What is the recommended protocol for withdrawing citalopram (Selective Serotonin Reuptake Inhibitor - SSRI)?

Recommended Protocol for Citalopram Withdrawal

Citalopram should be gradually tapered over several weeks to months rather than abruptly discontinued to minimize withdrawal symptoms. 1

Understanding Citalopram Withdrawal

Citalopram, like other SSRIs, can cause withdrawal symptoms when stopped abruptly or tapered too quickly. These symptoms may include:

• Somatic symptoms: Dizziness, light-headedness, nausea, vomiting, fatigue, lethargy, myalgia, chills, flu-like symptoms, sensory disturbances, and sleep disturbances 2
• Psychological symptoms: Anxiety, agitation, crying spells, and irritability 2

Recommended Tapering Protocol

Initial Assessment

• Evaluate current dosage and duration of treatment
• Assess risk factors for difficult withdrawal (higher doses, longer duration of treatment)
• Screen for previous withdrawal experiences

Tapering Schedule

1. Initial reduction: Decrease by no more than 25% of the current dose

   • For example, from 40mg to 30mg daily
   • Maintain this dose for 1-2 weeks to assess tolerability 1, 3

2. Subsequent reductions:

   • Continue with 25% reductions of the previous dose
   • Extend the interval between dose reductions if withdrawal symptoms emerge
   • For example: 40mg → 30mg → 20mg → 10mg → 5mg → discontinue

3. Final phase:

   • Use the lowest available dose (10mg or 5mg if available) before complete discontinuation
   • Consider alternate-day dosing in the final stages 3

4. Total duration:

   • Minimum 2-4 weeks for short-term users (less than 6 months)
   • 2-3 months or longer for long-term users or those experiencing withdrawal symptoms 3

Monitoring and Management

Follow-up Schedule

• First follow-up: 1-2 weeks after initiating taper
• Subsequent follow-ups: Every 2-4 weeks depending on symptom severity
• Additional follow-up 2-4 weeks after complete discontinuation

Managing Withdrawal Symptoms

• Mild symptoms: Reassurance that symptoms are typically transient 2
• Moderate to severe symptoms:
  • Return to the previous dose that was well-tolerated
  • Slow the rate of taper further
  • Consider extending the interval between dose reductions 3

Special Considerations

High-Risk Patients

• Elderly patients: Maximum recommended dose is 20mg/day; taper even more gradually 1
• Patients with hepatic impairment: Use more gradual tapering 1
• Long-term users: May require tapering to doses below the therapeutic minimum 3

Common Pitfalls to Avoid

1. Mistaking withdrawal for relapse: Withdrawal symptoms typically emerge within days of dose reduction and are often somatic, whereas depression relapse usually develops gradually over weeks 2

2. Tapering too quickly: Standard 2-4 week tapers often show minimal benefits over abrupt discontinuation; longer tapers are more successful 3

3. Stopping at minimum therapeutic dose: Tapering to doses below therapeutic minimums may be necessary to minimize withdrawal symptoms 3

4. Inconsistent dosing: Intermittent non-compliance can trigger withdrawal symptoms; emphasize the importance of consistent dosing during the tapering period 2

5. Overlooking sexual side effects: Some patients may experience sexual dysfunction as a withdrawal effect; specifically inquire about these symptoms 4

Patient Education

• Inform patients that withdrawal symptoms are common but manageable with proper tapering
• Emphasize that experiencing withdrawal symptoms does not indicate addiction
• Advise patients to report any symptoms promptly rather than abandoning the tapering plan
• Explain that some symptoms may be transient and will resolve as the body adjusts

Recent evidence suggests that only about 10% of patients receive prescriptions for the lowest available dose before discontinuation, indicating that proper tapering is not routine practice despite its importance in preventing withdrawal symptoms 5.