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Citalopram

Brands and Forms

  • Celexa
    • tablet: 10mg, 20mg scored, 40mg scored
  • Cipramil
  • Cipram
  • Dalsan
  • Recital
  • Emocal
  • Sepram
  • Seropram
  • Citox

Uses of Citalopram

Citalopram is commonly used for treating Depressive Disorders (including Major Depressive Disorder, Dysthymia, and Premenstrual Dysphoric Disorder) and Anxiety Disorders (including Panic Disorder, Generalized Anxiety Disorder, Social Phobia, PTSD, and Obsessive-Compulsive Disorder).

It can also be used for treating Bulimia Nervosa, Binge-Eating Disorder, Hypochondriasis, Body Dysmorphic Disorder, Trichotillomania, Depression in Bipolar Disorder, and impulsive behaviors associated with Borderline Personality Disorder and Dementia.

How Citalopram Works

Citalopram is an SSRI antidepressant. It blocks serotonin reuptake at the serotonin transporter, and thus boosts serotonin actions in the central nervous system. Citalopram also desensitizes serotonin 1a autoreceptors, and is a mild antagonist at the histamine H1 receptor.

Cautions when Using Citalopram

Citalopram should not be used at doses above 40mg daily, for at high doses it can cause cardiac arrhythmias (abnormal changes in the electrical activity and rhythm of the heart). For this reason, Citalopram should not be prescribed to people with pre-existing heart conditions, or low potassium or magnesium in the blood, and should not be combined with other medications that can prolong the QTc interval.

In patients older than 60, the maximum dose is 20mg daily, due to concerns over cardiac side-effects.

Citalopram can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Children and adolescents who use antidepressants like Citalopram may develop self-injurious or suicidal behaviors (for more information, see here).

Use with caution in people with a known seizure disorder, and in those who are taking anticoagulant (blood thinning) medication.

Long-term use of SSRI antidepressants like Citalopram has been associated with increased risk of osteoporosis and bone fractures in individuals above age 50.

Citalopram should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.

Dosing of Citalopram

The usual therapeutic range of Citalopram is 20-40mg/day; higher doses are contraindicated because of the risk of cardiac arrhythmias (abnormal changes in the electrical activity and rhythm of the heart), and because studies have not shown benefits of treating depression at doses higher than 40mg daily. It can be given once daily, either in the morning or at bedtime, though at bedtime may be preferred in cases where somnolence occurs as a side-effect.

Citalopram is usually started at 10mg/day for a week, and then increased to 20mg/day. The dose can be raised by 10-20mg every week, though it is common practice to wait 4 weeks at 20mg/day for therapeutic effects to take place before deciding to increase the dose. Dose increases are usually done at 2-week intervals to allow time for therapeutic effects to appear.

When wanting to stop this medication, the dose should be decreased gradually over a period of 6-8 weeks. A sudden cessation of the medication can result in an SSRI discontinuation syndrome.

Onset of action

Therapeutic effects are not expected before 2-4 weeks at a dose of 20mg/day. If no significant effects are seen after 6-8 weeks of use, including at least 2 weeks at a dose above 20mg/day, then the medication may not work at all.

Kidney impairment

No dose adjustment needed for mild or moderate kidney impairment. With severe impairment caution should be used.

Liver impairment

Maximum dose is 20mg/day.

Side-effects of Citalopram

Below is a list of most of the reported side-effects of Citalopram. Most of these side-effects occur in only a minority of individuals, and many also resolve with time while the medication is continued.

Cardiovascular: low blood pressure; rapid hear rate; heart rate abnormalities (very rare).

Central Nervous System: somnolence; insomnia; tremor; fatigue; reduced or increased appetite; decreased libido (see below on managing sexual side-effects); dizziness; yawning; weakness; confusion; impaired concentration; headaches; paresthesia; fever; akathisia and other extrapyramidal symptoms (rare); seizures (very rare); serotonin syndrome (very rare).

Dermatologic: excessive sweating; itchiness; rash; hair loss (rare).

Endocrine/Metabolic: elevated prolactin (very rare); SIADH (very rare).

Eyes, Ears, Nose and Throat: difficulty focusing vision; taste changes.

Gastrointestinal: nausea; dry mouth; diarrhea; dyspepsia; vomiting; abdominal pain; flatulence; increased saliva; GI hemorrhage (rare, due to the blood-thinning effects of the medication); pancreatitis (very rare).

Genitourinary: ejaculation disorder (see below on managing sexual side-effects); dysmenorrhea; impotence (see below on managing sexual side-effects); amenorrhea; excessive urination.

Hematologic: increases bleeding time (thins the blood); easy bruising; thrombocytopenia; thrombosis.

Muskuloskeletal: joint and muscle pain; risk of osteoporosis and bone fractures with long-term use of Citalopram.

Psychiatric: anxiety; agitation; apathy; worsening depression; suicidal thoughts (overall, Citalopram use helps to lower risk of suicide); self-injurious behaviors among children and adolescents; can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Respiratory: upper respiratory tract infection; rhinitis; sinusitis; coughing.

Common side-effects of Citalopram

Nausea, dry mouth, diarrhea, sedation/fatigue, insomnia, sweating, sexual dysfunction (about 5%, see below on managing sexual side-effects). Most of these side-effects resolve after a few weeks.

Rare but serious side-effects of note of Citalopram

  • Children and adolescents who use antidepressants like Citalopram may develop self-injurious or suicidal behaviors (for more information, see here).
  • Seizures

SSRI discontinuation syndrome

Individuals who suddenly stop using Citalopram after taking the medication at moderate or high doses over a significant period of time are at risk of developing a discontinuation syndrome, which can include the following symptoms: dizziness, electric shock-like sensations, sweating, nausea, insomnia, tremor, anxiety, restlessness, agitation, depressed mood, irritability, confusion, lethargy, and vertigo. These symptoms usually start anywhere from one day to one week after the medication was stopped, and can persists for days or even weeks.

This syndrome can be treated by restarting the medication at its prior dose. It can be prevented by decreasing the dose gradually over a period of 6-8 weeks when wanting to stop the medication. In rare cases, individuals may experience the discontinuation syndrome even when the medication is being tapered gradually; in such cases, an extremely slow and gradual taper will be necessary.

Managing sexual side-effects of Citalopram

Citalopram may have lower rates of sexual side-effects - like reduce libido, impotence, and ejeculation disorder - than other antidepressants. Nevertheless, in a minority of individuals these side-effects can occur. The first step to manage this is to try to lower the dose of the Citalopram. If this is not possible, or is not an effective solution, then either Bupropion, or Sildenafil (Viagra) or Vardenafil (Levitra), can be added [ref]. (Sildenafil and Vardenafil can be effective for female sexual side-effects as well, including difficulty achieving orgasm [ref, ref]).

Bupropion and Mirtazepine are two antidepressants that tend to have very low rates of sexual side-effects.

Citalopram overdose

Hyperventilation, nausea, dizziness, somnolence, sweating, tremor, vomiting, amnesia, confusion, rhabdomyolysis, sinus tachycardia, convulsions, cyanosis, ECG changes (including QT prolongation, nodal rhythm, ventricular arrhythmia, torsades de pointes), coma. Rare fatalities have been reported.

Citalopram and pregnancy

Category C: some animal studies show adverse effects at very high doses, but no controlled human studies have been done; should only be used in pregnancy if clearly needed and if benefits outweigh potential risks. For further information, see the section on treating Depression in pregnancy.

Medical Monitoring for Citalopram

None for healthy individuals.

Drug Interactions with Citalopram

  • Citalopram should not be combined with medications that can prolong the QTc interval.
  • Citalopram should not be combined with Cimetidine or other CYP2C19 inhibitors, which can increase Citalopram blood levels by 40%.
  • Caution should be used when combining Citalopram with other medications that can increase bleeding time and reduce blood clotting, including Aspirin, NSAIDs, anti-platelet agents, Heparin and Coumadin.
  • Combination with other serotonergic medications, including SSRI antidepressants, could potentially precipitate a serotonin syndrome.
  • Citalopram can increase blood concentrations of beta-blockers.
  • Cyproheptadine can decrease the pharmacological effects of Citalopram.
  • Citalopram should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.