What are the risks of stopping citalopram (Selective Serotonin Reuptake Inhibitor) abruptly?

Risks of Abrupt Citalopram Discontinuation

Abrupt discontinuation of citalopram is strongly discouraged due to significant risk of withdrawal symptoms that can impact morbidity and quality of life, and a gradual tapering approach over several weeks is essential. 1

Withdrawal Symptoms

Stopping citalopram suddenly can lead to numerous adverse effects:

• Neurological symptoms:

  • Dizziness
  • Electric shock-like sensations (brain zaps)
  • Headache
  • Tremors
  • Paresthesias

• Psychological symptoms:

  • Anxiety
  • Irritability
  • Agitation
  • Confusion
  • Emotional lability
  • Insomnia

• Physical symptoms:

  • Nausea
  • Sweating
  • Lethargy
  • Hypomania 1

In rare but serious cases, abrupt discontinuation has been associated with:

• New onset hypertension 2
• Sexual dysfunction including premature ejaculation 3

Proper Discontinuation Protocol

The FDA label explicitly states that citalopram should be tapered gradually rather than stopped abruptly 1. The recommended approach includes:

1. Gradual dose reduction:

   • Reduce the dose by small increments over several weeks
   • Each new dose should be approximately 90% of the previous dose 4
   • For standard doses, consider reducing by 5-10mg increments with 1-2 weeks at each step

2. Extended tapering for long-term users:

   • Patients who have been on citalopram for extended periods may require even slower tapering
   • Evidence suggests tapering over months rather than weeks may be more successful in reducing withdrawal symptoms 5

3. Monitoring during discontinuation:

   • Regular follow-up during the tapering process
   • Assessment for emergence of withdrawal symptoms
   • Evaluation for recurrence of original condition (e.g., depression)

Risk Factors for Severe Withdrawal

Certain factors increase the risk of experiencing more severe withdrawal symptoms:

• Higher doses of citalopram
• Longer duration of treatment
• History of withdrawal symptoms with previous medication changes
• Concurrent discontinuation of other medications

Management of Withdrawal Symptoms

If withdrawal symptoms emerge during tapering:

1. Slow or pause the taper:

   • Return to the previous well-tolerated dose
   • Resume tapering at a slower rate when symptoms subside

2. Supportive care:

   • Symptomatic management of specific withdrawal effects
   • Reassurance about the temporary nature of symptoms

Special Considerations

• Cardiovascular patients: Monitor blood pressure during discontinuation as hypertension has been reported following abrupt cessation 2

• Patients with sexual dysfunction: Be aware that new sexual side effects can emerge during discontinuation 3

• Elderly patients: May require even more gradual tapering due to increased sensitivity to medication changes 4

Common Pitfalls to Avoid

1. Mistaking withdrawal for relapse: Withdrawal symptoms can mimic depression recurrence, potentially leading to unnecessary long-term medication continuation 5

2. Inadequate tapering schedule: Short tapers of 2-4 weeks often show minimal benefits over abrupt discontinuation 5

3. Stopping at minimum therapeutic doses: Tapering should continue to doses lower than minimum therapeutic doses to minimize withdrawal 5

4. Abandonment of care: Abrupt withdrawal or major dose reduction without appropriate follow-up constitutes unacceptable medical care 4

By following a carefully planned, gradual tapering approach, the risks associated with citalopram discontinuation can be significantly minimized, improving patient outcomes and quality of life.