Safe Dose Reduction of Citalopram (Cipramil)
Discontinue citalopram over 10-14 days minimum by reducing the dose by 10-20% every 5-7 days, though slower tapering over months with hyperbolic dose reductions to very low doses (well below therapeutic minimums) is more effective at preventing withdrawal symptoms.
Recommended Tapering Protocol
Standard Approach
- Reduce the dose by 10-20% of the original dose every 5-7 days until complete discontinuation is achieved 1
- The entire taper should extend over a minimum of 10-14 days to limit withdrawal symptoms 1
- After 9 months of treatment, dose reduction should be used to reassess the need for continued medication 1
Optimal Approach for Minimizing Withdrawal
- Hyperbolic (exponential) tapering over months is superior to the standard 2-4 week tapers recommended in older guidelines 2
- Taper down to doses much lower than therapeutic minimums before complete cessation, as this approach shows greater success in reducing withdrawal symptoms 2
- Standard short tapers (2-4 weeks) show minimal benefits over abrupt discontinuation and are often not tolerated by patients 2
Understanding Withdrawal Risk
Incidence and Timing
- Withdrawal symptoms occur in approximately 45.6% of patients discontinuing SSRIs like citalopram 3
- Symptoms typically emerge within 2 weeks of discontinuation or dose reduction 3
- Treatment duration increases withdrawal risk: 6-12 weeks (35.1%), 12-24 weeks (42.7%), >24 weeks (51.4%) 3
Common Withdrawal Symptoms
- Somatic symptoms: dizziness, light-headedness, nausea, vomiting, fatigue, lethargy, myalgia, chills, flu-like symptoms, sensory disturbances, sleep disturbances 4
- Psychological symptoms: anxiety, agitation, crying spells, irritability 4
- Symptoms are generally mild, short-lived, and self-limiting but can be distressing and lead to missed work days 4
Critical Distinction: Withdrawal vs. Relapse
A major pitfall is mistaking withdrawal symptoms for depression relapse, which can lead to unnecessary long-term medication continuation 2, 5
- Withdrawal symptoms typically appear within days to 2 weeks of dose reduction 3
- Depression relapse typically occurs weeks to months after discontinuation
- The symptomatic overlap between withdrawal and relapse is significant and challenging to differentiate 5
Management of Withdrawal Symptoms
Mild Symptoms
- Reassure the patient that symptoms are usually transient and self-limiting 4
- Continue with the planned taper schedule 4
Severe Symptoms
- Reinstitute the previous dose of citalopram immediately 4
- Slow the rate of taper significantly once symptoms resolve 4
- Consider extending the taper over several months rather than weeks 2
Risk Factors for Severe Withdrawal
Patients at higher risk include those who are:
- Female 3
- Younger age 3
- Experiencing adverse effects early in treatment 3
- Taking higher doses or longer duration of medication 3
- Abruptly stopping rather than tapering 3
Key Clinical Pitfalls to Avoid
- Never abruptly discontinue citalopram, especially after prolonged use 2, 4
- Do not use standard 2-4 week tapers for patients on long-term treatment, as these are inadequate 2
- Do not stop at therapeutic minimum doses—continue tapering to much lower doses before complete cessation 2
- Do not misdiagnose withdrawal as relapse, which leads to unnecessary medication reinitiation 4, 5
- Avoid intermittent non-compliance during treatment, as this precipitates withdrawal symptoms 4
Practical Tapering Example
For a patient on citalopram 20mg daily for >6 months: