Discontinuing Lexapro (Escitalopram)
Lexapro should be tapered gradually over weeks to months rather than stopped abruptly, with the taper rate determined by the patient's tolerance to dose reductions and close monitoring for discontinuation symptoms. 1
Discontinuation Syndrome Risk
Escitalopram carries a relatively lower risk of discontinuation syndrome compared to paroxetine, fluvoxamine, and sertraline, but gradual tapering remains necessary. 2 The FDA label explicitly warns that abrupt discontinuation can trigger withdrawal symptoms including:
- Physical symptoms: dizziness, sensory disturbances (paresthesias, electric shock sensations), headache, lethargy 1
- Gastrointestinal symptoms: nausea, vomiting, diarrhea 1
- Psychiatric symptoms: dysphoric mood, irritability, agitation, anxiety, confusion, emotional lability, insomnia, hypomania 1
- Sleep disturbances: insomnia 1
While these symptoms are generally self-limiting, serious discontinuation symptoms have been reported. 1
Recommended Tapering Approach
The dose should be reduced gradually rather than stopped abruptly. 1 If intolerable symptoms emerge during dose reduction, resume the previous dose and then decrease more slowly. 1
Practical Tapering Strategy
- Duration: Taper over weeks to months, not days. 3, 4 Evidence suggests tapering periods exceeding four weeks are preferable. 4
- Dose reduction method: Each new dose should represent approximately 90% of the previous dose (not a straight-line reduction from starting dose to zero). 5 Some experts recommend the "10 percent rule" with hyperbolic dose reductions. 6
- Initial reductions: Start with very small dose decreases to address patient anxiety and build confidence in the process. 5
- Monitoring intervals: Assess tolerance at 1-2 week intervals given escitalopram's shorter half-life. 5
Critical Distinction: Withdrawal vs. Relapse
A common pitfall is confusing withdrawal symptoms with relapse of depression. 7 Withdrawal symptoms (low mood, dizziness, anxiety) can mimic depressive relapse but typically:
- Occur within days of dose reduction 3
- Include physical symptoms uncommon in depression (paresthesias, electric shock sensations) 1
- Improve with reinstatement of the previous dose 1
True relapse typically emerges weeks to months after the last dose, particularly in patients with recurrent depression. 5
Management of Discontinuation Symptoms
If intolerable symptoms develop during tapering:
- Restart the previously prescribed dose 1
- Resume tapering at a slower rate once symptoms resolve 1
- Provide symptomatic management as needed (the FDA label does not specify agents, but supportive care is appropriate) 3
Patient Education and Monitoring
Patients must be informed about potential discontinuation symptoms before starting therapy, as this education can reduce symptom severity when discontinuation occurs. 2
- Explain that withdrawal symptoms are expected, manageable, and do not indicate addiction 8
- Normalize the process to reduce nocebo effects 6
- Establish a monitoring plan with regular contact (in-person or telephone) 5
- Ensure parental oversight in adolescents 5
Special Populations
Older adults (≥60 years): Escitalopram is preferred for this population due to favorable side effects, though the maximum dose is limited to 20 mg/day. 2 The same gradual tapering principles apply.
Children and adolescents: Gradual tapering is critical, with monitoring needed for weeks to months after the last dose to identify delayed symptom return. 2 The risk of withdrawal symptoms must be balanced against the need for continued treatment.
Patients with recurrent depression: These individuals may require extended monitoring post-discontinuation, as they face higher relapse risk. 7
When Discontinuation May Be Inappropriate
Do not discontinue abruptly except in extreme cases such as serotonin syndrome, where immediate cessation of all serotonergic agents is required. 1 Even then, plan for managing potential withdrawal symptoms.
Avoid "cold referrals" to other clinicians without ensuring acceptance of care, as this constitutes patient abandonment. 5