What is the recommended tapering schedule for Celexa (citalopram) 20mg?

Tapering Celexa (Citalopram) 20mg

For citalopram 20mg, reduce the dose by 10% of the original dose (2mg) every 2-4 weeks, which means stepping down to 18mg, then 16mg, then 14mg, and so on, with slower monthly reductions for patients on long-term therapy. 1

Specific Tapering Schedule

Standard Taper Protocol

• Reduce by 2mg (10% of 20mg) every 2-4 weeks until reaching very low doses 1
• For patients on citalopram for years, slow to 10% reductions per month or less 1
• Monitor for withdrawal symptoms after each dose reduction before proceeding to the next step 1

Why Hyperbolic (Proportional) Tapering Matters

• Do NOT use alternate-day dosing (e.g., 20mg every other day) as this causes severe receptor occupancy fluctuations and withdrawal symptoms 2
• SSRIs like citalopram have a hyperbolic relationship between dose and serotonin transporter occupancy, meaning equal dose reductions at lower doses cause disproportionately larger biological effects 3
• Taper to doses much lower than minimum therapeutic doses (well below 10mg) before complete cessation to minimize withdrawal 3

Practical Dosing Steps from 20mg

1. 20mg → 18mg (hold 2-4 weeks)
2. 18mg → 16mg (hold 2-4 weeks)
3. 16mg → 14mg (hold 2-4 weeks)
4. 14mg → 12mg (hold 2-4 weeks)
5. 12mg → 10mg (hold 2-4 weeks)
6. Continue reducing by 10% of the previous dose (not original): 10mg → 9mg → 8mg → 7mg → 6mg → 5mg → 4.5mg → 4mg → 3.5mg → 3mg, etc. 3
7. Final doses may need to be as low as 0.5mg before complete cessation 3, 4

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Monitor

• Dizziness, nausea, headache, paresthesia (tingling/electric shock sensations) 1
• Irritability, anxiety, insomnia 1
• These symptoms typically emerge within days of dose reduction 3

Management Strategy

• If severe withdrawal occurs, return to the previous well-tolerated dose and slow the taper further 1
• For insomnia specifically, consider short-term non-benzodiazepine sleep aids 1
• Do not push forward if symptoms are severe—pause the taper and stabilize 1

Duration Expectations

• Minimum tapering duration: 2-3 months for short-term users 1
• Extended tapering: 6-12 months or longer for patients on long-term therapy 1
• Research shows slower tapers over months are associated with lower relapse rates compared to rapid tapers over weeks 3, 5

Critical Pitfalls to Avoid

The Alternate-Day Dosing Trap

• Never use "20mg every other day" as a tapering strategy 2
• This creates dramatic fluctuations in serotonin transporter occupancy between doses, triggering withdrawal symptoms 2
• The variation in receptor occupancy increases as doses decrease, making this approach particularly problematic at lower doses 2

Distinguishing Withdrawal from Relapse

• Withdrawal symptoms typically occur within days of dose reduction and improve with dose stabilization 3
• Depression relapse typically emerges more gradually over weeks 5
• Current guidelines provide inadequate guidance on this distinction, so err on the side of slowing the taper if uncertain 5

The "Therapeutic Minimum" Misconception

• Standard guidelines recommend tapering to half the minimum therapeutic dose (5-10mg for citalopram) then stopping 3, 5
• This approach shows minimal benefit over abrupt discontinuation 3
• Evidence demonstrates that tapering to much lower doses (1-2mg or less) significantly reduces withdrawal symptoms 3

Special Considerations

• Liquid formulations or compounded preparations may be necessary to achieve very small dose reductions at lower doses 3
• Some patients may need to pause the taper temporarily and resume when ready—this is acceptable as long as progress is being made 1
• The taper should be individualized based on withdrawal symptom severity, but the framework above provides the evidence-based structure 1