Does citalopram (Celexa) increase the risk of alcohol relapse or use?

Citalopram May Increase Alcohol Relapse and Should Not Be Used in Alcohol Dependence

Citalopram is not recommended for patients with alcohol dependence as it may increase alcohol relapse and lead to poorer drinking outcomes compared to placebo.

Evidence on Citalopram and Alcohol Use

Negative Impact on Alcohol Use Outcomes

The most recent and highest quality evidence from a randomized, double-blind, placebo-controlled trial demonstrates that citalopram provides no advantage over placebo in treating alcohol dependence and actually produces poorer outcomes in some measures 1:

• Patients taking citalopram had a higher number of heavy drinking days
• Citalopram led to smaller reductions in frequency and amount of alcohol consumption
• The medication showed no benefit regardless of whether patients were depressed or non-depressed

This evidence directly contradicts earlier, smaller studies that suggested potential benefits:

• While short-term studies from the 1980s and 1990s showed initial decreases in alcohol intake with citalopram 2, 3, these effects were not sustained in longer trials
• A 1995 study found that initial benefits of citalopram disappeared after the first week of treatment, with no long-term advantage over placebo 4

FDA Labeling Considerations

The FDA label for citalopram does not specifically address alcohol use disorder treatment but does note potential interactions between citalopram and alcohol 5:

• The label cautions that "the use of alcohol by depressed patients taking citalopram is not recommended"
• This warning is based on potential CNS effects when combining the medications, not on therapeutic efficacy for alcohol dependence

Evidence-Based Recommendations for Alcohol Dependence Treatment

According to clinical guidelines for alcohol dependence management 6, the following medications have demonstrated efficacy:

First-Line Medications for Alcohol Dependence

1. Acamprosate (Level A1 recommendation) 6

   • Significantly increases abstinence rates (OR 1.86,95% CI 1.49 to 2.33)
   • Most effective for maintaining abstinence after detoxification

2. Naltrexone (Level A1 recommendation) 6

   • Reduces alcohol consumption and prevents relapse
   • May be less effective for complete abstinence (OR 1.36,95% CI 0.97 to 1.91)

3. Topiramate 6

   • Associated with improved abstinence rates (OR 1.88,95% CI 1.06 to 3.34)

4. Baclofen (Level B2 recommendation) 6

   • Particularly useful in patients with advanced alcoholic liver disease
   • Safe and effective to prevent alcohol relapse in this population

Combination Approaches

Combined interventions show even greater efficacy than monotherapy 6:

• Acamprosate plus naltrexone (OR 3.68,95% CI 1.50 to 9.02)
• Acamprosate plus nurse visits (OR 4.59,95% CI 1.47 to 14.36)

Clinical Algorithm for Alcohol Dependence Treatment

1. Assessment:

   • Screen using AUDIT (gold standard) 6
   • Evaluate for liver disease severity
   • Assess for comorbid psychiatric conditions

2. Medication Selection:

   • For patients without advanced liver disease:

     • Acamprosate or naltrexone as first-line options
     • Consider topiramate as an alternative

   • For patients with advanced liver disease:

     • Avoid disulfiram, naltrexone, and acamprosate due to potential side effects 6
     • Consider baclofen as the preferred medication 6

3. Psychosocial Support:

   • All pharmacotherapy should be combined with brief motivational interventions 6
   • Counseling significantly enhances medication effectiveness

Important Caveats and Pitfalls

1. SSRIs in early recovery: The use of SSRIs like citalopram in early recovery from alcohol dependence, prior to establishing abstinence, may be contraindicated 1

2. Depression comorbidity: Despite theoretical benefits, citalopram does not improve alcohol outcomes even in depressed patients 1

3. Personality disorders: The presence of personality disorders predicts poorer treatment response regardless of medication choice 1

4. Acute withdrawal management: Benzodiazepines remain the treatment of choice for alcohol withdrawal syndrome (Level A1 recommendation) 6

5. Monitoring requirements: Regular follow-up is essential to assess medication effectiveness and adjust treatment as needed

By following these evidence-based recommendations and avoiding medications like citalopram that may worsen outcomes, clinicians can optimize treatment for patients with alcohol dependence.