What are the withdrawal symptoms of escitalopram and how should it be tapered in an adult on a therapeutic dose?

Escitalopram Withdrawal Symptoms and Tapering Strategy

Withdrawal Symptoms

Escitalopram discontinuation syndrome occurs frequently and can be severe, with symptoms typically emerging within 2-4 days of cessation and lasting 1-4 weeks, though protracted cases extending 6-12 months have been documented. 1, 2, 3

Common Symptoms Include:

• Neurological: Dizziness (44%), paresthesias/electric shock sensations, vertigo 1, 4
• Somatic: Muscle tension (44%), chills (44%), headache 1, 4
• Cognitive: Confusion, trouble concentrating (40%), memory impairment (28%), amnesia 1, 4, 3
• Psychiatric: Emotional lability, crying (28%), anxiety, irritability, lethargy 1, 4, 3
• Gastrointestinal: Vomiting, diarrhea 2
• Rare but serious: Hypomania/mania (even in unipolar depression), hallucinations, seizures 1, 5, 3

Risk Factors for Severe Withdrawal:

• Higher therapeutic doses and plasma concentrations significantly increase risk 4
• Duration of treatment does not predict severity 4
• Abrupt discontinuation versus inadequate tapering both cause symptoms 3, 1

Tapering Protocol

Gradual dose reduction using hyperbolic (exponential) tapering over months to very small doses—far below minimum therapeutic levels—is necessary to minimize withdrawal symptoms, as short 2-4 week tapers show minimal benefit over abrupt cessation. 6, 3

Specific Tapering Approach:

• Decrease in the smallest available increments at 1-2 week intervals (escitalopram has a shorter half-life requiring more frequent monitoring than longer half-life SSRIs) 3
• Continue tapering to doses much lower than the 10mg minimum therapeutic dose before complete cessation 6
• Do NOT use the commonly recommended rapid taper to half-minimum dose over 2-4 weeks—this approach fails to prevent withdrawal 6

Monitoring Schedule:

• Weekly contact during first 2-4 weeks after any dose reduction 3
• Every 2-4 weeks throughout the taper process 3
• Monthly monitoring for 6-12 months after complete cessation to detect delayed relapse versus protracted withdrawal 3
• Extended monitoring up to 2 years if this represents a recurrent depressive episode 3

Management of Withdrawal Symptoms

If intolerable symptoms emerge during tapering, restart escitalopram at the previous therapeutic dose until symptoms fully resolve, then implement a slower, more gradual taper. 1, 3

Critical Actions:

• Do NOT restart at subtherapeutic doses—this will not adequately suppress withdrawal symptoms 3
• Do NOT misinterpret withdrawal as psychiatric relapse alone, though both can coexist 3
• Do NOT rush the subsequent taper if symptoms recur—slow down the reduction schedule 3, 1

Distinguishing Withdrawal from Relapse:

• Withdrawal symptoms typically emerge within days and resolve within 1-4 weeks 3, 2
• Psychiatric relapse is more likely at 3+ months post-discontinuation rather than in the immediate weeks after stopping 3
• Conduct thorough psychiatric reassessment at 3 months to differentiate protracted withdrawal from true relapse 3

Special Populations

Elderly Patients:

• May experience more severe cognitive effects and require slower tapers 3
• Higher risk of hyponatremia with associated confusion, memory impairment, and falls 1

Patients with Anxiety Disorders:

• Symptom return may occur weeks to months after final dose, requiring extended monitoring 3

Critical Pitfalls to Avoid

• Never discontinue abruptly—even "low doses" carry significant withdrawal risk 4, 2
• Never assume 2-4 week tapers are adequate—this is outdated guidance that fails most patients 6
• Never stop at minimum therapeutic doses—taper must continue to much lower doses 6
• Never dismiss persistent symptoms as "just anxiety"—withdrawal can be severe and disabling 4, 2