What is the recommended protocol for tapering off Lexapro (escitalopram)?

Tapering Off Lexapro (Escitalopram)

Reduce Lexapro gradually over several weeks to months rather than stopping abruptly, using a hyperbolic tapering schedule that decreases the dose by 10% of the most recent dose (not the original dose) every 2-4 weeks, extending down to very small final doses before complete discontinuation. 1, 2

FDA-Approved Discontinuation Guidance

The FDA label for escitalopram explicitly states: "A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate." 1

Recommended Tapering Protocol

Standard Taper for Most Patients

• Reduce by 10% of the current dose every 2-4 weeks, not 10% of the original starting dose—this prevents disproportionately large reductions at the end of the taper 3, 2
• For a patient on 10 mg daily: reduce to 9 mg for 2-4 weeks, then to 8.1 mg, then to 7.3 mg, continuing this pattern 2
• The final doses before complete cessation should be very small (potentially 1-2 mg or less) to prevent a large drop in serotonin transporter occupancy when stopped 2

Extended Taper for High-Risk Patients

• Patients on higher doses (20 mg), those with previous withdrawal difficulties, or those who have been on escitalopram for years should expect 6-12 months or longer for the complete taper 3, 4
• Consider reducing by only 5-10% of the current dose every 4 weeks for these patients 3

Why Hyperbolic Tapering Matters

• PET imaging studies demonstrate that SSRIs have a hyperbolic relationship between dose and serotonin transporter occupancy—linear dose reductions cause exponentially larger biological effects at lower doses 2
• Traditional "therapeutic minimum dose" tapers (reducing to 5 mg then stopping) show minimal benefit over abrupt discontinuation and are often not tolerated 2

Monitoring and Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Watch For

• Dizziness (44%), muscle tension (44%), chills (44%), confusion or trouble concentrating (40%) are the most frequent symptoms with escitalopram specifically 4
• Also monitor for anxiety, irritability, insomnia, headache, nausea, sensory disturbances ("brain zaps"), and mood changes 3, 5, 4
• These symptoms typically emerge in the final stages of tapering and should not automatically be interpreted as depression relapse 5

Follow-Up Schedule

• Schedule appointments at least monthly during active tapering, with more frequent contact (every 1-2 weeks) during difficult phases or when symptoms emerge 3
• If withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 1

Adjunctive Medications for Symptom Management

• Trazodone for anxiety or insomnia (short-term use) 3
• Gabapentin for anxiety and sensory symptoms 3
• Mirtazapine for insomnia and anxiety 3
• These are used temporarily to ease the transition, not as long-term substitutes 3

Risk Factors for Severe Withdrawal

• Higher treatment doses and higher plasma concentrations of escitalopram significantly increase the risk of discontinuation syndrome 4
• Duration of treatment does not appear to correlate with withdrawal severity, but very slow tapering is recommended for all patients regardless 4
• Age and sex do not predict withdrawal risk 4

Critical Pitfalls to Avoid

Never Taper Too Quickly

• The traditional 2-4 week taper recommended in older guidelines shows minimal benefit over abrupt cessation 2
• Setting arbitrary deadlines is inappropriate—the taper rate must be determined by the patient's tolerance, not a rigid schedule 3

Don't Misinterpret Withdrawal as Relapse

• Withdrawal symptoms often occur when the underlying depression is actually improving 5
• Healthcare professionals must adopt a reassuring yet non-minimizing approach, providing clear information to normalize the process and reduce nocebo effects 5

Avoid Stopping at "Therapeutic Minimum" Doses

• Stopping at 5 mg (half the minimum therapeutic dose) still causes a large drop in serotonin transporter occupancy 2
• Continue tapering to doses much lower than therapeutic minimums (1-2 mg or less) before complete cessation 2

Special Considerations

If Withdrawal Symptoms Become Intolerable

• Resume the previously prescribed dose immediately 1
• Once stabilized, restart the taper at a slower rate (e.g., 5% reductions instead of 10%, or extend intervals to 4-6 weeks between reductions) 3

Realistic Timeline and Goals

• Minimum tapering duration: 4-8 weeks for standard cases; 6-12 months or longer for complex cases 3
• Success is measured by tolerability and completion, not speed 3
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 3