What can be added to Celexa (citalopram) to help with anxiety?

Medications to Augment Celexa (Citalopram) for Anxiety Treatment

Buspirone (BuSpar) is the most appropriate medication to add to Celexa (citalopram) for anxiety, with an initial dosage of 5 mg twice daily and a maximum dosage of 20 mg three times daily. 1

First-Line Augmentation Options

• Buspirone (BuSpar):

  • Initial dosage: 5 mg twice daily
  • Maximum dosage: 20 mg three times daily
  • Particularly useful for mild to moderate anxiety
  • Takes 2-4 weeks to become fully effective
  • Well-tolerated with minimal drug interactions with citalopram 1

• Mirtazapine (Remeron):

  • Initial dosage: 7.5 mg at bedtime
  • Maximum dosage: 30 mg at bedtime
  • Potent and well-tolerated
  • Promotes sleep, appetite, and weight gain
  • Good option for anxiety patients with insomnia or poor appetite 1

Second-Line Augmentation Options

• Nefazodone:

  • Initial dosage: 50 mg twice daily
  • Maximum dosage: 150-300 mg twice daily
  • Especially effective for anxiety
  • Caution: Requires monitoring for hepatotoxicity
  • Reduce dose of any co-administered benzodiazepines by 50% 1

• Tricyclic antidepressants:

  • Nortriptyline (Pamelor):

    • Initial dosage: 10 mg at bedtime
    • Maximum dosage: 40 mg per day (given twice daily)
    • Useful for patients with agitated anxiety and insomnia
    • Therapeutic blood level window: 50-150 ng/mL 1

  • Desipramine (Norpramin):

    • Initial dosage: 10-25 mg in the morning
    • Maximum dosage: 150 mg in the morning
    • Tends to be activating (reduces apathy)
    • Lower risk for cardiotoxic, hypotensive, and anticholinergic effects 1

Special Considerations

Drug Interactions and Safety

• When adding a second serotonergic medication to citalopram:

  • Start with a low dose
  • Increase dose slowly
  • Monitor for serotonin syndrome symptoms, especially in the first 24-48 hours after dosage changes 1

• Avoid combining citalopram with:

  • MAOIs (contraindicated due to risk of serotonin syndrome)
  • Drugs that prolong QT interval (citalopram itself can cause QT prolongation) 1

Combination Therapy

• Consider adding cognitive behavioral therapy (CBT) to medication treatment for better outcomes
• Combined treatment (CBT plus SSRI) shows superior efficacy compared to either treatment alone 1

Monitoring and Dose Adjustments

• Monitor for initial worsening of anxiety when starting or adjusting medications
• Consider starting with subtherapeutic "test" doses to assess tolerability 1
• Assess response using standardized symptom rating scales 1
• For citalopram specifically, do not exceed 40 mg daily due to risk of QT prolongation 1

Cautions and Contraindications

• Avoid bupropion in patients with agitation or seizure disorders 1
• Be aware that switching between brand name and generic citalopram may affect treatment response in some anxiety patients 2
• Monitor for discontinuation syndrome with missed doses, particularly with shorter-acting medications 1
• Be vigilant for signs of serotonin syndrome when combining serotonergic medications 1