Can Citalopram Cause Hypomania?
Yes, citalopram can cause hypomania, though it occurs rarely—this is a recognized adverse effect documented in FDA labeling and clinical guidelines that requires careful monitoring, particularly in patients with risk factors for bipolar disorder. 1
Incidence and Clinical Evidence
The FDA drug label for citalopram explicitly warns about activation of mania/hypomania, reporting it occurred in 0.2% of 1,063 patients treated with citalopram in placebo-controlled trials (compared to 0% in placebo-treated patients). 1 This represents a rare but documented risk that clinicians must consider when prescribing this medication.
The American Academy of Child and Adolescent Psychiatry (AACAP) guidelines confirm that rare reports of mania/hypomania have occurred with SSRIs as a class, including citalopram. 2
Distinguishing Hypomania from Behavioral Activation
A critical clinical distinction must be made between true hypomania and behavioral activation/agitation, as they have different time courses and management strategies:
Behavioral activation typically occurs early in treatment (first month) or with dose increases, presents as motor/mental restlessness, insomnia, impulsiveness, talkativeness, disinhibited behavior, or aggression, and usually improves quickly after SSRI dose reduction or discontinuation. 2
True mania/hypomania may appear later in treatment, persists despite dose reduction, and requires more active pharmacological intervention (often mood stabilizers or antipsychotics). 2
High-Risk Populations Requiring Caution
Citalopram should be used cautiously in patients with a history of mania or bipolar disorder. 1 The AACAP guidelines for bipolar disorder specifically note that antidepressants including SSRIs may destabilize mood or incite manic episodes in bipolar patients, and should only be used as adjuncts when patients are already taking at least one mood stabilizer. 2
Research evidence supports this concern: in a study of bipolar depression treated with citalopram added to mood stabilizers, 1 out of 10 patients experienced a switch to hypomania. 3 However, treatment with SSRIs should be avoided entirely in patients with bipolar disorder history unless adequately covered by mood stabilizers. 2
Dose-Related Considerations
While the evidence for citalopram specifically is limited, case reports with escitalopram (the S-enantiomer of citalopram) suggest a dose-related pattern, with manic/hypomanic symptoms emerging within 1 month after dosage increases to 20 mg/day, and symptoms subsiding with dose reduction. 4 This supports the AACAP recommendation for slow up-titration and close monitoring, particularly starting with subtherapeutic "test" doses. 2
Clinical Monitoring and Management
Close monitoring is essential, especially:
- During the first months of treatment 1
- Following dosage adjustments 1
- In younger children (who have higher rates of behavioral activation) 2
- In patients with any personal or family history of bipolar disorder 1
If hypomania develops:
- Discontinue citalopram immediately 1
- Consider whether this represents unmasking of underlying bipolar disorder versus substance-induced mania (the latter is the DSM classification for antidepressant-precipitated manic episodes) 2
- Initiate appropriate mood stabilizer treatment if symptoms persist after discontinuation 2
Key Clinical Pitfall
The most important pitfall is failing to distinguish between early behavioral activation (which may resolve with dose adjustment) and true hypomania (which requires discontinuation and mood stabilizer treatment). Behavioral activation improves quickly with dose reduction, while hypomania persists and worsens. 2