Is it recommended to discontinue escitalopram (Selective Serotonin Reuptake Inhibitor) and continue Cognitive Behavioral Therapy (CBT)?

Discontinuing Escitalopram and Continuing CBT

Do not abruptly discontinue escitalopram without a gradual taper and careful monitoring for withdrawal symptoms and relapse risk. The decision to discontinue depends critically on your clinical context: diagnosis (depression vs. anxiety), number of prior episodes, treatment duration, current symptom status, and whether adequate CBT has been established.

Key Clinical Considerations Before Discontinuation

For Anxiety Disorders (Social, Generalized, Separation, Panic)

• Combination therapy (CBT + SSRI) is preferentially recommended over monotherapy in children and adolescents aged 6-18 years with anxiety disorders 1
• If you are treating anxiety, maintaining combination therapy typically yields superior outcomes compared to either treatment alone 1

For Major Depressive Disorder (MDD)

• CBT alone and escitalopram alone show comparable efficacy for initial treatment of moderate to severe MDD in adults 1
• Switching from escitalopram to CBT shows similar efficacy to switching to another antidepressant, with no significant difference in response or remission rates 1
• Augmenting escitalopram with CBT shows no difference in discontinuation rates compared to escitalopram monotherapy 1

Critical Risk Factors for Relapse

• Recurrent depression (≥2 prior episodes) carries substantially higher relapse risk when discontinuing antidepressants 2
• Very low-certainty evidence suggests abrupt discontinuation increases relapse risk (HR 2.09,95% CI 1.59-2.74) 2
• Even tapered discontinuation may increase relapse risk (HR 2.97,95% CI 2.24-3.93) compared to continuation 2

Discontinuation Protocol If Proceeding

Tapering Requirements

• Never discontinue abruptly - escitalopram requires gradual dose reduction to minimize withdrawal syndrome 1, 3
• Most studies used tapers of 4 weeks or less, but very slow tapering is recommended for all patients, particularly those on higher doses 4
• The FDA label explicitly states: "A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" 3

Withdrawal Syndrome Monitoring

Escitalopram discontinuation syndrome occurs in approximately 56% of patients (14 of 25 in one study) 4 and includes:

• Dizziness (44%), muscle tension (44%), chills (44%) 4
• Confusion/concentration problems (40%), amnesia (28%), emotional lability (28%) 4
• Sensory disturbances (paresthesias, "electric shock" sensations), anxiety, irritability, agitation 1, 3
• Higher doses and plasma concentrations significantly increase withdrawal risk 4

Distinguishing Withdrawal from Relapse

• This is the most critical clinical challenge - withdrawal symptoms (low mood, anxiety, dizziness) can mimic depression/anxiety relapse 2
• Withdrawal symptoms typically emerge within days of dose reduction and are self-limiting 3
• True relapse typically develops more gradually over weeks 2
• If intolerable symptoms occur, resume the previous dose and taper more gradually 3

Recommended Approach

If First Episode Depression with Good Response

• Consider discontinuation with slow taper (longer than 4 weeks) while maintaining CBT 2
• Close monitoring every 1-2 weeks during taper for withdrawal symptoms and mood changes 1, 3

If Recurrent Depression (≥2 Episodes)

• Strongly consider continuing escitalopram given high relapse risk in this population 2
• If discontinuation is essential, combine slow taper with established CBT or preventive cognitive therapy 2
• Evidence suggests 40-75% successful discontinuation rates when combining taper with psychological support 2

Monitoring Schedule

• Contact within first week after any dose reduction (in-person or telephone) 1
• Monitor for: clinical worsening, suicidal thoughts, unusual behavior changes, withdrawal symptoms 1, 3
• Continue monitoring for several months post-discontinuation, as relapse risk extends beyond the taper period 3, 2

Common Pitfalls to Avoid

• Tapering too rapidly (most studies used ≤4 weeks, which may be insufficient) 2, 4
• Misinterpreting withdrawal symptoms as treatment failure and unnecessarily restarting or switching medications 2
• Discontinuing in patients with recurrent depression without adequate psychological support 2
• Failing to distinguish between discontinuation in anxiety disorders (where combination is preferred) versus single-episode depression 1, 2

The evidence base for discontinuation strategies remains limited by confounding between withdrawal and relapse symptoms 2. When in doubt, err on the side of slower tapering and closer monitoring.