Tapering Lexapro (Escitalopram): Recommended Protocol
Gradually reduce escitalopram over several weeks to months rather than stopping abruptly, as discontinuation symptoms are common and can be severe with SSRIs. 1, 2
FDA-Approved 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 Schedule
Reduce the dose by 10-25% of the current dose (not the original dose) every 1-4 weeks, extending the taper over a minimum of several weeks to months. 3, 4
Specific Tapering Algorithm:
For patients on 10 mg daily: Reduce to 5 mg daily for 2-4 weeks, then consider further reduction to 2.5 mg daily for another 2-4 weeks before complete discontinuation 2, 5
For patients on 20 mg daily: Reduce to 15 mg for 2-4 weeks, then 10 mg for 2-4 weeks, then 5 mg for 2-4 weeks, then 2.5 mg for 2-4 weeks before stopping 3, 4
The taper rate must be determined by the patient's tolerance of withdrawal symptoms, not by a rigid schedule 6
Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 6
Why Slow Tapering Matters
Escitalopram has a relatively short half-life compared to fluoxetine, making it more prone to withdrawal symptoms. 2, 5 Research demonstrates that tapers of 2-4 weeks (as traditionally recommended) show minimal benefit over abrupt discontinuation and are often not tolerated by patients. 4 Longer tapers over months, reaching doses much lower than minimum therapeutic doses, have shown greater success in reducing withdrawal symptoms. 4
The hyperbolic dose-reduction approach (reducing by percentage of current dose) is critical because SSRI receptor occupancy follows a hyperbolic curve—small dose reductions at lower doses produce proportionally larger changes in biological effect. 4
Monitoring for Withdrawal Symptoms
Monitor closely for discontinuation symptoms at each dose reduction before proceeding to the next step. 6, 3
Common withdrawal symptoms include:
Somatic symptoms: Dizziness, light-headedness, nausea, fatigue, myalgia, flu-like symptoms, sensory disturbances (electric shock sensations), sleep disturbances 2, 3
Psychological symptoms: Anxiety, agitation, crying spells, irritability, mood disturbances 2, 3
Symptoms typically emerge within days of dose reduction and can last days to months, with different symptoms having different durations 3
Managing Withdrawal Symptoms
If intolerable symptoms occur, return to the previous well-tolerated dose and slow the taper further. 1, 3
Mild symptoms can be managed with reassurance that they are usually transient 2
Severe symptoms require reinstating the previous dose and tapering more gradually (extending intervals between reductions to 4-6 weeks or longer) 2, 5, 3
Consider symptomatic management as needed (e.g., antiemetics for nausea, NSAIDs for myalgias) 6
Critical Pitfall to Avoid
Do not mistake withdrawal symptoms for relapse of depression. 2, 7 Withdrawal symptoms like low mood, anxiety, and irritability can mimic depression recurrence, potentially leading to unnecessary reinitiation of long-term antidepressant therapy. 7 The key distinction: withdrawal symptoms typically emerge within days of dose reduction and include prominent somatic features (dizziness, electric shock sensations, flu-like symptoms), whereas true relapse develops more gradually over weeks. 2, 3
Follow-Up Schedule
Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases or after each dose reduction. 6
Alternative Strategy: Switch to Fluoxetine
For patients experiencing severe withdrawal symptoms despite slow tapering, consider switching to fluoxetine before discontinuation. 5 Fluoxetine's exceptionally long half-life (4-6 days for the parent compound, 4-16 days for the active metabolite) provides a built-in buffer against withdrawal symptoms. 8, 5
- Cross-taper by reducing escitalopram while starting fluoxetine 10 mg daily or every other morning 8
- After 1-2 weeks on fluoxetine, discontinue escitalopram completely 5
- Continue fluoxetine for 2-4 weeks, then discontinue without taper (fluoxetine's long half-life makes gradual taper unnecessary) 5
Patient Education
Educate patients before starting the taper that withdrawal symptoms are common, not dangerous, and do not indicate addiction. 2, 5 Reassurance throughout the discontinuation process is essential. 5 Some evidence suggests cognitive behavioral therapy may help ease distress during discontinuation, though this is based on limited data. 5
Realistic Timeline
The complete taper will likely require a minimum of 2-3 months, and possibly 4-6 months or longer for patients on higher doses or those with previous failed discontinuation attempts. 3, 4 The goal is durability of the taper, not speed. 6