Is Citalopram (Celexa) effective for treating night terrors?

Citalopram for Night Terrors

Citalopram (Celexa) is not recommended as a first-line treatment for night terrors, as there is insufficient evidence supporting its efficacy for this specific condition. Instead, Image Rehearsal Therapy (IRT) is the recommended first-line treatment for nightmare disorders, including night terrors 1, 2.

First-Line Treatments for Night Terrors

Non-Pharmacological Approaches

• Image Rehearsal Therapy (IRT) is the recommended first-line treatment for nightmare disorders, showing significant reductions in nightmare frequency (60-72%) 3
• IRT involves recalling the nightmare, changing negative elements to positive ones, and rehearsing the rewritten dream scenario for 10-20 minutes daily 3, 2
• Other effective non-pharmacological options include Exposure, Relaxation, and Rescripting Therapy (ERRT) and Eye Movement Desensitization and Reprocessing (EMDR) 3

Pharmacological Options for Night Terrors

First-Line Medication (If Pharmacotherapy is Needed)

• Prazosin is the most established medication for PTSD-related nightmares, with Level A evidence 4, 2
• Starting dose is 1 mg at bedtime, gradually increasing by 1-2 mg every few days until clinical response 4, 2
• Effective doses range from 3-4 mg/day for civilians to 9.5-15.6 mg/day for military veterans 4, 2

Alternative Medications

• Clonidine (0.2-0.6 mg in divided doses) is recommended as the primary alternative to prazosin with Level C evidence 1, 3
• Trazodone may be used with an effective dose range of 25-600 mg (mean 212 mg), shown to reduce nightmare frequency from 3.3 to 1.3 nights per week 1, 3
• Other medications that may be considered include atypical antipsychotics (olanzapine, risperidone, aripiprazole), topiramate, and tricyclic antidepressants 1, 2

Evidence Regarding SSRIs for Night Terrors

• There is limited evidence specifically for citalopram in treating night terrors 5
• While there is a case report of successful treatment of night terrors with paroxetine (another SSRI) 6, this represents low-quality evidence
• Escitalopram (the S-enantiomer of citalopram) has been reported to successfully treat recurrent isolated sleep paralysis, but not specifically night terrors 7
• The American Academy of Sleep Medicine guidelines do not specifically recommend citalopram for night terrors 1
• Fluvoxamine (another SSRI) may be considered for PTSD-associated nightmares according to the American Academy of Sleep Medicine, but with low-grade evidence 1

Treatment Algorithm

1. Start with Image Rehearsal Therapy as first-line treatment 3, 2
2. If response is inadequate and pharmacotherapy is needed, consider prazosin as the first medication option 4, 2
3. If prazosin is ineffective or poorly tolerated, consider clonidine as the next alternative 1, 3
4. Third-line options include trazodone, topiramate, or atypical antipsychotics 1, 3

Important Clinical Considerations

• Monitor blood pressure when using prazosin or clonidine due to potential hypotensive effects 4, 2
• Discontinuation of medications may lead to a return of nightmares to baseline intensity 2
• Untreated nightmares significantly impair quality of life, causing sleep avoidance and exacerbating psychiatric symptoms 4, 3
• Clonazepam and venlafaxine are specifically not recommended for nightmare disorder 1, 3

Caution

• While some tricyclic antidepressants like imipramine have shown efficacy in case reports of night terrors 8, 9, they have more side effects than newer agents
• SSRIs like citalopram lack specific evidence for night terrors, despite their general favorable safety profile 5