Tapering Citalopram from 40mg Daily
Reduce citalopram from 40mg to 20mg daily and maintain this dose for at least 2-4 weeks before considering further reduction or discontinuation. 1
Rationale for Gradual Dose Reduction
The FDA-approved prescribing information explicitly states that "a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" when discontinuing citalopram 1. This approach minimizes the risk of discontinuation syndrome, which can manifest as dizziness, fatigue, lethargy, general malaise, myalgias, chills, headaches, nausea, vomiting, diarrhea, insomnia, imbalance, vertigo, sensory disturbances, paresthesias, anxiety, irritability, and agitation 2.
Specific Tapering Protocol
- First step: Reduce to 20mg daily - This represents a 50% dose reduction from your current 40mg dose 1
- Duration at 20mg: Maintain for 2-4 weeks minimum - This allows time to assess for withdrawal symptoms and ensures stabilization before further reduction 1
- Monitor closely during the first 2-4 weeks after dose reduction, as discontinuation symptoms typically emerge during this period 2
Critical Warnings About Alternate-Day Dosing
Do not attempt alternate-day dosing (e.g., 40mg every other day) as a tapering strategy. Recent pharmacokinetic modeling demonstrates that prolonging the inter-dose interval with citalopram leads to pronounced increases in receptor occupancy variation, which significantly increases the risk of severe withdrawal effects 3. This approach cannot be recommended as a prudent tapering strategy 3.
Monitoring for Discontinuation Syndrome
Watch for these specific symptoms after dose reduction 2:
- Neurological: Dizziness, vertigo, sensory disturbances, paresthesias, imbalance
- Gastrointestinal: Nausea, vomiting, diarrhea
- Psychiatric: Anxiety, irritability, agitation, insomnia
- Somatic: Fatigue, lethargy, myalgias, chills, headaches
If intolerable symptoms occur following the dose reduction, resume the previously prescribed 40mg dose and subsequently decrease at a more gradual rate 1.
Additional Considerations
Clinical context matters: A large Veterans Health Administration study of 35,848 patients found that reducing citalopram from doses >40mg to ≤40mg was associated with increased hospitalizations (adjusted hazard ratio=4.5), particularly for depression-related admissions 4. While your situation involves tapering off entirely rather than dose-limiting for safety, this underscores the importance of gradual reduction and close monitoring.
Citalopram has a shorter half-life compared to fluoxetine, making it more susceptible to discontinuation syndrome 2. The recommended 1-2 week intervals between dose adjustments for shorter half-life SSRIs like citalopram should guide your tapering schedule 2.
If Further Reduction is Needed
After successfully maintaining 20mg for 2-4 weeks without significant withdrawal symptoms, consider reducing to 10mg daily for another 2-4 weeks before complete discontinuation 1. The 10mg dose has demonstrated antidepressant efficacy in clinical trials, though with lower effect sizes than higher doses 5, and produces side effects comparable to placebo 5.