Can Discontinuing Low-Dose Citalopram Cause Sleepwalking?
Discontinuing low-dose citalopram is unlikely to directly cause sleepwalking, but it can trigger a discontinuation syndrome that includes insomnia, which may theoretically unmask or worsen underlying sleep disorders including parasomnias. However, the evidence linking SSRI discontinuation specifically to sleepwalking is extremely limited.
Understanding SSRI Discontinuation Syndrome
The primary concern with stopping citalopram relates to discontinuation syndrome, not sleepwalking per se:
Citalopram discontinuation syndrome is characterized by dizziness, fatigue, lethargy, general malaise, myalgias, chills, headaches, nausea, vomiting, diarrhea, insomnia, imbalance, vertigo, sensory disturbances, paresthesias, anxiety, irritability, and agitation 1, 2.
Citalopram has a relatively lower risk of discontinuation syndrome compared to paroxetine, fluvoxamine, and sertraline, which are more commonly associated with withdrawal symptoms 1, 2.
The insomnia component of discontinuation syndrome could potentially disrupt normal sleep architecture and theoretically contribute to parasomnias, though this is not directly documented 1.
SSRIs and Sleepwalking: The Evidence
The relationship between SSRIs and sleepwalking is complex and primarily involves active use rather than discontinuation:
SSRIs (including citalopram) have been shown to induce or exacerbate REM Behavior Disorder (RBD) during active treatment, along with tricyclic antidepressants and MAOIs 1.
RBD involves complex, often violent motor behaviors during sleep with loss of normal REM sleep atonia, which is distinct from typical sleepwalking (a non-REM parasomnia) 1.
Sleepwalking has been reported with alcohol and barbiturate withdrawal, suggesting that withdrawal states from CNS-active medications can trigger parasomnias 1.
Clinical Reasoning and Risk Assessment
The more plausible scenario is that citalopram discontinuation causes insomnia (part of discontinuation syndrome), which then disrupts sleep quality and potentially unmasks latent parasomnia tendencies:
Sleep deprivation and fragmented sleep are known triggers for parasomnias in susceptible individuals 1.
If sleepwalking occurs after stopping citalopram, consider whether the patient has a personal or family history of parasomnias, as this would increase susceptibility 1.
Important Caveats and Alternative Explanations
If sleepwalking develops after stopping citalopram, investigate these alternative causes:
Concurrent medications: Zolpidem, other benzodiazepine receptor agonists, and certain antidepressants (mirtazapine) are directly associated with sleepwalking 1, 3, 4, 5.
Drug interactions: If the patient is taking zolpidem or similar sleep aids, these are known to cause sleepwalking and carry FDA warnings about complex sleep behaviors 1, 3, 4.
Underlying neurological conditions: RBD can be associated with Parkinson's disease, brainstem abnormalities, or other neurodegenerative disorders 1.
Alcohol or other substance withdrawal: These are established causes of parasomnias 1.
Practical Management Approach
If sleepwalking occurs after citalopram discontinuation:
Reinitiate citalopram temporarily and taper more gradually over several weeks rather than stopping abruptly 1, 2.
Review all medications, particularly any sleep aids (zolpidem, zaleplon, eszopiclone) which have direct causal links to sleepwalking 1, 3, 4.
Implement environmental safety measures: Remove dangerous objects, pad surfaces around the bed, use heavy window coverings, and consider placing the mattress on the floor 1.
Consider polysomnography if episodes are recurrent or severe to evaluate for RBD or other primary sleep disorders 1.
Evaluate for underlying sleep disorders such as sleep apnea, which can trigger parasomnias when untreated 1.