Is it safe to continue taking Celexa (citalopram) during pregnancy, and what is the recommended dosage for a patient with post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) at 6 weeks gestation?

Citalopram (Celexa) Use at 6 Weeks Pregnancy for PTSD and MDD

Continue citalopram during pregnancy at the lowest effective dose that maintains symptom control, as the risks of untreated PTSD and MDD to both mother and fetus likely outweigh the minimal fetal risks associated with this medication. 1, 2

Why Continue Treatment

• Untreated maternal depression and PTSD carry substantial documented risks including premature birth, decreased breastfeeding initiation, harm to the mother-infant relationship, and potential effects on fetal central nervous system development 1, 3
• Women who discontinue antidepressants during pregnancy show significantly increased relapse rates of major depression compared to those who continue treatment 2
• The decision to treat psychiatric illness during pregnancy must weigh risks of the disorder against medication risks on a case-by-case basis, but established benefits of treating depression generally favor continuation 2

Safety Profile of Citalopram in Pregnancy

Malformation Risk

• No increased risk of major congenital malformations has been demonstrated with first-trimester SSRI use in large population-based studies 1
• The FDA label notes that citalopram showed teratogenic effects (cardiovascular and skeletal defects) in rats only at doses 18 times the maximum human dose, with maternal toxicity present 2
• Animal studies showed a no-effect dose at approximately 9 times the human therapeutic dose 2

Third-Trimester Considerations

• Neonates exposed to SSRIs late in the third trimester may develop transient complications including respiratory distress, jitteriness, tremors, feeding difficulty, irritability, and temperature instability 1, 2
• These symptoms typically appear within hours to days after birth and usually resolve within 1-2 weeks 1
• Arrange for early follow-up after hospital discharge and monitor infants for signs of drug toxicity or withdrawal over the first week of life 1

Persistent Pulmonary Hypertension Risk

• Late pregnancy SSRI exposure has a possible association with persistent pulmonary hypertension of the newborn (PPHN), with a number needed to harm of 286-351 1
• PPHN occurs in 1-2 per 1,000 live births in the general population; several epidemiologic studies suggest a positive statistical association with SSRI use, though other studies do not show significant association 2

Dosing Recommendations

Current Pregnancy Management

• Use the lowest effective dose throughout pregnancy rather than discontinuing treatment 1
• Citalopram doses of 20-40 mg once daily resulted in low maternal trough plasma concentrations during pregnancy, with only one subject requiring dose increase in a prospective study 4
• Pregnancy induces CYP2D6 metabolism, which may lower citalopram levels, particularly in late pregnancy 4, 5
• Dose increases may be needed for citalopram, especially late in pregnancy, due to pharmacokinetic changes 5

Monitoring Strategy

• Close clinical monitoring of mood and PTSD symptoms is essential to detect if current dose remains therapeutic 5
• If symptoms worsen despite adherence, consider that pregnancy-related pharmacokinetic changes may have lowered drug levels and dose adjustment may be needed 5
• Therapeutic drug monitoring can be considered for citalopram to minimize fetal exposure while maintaining maternal therapeutic benefit 4

Alternative Considerations

Sertraline as First-Line Alternative

• If switching SSRIs is considered, sertraline should be the first-line choice due to minimal excretion in breast milk (important for postpartum planning) and low infant-to-maternal plasma concentration ratios 1
• Start sertraline at 25-50 mg daily and slowly titrate upward while monitoring symptoms 1
• However, switching medications during pregnancy carries its own risks of symptom destabilization

PTSD-Specific Treatment

• SSRIs including citalopram are considered first-line medication treatment for PTSD, with limited but favorable data supporting citalopram's efficacy 6
• Escitalopram (the S-enantiomer of citalopram) showed significant improvement in PTSD symptoms in open-label trials, with 45% of patients much or very much improved 6
• Psychological interventions for prenatal PTSD are extremely limited in evidence, with only psychoeducation interventions showing small to large effect sizes (Cohen's d = 0.16-0.78) 7

Postpartum and Breastfeeding Planning

• Citalopram is excreted in human breast milk, with concentrations 2-3 fold higher than maternal plasma concentrations 4
• However, infant plasma concentrations during breastfeeding were very low or undetectable in prospective studies 4
• Two case reports exist of infants experiencing excessive somnolence, decreased feeding, and weight loss with breastfeeding from citalopram-treated mothers, with one infant recovering completely upon discontinuation 2
• If breastfeeding is planned, discuss switching to sertraline postpartum, as it is minimally excreted in breast milk and provides the infant with less than 10% of maternal daily dose 1

Key Clinical Pitfalls to Avoid

• Do not discontinue citalopram abruptly due to pregnancy, as this significantly increases relapse risk and may harm both mother and fetus more than continued treatment 1, 2
• Do not avoid treatment altogether due to fear of medication risks, as untreated maternal psychiatric illness carries substantial documented risks 1
• Do not assume the pre-pregnancy dose will remain therapeutic throughout pregnancy, as pharmacokinetic changes may necessitate dose adjustments 5
• Coordinate care closely with obstetrics and document all risk-benefit discussions thoroughly 3