What is the recommended taper schedule for 20 mg of escitalopram (Lexapro)?

Recommended Taper for 20mg Lexapro (Escitalopram)

Reduce escitalopram from 20 mg to 10 mg over 1–2 weeks to minimize discontinuation symptoms, then maintain 10 mg for at least one week before further dose reduction if complete cessation is planned. 1

Standard Tapering Protocol

Initial Dose Reduction (20 mg → 10 mg)

• Decrease from 20 mg to 10 mg over a 1–2 week period using a gradual reduction schedule 1
• This approach minimizes common discontinuation symptoms including dizziness, fatigue, headache, nausea, insomnia, and anxiety 1
• Escitalopram has a relatively favorable discontinuation profile compared to shorter-acting SSRIs like paroxetine, but gradual tapering remains the standard of care 1

If Continuing to Complete Cessation

• After reaching 10 mg, maintain this dose for at least one week before considering further reduction 2
• The FDA label recommends "a gradual reduction in the dose rather than abrupt cessation" whenever possible 2
• If intolerable symptoms occur, resume the previously prescribed dose and subsequently decrease at a more gradual rate 2

Evidence-Based Rationale for Slower Tapering

Why Standard Short Tapers Are Often Insufficient

• Guidelines traditionally recommend 2–4 week tapers down to therapeutic minimum doses, but studies show these brief tapers provide minimal benefit over abrupt discontinuation and are often not tolerated by patients 3
• Tapers extending over months and reaching doses much lower than minimum therapeutic doses have demonstrated greater success in reducing withdrawal symptoms 3
• Hyperbolic (exponential) tapering that reduces the biological effect at serotonin transporters by fixed amounts—similar to benzodiazepine tapering—minimizes withdrawal symptoms more effectively than linear dose reductions 3

For Patients with Severe Discontinuation Symptoms

• Consider extending the taper over several months rather than weeks 3
• Reduce to doses lower than the 10 mg therapeutic minimum (e.g., 5 mg, 2.5 mg) before complete cessation 3
• This approach aligns with PET imaging data showing that hyperbolic dose reductions produce linear decreases in serotonin transporter occupancy 3

Critical Monitoring Requirements

Early Contact and Assessment

• Contact the patient within 1 week of initiating the dose reduction (in-person or by telephone) to assess for discontinuation symptoms and adherence 1
• Distinguish between discontinuation symptoms and relapse of the underlying condition 1

Suicidality Monitoring

• Monitor for suicidality during the first 1–2 months after any dose change, as this period carries heightened risk for treatment-emergent suicidal ideation, especially in younger adults 1
• This monitoring requirement applies to all dose adjustments, not only complete cessation 1

Common Pitfalls to Avoid

Do Not Stop Abruptly

• Never stop 20 mg abruptly and start 10 mg the next day without a gradual transition—this increases the risk of discontinuation syndrome 1
• Abrupt discontinuation or excessively rapid tapering can trigger withdrawal symptoms that may be mistaken for disease relapse, leading to unnecessary long-term medication 3

Recognize Discontinuation Syndrome

• Common symptoms include dizziness, fatigue, lethargy, headaches, nausea, insomnia, anxiety, irritability, and sensory disturbances 1
• Although escitalopram has lower discontinuation risk than paroxetine or sertraline, symptoms can still occur and require monitoring 1

If Symptoms Are Intolerable

• Resume the previously prescribed dose if intolerable symptoms develop 2
• After symptom resolution, continue decreasing the dose at a more gradual rate 2

Alternative Extended Taper for High-Risk Patients

For patients with prior severe discontinuation reactions or those on escitalopram for >1 year:

• Week 1–2: Reduce from 20 mg to 15 mg daily
• Week 3–4: Reduce from 15 mg to 10 mg daily
• Week 5–8: Maintain 10 mg daily
• Week 9–10: Reduce from 10 mg to 5 mg daily
• Week 11–14: Maintain 5 mg daily
• Week 15+: Consider further reduction to 2.5 mg before complete cessation 3

This extended schedule follows the principle that tapers over months with reductions to sub-therapeutic doses show greater success than brief tapers 3