From the Guidelines
Bupropion (Wellbutrin) is the recommended antidepressant to be used in combination with citalopram (Celexa) due to its efficacy in decreasing depression severity and lower discontinuation rates due to adverse events compared to other options 1.
Key Considerations
- The combination of bupropion and citalopram is often prescribed for patients who experience incomplete response to citalopram alone or have specific symptoms like fatigue or low energy that persist despite citalopram treatment.
- Typical dosing for bupropion when added to citalopram ranges from 150-300 mg daily, usually starting at 150 mg once daily and potentially increasing after 1-2 weeks if needed.
- This combination works well because the medications have different mechanisms of action - citalopram is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, while bupropion affects dopamine and norepinephrine systems.
Monitoring and Precautions
- Patients should be monitored for potential side effects including increased blood pressure, anxiety, or insomnia when using this combination.
- The combination should be initiated and monitored by a healthcare provider, as they need to consider individual factors like other medications, medical conditions, and specific symptoms being targeted.
Evidence Summary
- Low-quality evidence from trials showed no difference in response or remission for augmentation of citalopram treatment with bupropion compared with augmentation with buspirone, but bupropion decreased depression severity more than buspirone 1.
- Moderate-quality evidence showed that discontinuation due to adverse events was lower with bupropion than with buspirone 1.
From the FDA Drug Label
Lithium - Coadministration of citalopram tablets (40 mg/day for 10 days) and lithium (30 mmol/day for 5 days) had no significant effect on the pharmacokinetics of citalopram or lithium. Imipramine and Other Tricyclic Antidepressants (TCAs) - In vitro studies suggest that citalopram is a relatively weak inhibitor of CYP2D6. Coadministration of citalopram tablets (40 mg/day for 10 days) with the TCA imipramine (single dose of 100 mg), a substrate for CYP2D6, did not significantly affect the plasma concentrations of imipramine or citalopram
The antidepressants that can be used in combination with citalopram are:
- Lithium: can be coadministered with citalopram, but plasma lithium levels should be monitored
- Imipramine and other Tricyclic Antidepressants (TCAs): can be coadministered with citalopram, but caution is indicated due to potential increased levels of TCA metabolites 2 2
From the Research
Antidepressant Combination with Citalopram
- Bupropion can be used in combination with citalopram, as shown in a study where sustained-release bupropion was added to citalopram therapy in patients with nonpsychotic major depressive disorder without remission despite citalopram therapy 3.
- Buspirone can also be used in combination with citalopram, as demonstrated in the same study, although sustained-release bupropion had certain advantages, including a greater reduction in symptoms and fewer side effects 3.
- Another study found that the combination of escitalopram (a related medication to citalopram) and bupropion-SR was effective and well-tolerated in outpatients with major depressive disorder, suggesting that bupropion may be a suitable combination therapy for citalopram as well 4.
- A study comparing cognitive therapy and medication augmentation strategies, including sustained-release bupropion, for patients who had received inadequate benefit from an initial trial of citalopram, found that medication augmentation resulted in significantly more rapid remission than augmentation with cognitive therapy 5.
Other Considerations
- When considering combination therapy, it is essential to evaluate the safety and efficacy of the specific medications being used together, as well as the patient's individual needs and medical history.
- The use of antidepressants in certain populations, such as people with epilepsy, requires careful consideration of the potential risks and benefits, and some antidepressants, like bupropion, may not be recommended due to the risk of seizures 6.