When does escitalopram (Lexapro) withdrawal syndrome occur?

Timing of Escitalopram Withdrawal Syndrome

Escitalopram withdrawal syndrome typically begins within hours to several days after discontinuation, with symptoms reaching maximum intensity around day 5 and usually resolving within 1-2 weeks, though some cases persist for 4 weeks or longer. 1

Onset Timeline

• Initial symptom onset occurs within hours to several days after the last dose, as documented in neonatal studies that mirror adult patterns 1
• The FDA label confirms that withdrawal symptoms emerge "particularly when abrupt" discontinuation occurs 2
• Research on paroxetine (a similar SSRI) shows withdrawal syndrome generally begins within 24-48 hours after discontinuing the drug, with signs reaching maximum intensity on day 5 3

Duration of Symptoms

• Most withdrawal symptoms resolve within 1-2 weeks in the majority of patients 1
• However, symptoms can persist through 4 weeks or longer in some individuals, as documented in pediatric cases 1
• Recent research challenges the traditional "self-limiting" narrative, noting that withdrawal symptomatology does not necessarily subside within a few weeks and may be more prolonged than previously recognized 4

Clinical Manifestations to Monitor

The withdrawal syndrome presents with a characteristic constellation of symptoms:

• Sensory disturbances (paresthesias, electric shock sensations) 2
• Neurological symptoms: dizziness, vertigo, headache, confusion 2, 3
• Psychiatric symptoms: dysphoric mood, irritability, agitation, anxiety, emotional lability, insomnia 2
• Physical symptoms: nausea, lethargy, flu-like symptoms 3
• In neonatal cases (which inform adult patterns): crying, tremors, hypertonia, tachypnea, feeding difficulty, hypoglycemia 1

Risk Factors for Withdrawal

Higher doses and higher plasma concentrations of escitalopram significantly increase the risk of discontinuation syndrome 5:

• A 2016 study found treatment doses and plasma concentrations were significantly higher in patients who developed withdrawal syndrome 5
• Duration of treatment before discontinuation did not differ between those with and without withdrawal syndrome 5
• Abrupt cessation carries greater risk than gradual tapering 2

Critical Prevention Strategy

The FDA explicitly recommends "a gradual reduction in the dose rather than abrupt cessation whenever possible" 2:

• If intolerable symptoms occur following dose reduction, resume the previously prescribed dose, then decrease more gradually 2
• Traditional guidelines recommending 2-4 week tapers show minimal benefits over abrupt discontinuation 6
• Very slow tapering is recommended for all patients, particularly those on higher doses 5
• Hyperbolic tapering to doses much lower than therapeutic minimums (rather than stopping at half-minimum doses) has shown greater success in reducing withdrawal symptoms 6

Common Pitfall to Avoid

Do not mistake withdrawal symptoms for recurrence of depression, which can lead to unnecessary long-term medication continuation 6. The withdrawal syndrome can be differentiated from recurrence by its temporal relationship to discontinuation (hours to days) and characteristic sensory/physical symptoms not typical of depression relapse 2, 3.