Citalopram

What Does Citalopram Do?

Citalopram is a selective serotonin reuptake inhibitor (SSRI) primarily used to treat major depressive disorder (MDD) and various anxiety disorders, like panic disorder, social anxiety disorder, and generalised anxiety disorder. The off-label applications of Citalopram encompass treatment of obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and eating disorders, such as bulimia nervosa. Citalopram is widely prescribed in the UK by GPs and doctors for any kind of low mood. 

How Does Citalopram Work? (the complicated stuff)

Citalopram works by selectively restraining serotonin reuptake, enabling more of this neurotransmitter in the synaptic cleft to bind and stimulate serotonin receptors. This results in heightened serotonergic neurotransmission, contributing to its mood-improvement influences and anxiety reduction. Its selectiveness is due to its higher affinity for the serotonin transporter than other neurotransmitter transporters.

Drug Type and Category of Citalopram

Citalopram is a selective serotonin reuptake inhibitor (SSRI).

What dosage of Citalopram should you be taking?

• The usual dose for adults is 20 mg once daily, which can be increased to a maximum of 40 mg daily if required. ¹
• For elderly patients over 65 or those with liver problems, the maximum recommended dose is 20 mg daily. ²
• For children, the usual starting dose is 10 mg once daily, which may be increased to a maximum of 40 mg daily. ²
• Citalopram should be started at a low dose and increased gradually in 10 mg increments to optimise therapy and minimise adverse effects. ³
• Dosages above 40 mg daily are not recommended due to the increased risk of QT prolongation. ³

In summary, the NICE guidelines recommend starting adults on 20 mg citalopram once daily, with a maximum dose of 40 mg for most patients. Lower starting doses and maximum doses are advised for the elderly, those with liver problems, and children.

What are the side-effects of Citalopram?

Common side effects include:

• Gastrointestinal issues: Nausea (this is very common), vomiting, diarrhea, dry mouth, and indigestion.
• Neurological effects: Dizziness, headache, drowsiness, fatigue, and insomnia.
• Psychological effects: Anxiety, agitation, restlessness, and increased sweating.
• Sexual dysfunction: Decreased libido, difficulty achieving orgasm, and erectile dysfunction.
• Weight changes: Weight gain or loss, although less common compared to other antidepressants.
• Cardiovascular effects: Increased heart rate and palpitations.
• Other effects: Blurred vision, yawning, and tremors.

Severe side effects, though rare, can include:

• Serotonin syndrome: A potentially life-threatening condition characterised by high fever, agitation, confusion, rapid heart rate, and high blood pressure.
• QT prolongation: An abnormal heart rhythm that can lead to serious complications.
• Allergic reactions: Rash, itching, swelling, severe dizziness, and trouble breathing.

Drug Interactions

1. Monoamine Oxidase Inhibitors (MAOIs): Combining citalopram with MAOIs can lead to serious and potentially fatal reactions, including serotonin syndrome. At least 14 days should elapse between discontinuation of an MAOI and initiation of citalopram.
2. Other SSRIs and SNRIs: Concurrent use can increase the risk of serotonin syndrome, which is characterised by symptoms like agitation, hallucinations, coma, or other changes in mental status, coordination problems, or muscle twitching.
3. Tricyclic Antidepressants (TCAs): Citalopram can increase the blood levels of TCAs, leading to increased risk of side effects.
4. Anticoagulants and Antiplatelet Drugs: These medications, including aspirin, NSAIDs, and warfarin, can increase the risk of bleeding when taken with citalopram.
5. Antipsychotics: Some antipsychotics may increase the risk of QT prolongation, which is also a concern with citalopram.
6. Benzodiazepines: Citalopram can increase the sedative effects of benzodiazepines.
7. St. John's Wort: This herbal supplement can increase the risk of serotonin syndrome.
8. Alcohol: Combining alcohol with citalopram can enhance the depressant effects of alcohol.
9. CYP2C19 and CYP3A4 Inhibitors: Drugs that inhibit these enzymes can increase citalopram levels, leading to increased risk of side effects.

Natural Alternatives to Citalopram

Herbal Remedies

• St. John's Wort: A flowering plant that may be as effective as antidepressants for mild-to-moderate depression, although its efficacy for severe depression is uncertain. ^4,6
• SAM-e (S-adenosylmethionine): A naturally occurring substance in the body that may help alleviate depression symptoms, but caution is advised for those with certain health conditions. ⁴
• Omega-3 fatty acids: Found in fatty fish or supplements, omega-3s have shown promise in reducing depression, possibly by lowering inflammation or impacting stress hormones. ⁴

Lifestyle Changes

While GPs may be eager to prescribe, natural health therapists and non-prescribers are often keen that patients address the underlying issues, and look to improve their lives through education and lifestyle. 

• Physical exercise: Regular physical activity can lift mood, boost energy levels, and help manage depressive symptoms naturally. ⁶
• Sunlight exposure: Getting enough sunlight can improve cognitive function in those with depression. ⁵
• Relaxation therapies: Practices like meditation, mindfulness, and yoga can be effective alternatives to medication. ^5,6
• Dietary changes: Eating a balanced, nutritious diet and staying hydrated may help manage depression symptoms. ⁶

Therapy and Counseling

• Talk therapy: Cognitive behavioral therapy (CBT) and other forms of counseling are recommended by NICE guidelines as a first-line treatment for mild depression, often before medication. ⁶
• Holistic treatment programs: Integrative approaches that address potential root causes like hormonal imbalances, nutrient deficiencies, and adrenal fatigue may serve as alternatives to long-term medication use. ⁵

Interesting facts about Citalopram

High doses of citalopram (above 40 mg per day) have been associated with an increased risk of QT interval prolongation, a heart rhythm disturbance.

Citalopram is considered non-addictive, but there’s a high risk of withdrawal symptoms. 

Disclaimer

This article is generated for informational purposes only. It was created in December 2024. Medications and medical guidance can change over time. Therefore, it is essential to consult with your general practitioner or healthcare provider before making any decisions regarding medications or treatment plans. Your GP can provide personalised advice based on your specific health needs and conditions.

References

1. https://bnfc.nice.org.uk/drugs/citalopram/
2. https://www.nhs.uk/medicines/citalopram/how-and-when-to-take-citalopram/
3. https://www.ncbi.nlm.nih.gov/books/NBK482222/
4. https://www.medicalnewstoday.com/articles/6-natural-antidepressants
5. https://www.alternativetomeds.com/blog/citalopram-alternatives/
6. https://www.mind.org.uk/information-support/drugs-and-treatments/antidepressants/alternatives-to-antidepressants/