What are the recommendations for a patient taking citalopram (Celexa) with a family history of suicidal ideation who has been prescribed generic Contrave (naltrexone-bupropion)?

Recommendations for a Patient Taking Citalopram with Family History of Suicidal Ideation Who Has Been Prescribed Generic Contrave

Naltrexone-bupropion (generic Contrave) is contraindicated for this patient due to the significant risk of increased suicidal ideation when combined with citalopram and the patient's family history of suicidal behavior. 1, 2

Risk Assessment

The combination of citalopram and bupropion (a component of Contrave) presents several serious concerns:

1. Increased suicide risk:

   • The FDA label for citalopram includes a black box warning about increased risk of suicidal thinking and behavior, particularly in young adults 1
   • The patient's family history of suicidal ideation in his sister significantly increases his risk profile
   • Bupropion also carries a black box warning for suicidal ideation 2

2. Potential for serotonin syndrome:

   • Combining citalopram (an SSRI) with bupropion can increase the risk of serotonin syndrome, characterized by mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity 3
   • Serotonin syndrome can be life-threatening and requires immediate medical attention

3. Drug-drug interactions:

   • Both medications affect serotonergic and dopaminergic pathways, potentially causing additive effects 2
   • This combination may increase the risk of seizures, as bupropion lowers the seizure threshold 2

Alternative Recommendations

For a patient requiring both depression and weight management treatment:

1. First option: Optimize current citalopram therapy

   • Ensure optimal dosing of citalopram (not exceeding 40mg daily due to QT prolongation risk) 1
   • Add non-pharmacological weight management strategies (dietary changes, physical activity)

2. Second option: Consider switching antidepressants

   • If weight management is a priority, consider switching from citalopram to an antidepressant with better weight profile
   • Fluoxetine or sertraline may have more neutral weight effects while still treating depression

3. Third option: If medication for weight management is essential

   • Consider orlistat, which has minimal CNS effects and no known interactions with citalopram
   • Avoid all medications containing bupropion due to the increased suicide risk

Monitoring Requirements

If any medication changes are implemented:

• Weekly monitoring for suicidal ideation during the first month of treatment
• Regular assessment of mood, behavior, and emergence of suicidal thoughts
• Blood pressure and heart rate monitoring
• Electrolyte monitoring, particularly if starting a new medication

Important Considerations

• Research shows that patients with a family history of suicide attempts have 1.72 times higher odds of worsening suicidal ideation during antidepressant treatment 4
• The combination of serotonergic medications like citalopram with other agents affecting neurotransmitters requires extreme caution 3
• Even in clinical trials where high-risk patients were excluded, careful monitoring was required for emergence of suicidal ideation with citalopram 5

Common Pitfalls to Avoid

1. Assuming that weight management medications are benign additions to psychiatric regimens
2. Overlooking family history of suicidal behavior as a major risk factor
3. Failing to recognize the potential for serotonin syndrome when combining serotonergic medications
4. Not providing adequate monitoring during medication transitions or additions

This patient's case requires prioritizing safety over weight management goals, with careful consideration of the significant risks posed by combining citalopram with bupropion-containing products like Contrave.