipolar disorder before starting; monitor for emergence of hypomania or mania.
• Track common adverse reactions reported in pediatric studies, such as headache, nausea, somnolence, hyperhidrosis and abdominal pain; monitor weight and sleep patterns during follow-up visits.
• Watch for signs of serotonin syndrome when escitalopram is combined with other serotonergic agents; avoid concurrent MAOIs and wait the recommended washout period (typically 14 days) between MAOIs and escitalopram.
• Review concomitant medications for interactions–strong CYP2C19 inhibitors can raise escitalopram exposure; consider dose adjustment or closer monitoring if such drugs are necessary.

Discontinuation and follow-up:

1. Taper gradually to reduce discontinuation symptoms. Practical approaches: reduce 10 mg → 5 mg for several days to a week before stopping, or split 20 mg → 10 mg → 5 mg with 1–2 week intervals as clinically appropriate.
2. Expect initial symptom improvement within 1–4 weeks; evaluate full response by 6–8 weeks before making long-term management decisions.
3. Document response, adverse events, and growth/weight at regular intervals; adjust therapy based on benefit versus tolerability and specialist input when needed.

Typical starting doses, titration steps, and dose adjustments for adults

Initiate most adults at 10 mg once daily. Maintain 10 mg for 1–2 weeks to assess tolerability; increase to 20 mg once daily only if clinical response is inadequate and the 10 mg dose is well tolerated. Do not exceed 20 mg/day.

Standard titration schedule

Typical pathway: 10 mg once daily for 1–2 weeks → 20 mg once daily if needed. Evaluate symptomatic change and side effects at 2–4 weeks; continue assessment through 6–8 weeks to determine full response. If partial response occurs at 20 mg after an adequate trial (generally 4–6 weeks), consider switching therapy or adding a documented augmentation strategy.

For patients who experience early intolerable adverse effects on 10 mg, reduce to 5 mg daily and reassess after several days; if tolerated, attempt re-escalation to 10 mg. Tablets and oral solution allow 5 mg step adjustments.

Dose adjustments and special populations

Older adults and patients with hepatic impairment: start at 5 mg once daily, increase cautiously; usual target for these groups is 10 mg/day and the maximum generally recommended is 10 mg/day unless careful monitoring justifies higher dosing. For known CYP2C19 poor metabolizers or concomitant strong CYP2C19 inhibitors, limit dose to 10 mg/day.

Renal impairment: no routine dose reduction needed for mild-to-moderate renal dysfunction; monitor clinically in severe renal impairment and adjust by 5 mg steps if adverse effects emerge. When stopping treatment, taper by 5 mg decrements over 1–2 weeks or longer based on tolerability to reduce discontinuation symptoms.

Drug interactions and switching: allow a minimum 14-day washout after an MAOI before initiating escitalopram and wait at least 14 days after stopping escitalopram before starting an MAOI. Review concomitant QT-prolonging agents and serotonergic drugs; modify dose or monitoring strategy when combining therapies that increase QT risk or serotonin syndrome risk.

Contraindications, boxed warnings, and required monitoring during treatment

Do not prescribe escitalopram to patients receiving an MAOI (including linezolid or intravenous methylene blue) or to anyone with known hypersensitivity to escitalopram or citalopram; avoid coadministration with pimozide.

Boxed warning: escitalopram increases the risk of suicidal thinking and behavior in children, adolescents, and young adults aged 18–24 during initial treatment and after dose changes. Arrange clinical contact within 1 week of treatment start or any dose adjustment, and perform frequent reassessments during the first month. Ask caregivers to report new or worsening suicidal ideation, unusual behavioral changes, agitation, severe anxiety, panic attacks, insomnia, or signs of self-harm immediately.

Monitor for serotonin syndrome when escitalopram is combined with other serotonergic agents (e.g., other SSRIs/SNRIs, TCAs, triptans, tramadol, fentanyl, certain antiemetics, St. John's wort). Watch for rapid onset of agitation, hyperreflexia, clonus, hyperthermia, autonomic instability, or altered mental status; discontinue escitalopram and offending agents, provide supportive care, and consider cyproheptadine for severe cases. Hospitalize when symptoms are severe or progressive.

QTc prolongation and cardiac monitoring: escitalopram causes dose-dependent QTc prolongation. Obtain a baseline ECG for patients with congenital long QT, ischemic heart disease, symptomatic bradycardia, electrolyte abnormalities, or those taking other QT-prolonging drugs (e.g., certain antiarrhythmics, antipsychotics). Reassess ECG if the patient develops syncope, palpitations, or new arrhythmia; correct hypokalemia and hypomagnesemia prior to initiation when possible.

Bleeding risk: SSRIs impair platelet aggregation. Review concurrent use of NSAIDs, aspirin, antiplatelet agents, or anticoagulants; monitor for signs of gastrointestinal or other bleeding and check CBC if bleeding or unexplained anemia occurs. Consider dose adjustment or gastroprotection in patients with high bleeding risk.

Hyponatremia/SIADH: monitor serum sodium in elderly patients, those on diuretics, or anyone with symptoms such as confusion, weakness, orthostatic dizziness, or seizures. Check sodium within 1–2 weeks after initiation or dose change in at-risk patients and sooner if symptoms develop.

Screen for bipolar disorder before starting escitalopram. If symptoms of mania or hypomania appear (increased energy, decreased need for sleep, grandiosity, pressured speech, risky behavior), stop escitalopram and reassess the diagnosis and treatment plan.

Hepatic and renal impairment: expect increased exposure in hepatic impairment and reduced clearance in certain renal impairment; monitor for worsening adverse effects and conduct more frequent clinical follow-up and liver function testing when preexisting hepatic disease or signs of hepatic dysfunction are present.

Pregnancy and lactation: counsel women on the potential for neonatal adaptation syndrome and a small increased risk of persistent pulmonary hypertension of the newborn after late-pregnancy SSRI exposure. If exposure occurs near delivery, monitor the neonate for respiratory distress, temperature instability, feeding difficulty, hypoglycemia, tremor, or irritability.

Withdrawal and dose reductions: reduce escitalopram gradually rather than stopping abruptly to reduce risk of discontinuation symptoms such as dizziness, paresthesias, irritability, sleep disturbance, and mood changes. Increase follow-up frequency during tapering and for several weeks after discontinuation.

Practical monitoring checklist: baseline ECG and electrolytes in at-risk patients; serum sodium in elderly/diuretic users within 1–2 weeks; symptom assessment for suicidality within 1 week and regularly for the first month; periodic review for bleeding, serotonin syndrome, manic switch, and hepatic dysfunction throughout treatment.

Strategies for tapering and managing discontinuation symptoms

Initiate a personalized, gradual reduction of escitalopram rather than stopping abruptly; select pace based on current dose, treatment duration, prior discontinuation reactions and clinical stability.

Practical taper schedules

Clinical scenario	Typical taper steps	Monitoring interval
Short-term treatment (<3 months) or low dose (≤10 mg)	Reduce by 5 mg (or 50% if appropriate) for 7–14 days, then stop	Weekly check (phone or visit) during taper
Standard adult on ≥10 mg for months	Reduce by 5 mg every 1–2 weeks (example: 20 → 15 → 10 → 5 → 0). If reactions occur, pause or slow schedule	Visit or phone every 1–2 weeks during active taper
Long-term/high-dose use, prior severe discontinuation	Reduce by ~10% of current dose every 2–4 weeks using liquid formulation or compounded doses (e.g., 20 → 18 → 16 mg, etc.)	Clinical review every 2 weeks initially; extend to monthly if stable
Severe prior discontinuation or intolerance to small drops	Consider switching to fluoxetine under clinician supervision (longer half‑life) before tapering; clinician determines equivalent dosing and schedule	Close follow-up with clinician; individualized plan

Use the smallest available tablet or pharmacy-compounded liquid to achieve small dose decrements. If standard tablet sizes prevent fine reductions, ask the pharmacist about titration packs or liquid preparations. If discontinuation symptoms begin, pause further reductions and maintain the last tolerated dose until symptoms remit.

Managing common discontinuation symptoms

Track symptoms daily (type, severity, onset, triggers) and report changes promptly. Typical symptoms include dizziness, "electric" sensations, insomnia, nausea, headache, irritability and transient anxiety spikes. For mild–moderate symptoms, employ behavioral measures first: maintain sleep regularity, hydrate, avoid sudden changes in caffeine or alcohol, and reduce driving or heavy machinery use while symptomatic.

Use targeted short-term treatments under prescriber guidance: low-dose melatonin (OTC) or short-course sedating antihistamine for sleep, antiemetic or taking dose with food for nausea, and short-term prescription anxiolytics only when clinically justified. For persistent or severe symptoms, reinstate the prior dose and retaper more slowly. If suicidal thoughts or marked functional decline emerge at any point, seek urgent clinical evaluation or emergency care.

Document the taper plan in the medical record, schedule follow-ups, and coordinate with the pharmacy. Inform patients that a slower taper reduces the chance of discontinuation reactions and that adjustments will be individualized based on tolerance and life circumstances.

Common off-label uses, supporting evidence, and practical prescribing considerations

Use escitalopram off-label for panic disorder and social anxiety disorder when patient preference, tolerability profile, or contraindications to other options favor an SSRI; document the rationale and obtain informed consent prior to initiation.

Evidence summaries by condition

• Panic disorder – Several randomized controlled trials report superiority of escitalopram versus placebo with moderate effect sizes and reduced panic frequency. Expect early transient activation in some patients; plan early follow-up and symptomatic management (e.g., short benzodiazepine bridge if needed).

• Social anxiety disorder (SAD) – Multiple RCTs and pooled analyses show benefit for social anxiety symptoms. Combine with cognitive-behavioral therapy for partial responders. Anticipate a slower onset of meaningful social-function improvement than for somatic anxiety symptoms.

• Obsessive–compulsive disorder (OCD) – Data are limited and less consistent than for SSRIs with stronger OCD evidence. When used, permit longer trials and evaluate need for higher SSRI exposure or augmentation (e.g., antipsychotic) in collaboration with a specialist.

• Post-traumatic stress disorder (PTSD) – Controlled evidence for escitalopram is mixed; prioritize trauma-focused psychotherapy and use escitalopram only after discussing relative benefits and alternatives with the patient.

• Premenstrual dysphoric disorder (PMDD) and vasomotor symptoms – Robust data favor fluoxetine/sertraline for PMDD and several SSRIs for hot flashes; escitalopram has sparse evidence and should be reserved for select cases when other agents are unsuitable.

• Chronic neuropathic pain – Escitalopram shows minimal analgesic benefit; SNRIs or TCAs provide stronger evidence for neuropathic pain and are preferable for that indication.

Practical prescribing checklist for off-label use

• Document indication-specific rationale, expected benefits, alternate options reviewed, and a measurable treatment goal (e.g., % reduction on PDSS, LSAS, Y‑BOCS).
• Establish baseline measures: symptom severity score, suicidality screening, list of current medications, and risk factors for QT prolongation (cardiac history, electrolytes, concurrent QT-prolonging drugs).
• Assess drug–drug interactions: escitalopram clearance is influenced by CYP2C19; review inhibitors (e.g., omeprazole) and inducers, and adjust plan if polypharmacy raises exposure or bleeding risk with anticoagulants/NSAIDs.
• Plan monitoring visits at 2–4 weeks for tolerability and at 8–12 weeks for efficacy; document response on a validated scale before labeling treatment as failed.
• Manage early activation or increased anxiety with slower titration, brief benzodiazepine use, or dose hold if severe; counsel about sexual side effects and strategies (dose timing, dose adjustment, or switch) if they reduce adherence.
• Use ECG selectively when baseline risk of QT prolongation exists or when combining with other QT‑prolonging agents; check sodium in elderly or frail patients due to hyponatremia risk.
• For women who are pregnant or breastfeeding, discuss neonatal adaptation symptoms and available safety data; involve obstetrics/perinatal psychiatry for complex cases.
• Set a prespecified trial length and exit strategy: if no clinically meaningful improvement by the predefined timepoint, stop or switch and document the switch rationale and washout timing for MAOI interactions.
• When escalation or augmentation is contemplated, consult specialty services for OCD or treatment‑resistant anxiety-spectrum disorders rather than empirical polypharmacy.