What is the recommended treatment and dosage for depression using Citalopram (Selective Serotonin Reuptake Inhibitor - SSRI)?

Citalopram for Depression: Treatment and Dosing Recommendations

Start citalopram at 20 mg once daily for most adult patients with depression, which can be increased to a maximum of 40 mg/day after at least one week if clinical response is insufficient. 1, 2

Initial Dosing Strategy

• Begin with 20 mg once daily (morning or evening, with or without food) for the majority of adult patients under 60 years of age 2
• Allow at least one week before considering dose escalation to assess initial response 1, 2
• The 40 mg/day and 60 mg/day doses demonstrate particularly robust efficacy for moderate-to-severe depression, especially for symptoms of depressed mood and melancholia 3
• Never exceed 40 mg/day due to dose-dependent QT interval prolongation risk; the 60 mg dose offers no additional benefit over 40 mg 2, 3

Special Population Dose Adjustments

Maximum dose is 20 mg/day for the following high-risk groups 1, 2:

• Patients ≥60 years of age (increased QT prolongation risk) 1, 2
• Hepatic impairment (any severity) 2
• CYP2C19 poor metabolizers or patients taking CYP2C19 inhibitors like cimetidine 2

For anxious or sensitive patients, consider starting at 10 mg/day initially, though this lower dose shows less robust efficacy than 20-40 mg 1, 3

Treatment Duration

• Acute phase: Continue treatment for at least 4 months after achieving remission of a first depressive episode 1
• Maintenance therapy: Patients with recurrent depression require prolonged treatment, potentially 24 weeks or longer after initial stabilization 1, 2
• Evidence supports maintaining the same dose during continuation that achieved acute remission (20-40 mg/day) 2
• Important caveat: Data suggest that full-dose antidepressant (40 mg/day) may be superior to reduced-dose (20 mg/day) for preventing recurrence in high-risk patients with frequent recurrences 4

Monitoring Requirements

QT interval monitoring is essential, particularly when 1:

• Initiating treatment in elderly patients
• Adjusting doses upward
• Combining with other QT-prolonging medications

Watch for hyponatremia, which occurs in 0.5-12% of older adults taking SSRIs 1

Common adverse effects requiring monitoring include 1, 3:

• Nausea and vomiting (most common reason for discontinuation, though only 15% discontinue overall)
• Sexual dysfunction
• Dry mouth, somnolence, insomnia, increased sweating

Discontinuation Protocol

• Taper gradually over 10-14 days rather than abrupt cessation to minimize withdrawal symptoms 5, 2
• Monitor for discontinuation symptoms including dizziness, sensory disturbances, anxiety, and mood changes 2
• If intolerable symptoms emerge during taper, resume the previous dose and decrease more gradually 2

Drug Interaction Precautions

• Allow 14 days between discontinuing an MAOI and starting citalopram (and vice versa) 2
• Exercise caution with other serotonergic medications due to serotonin syndrome risk 1
• Avoid combining with CYP2C19 inhibitors unless dose is reduced to maximum 20 mg/day 2

Clinical Pitfalls to Avoid

• Do not exceed 40 mg/day in any patient—the QT prolongation risk outweighs any potential benefit 2, 3
• Do not use 20 mg maintenance dosing in patients with highly recurrent depression (≥2 episodes in 18 months); these patients may require 40 mg/day for adequate prophylaxis 4
• Do not rush dose escalation—allow full week intervals to assess response and tolerability 2
• Patients with persistent psychosocial impairment despite symptom improvement remain at higher recurrence risk and may need longer treatment duration 4