Should a patient with a history of obesity and potential mental health conditions, currently taking Celexa (citalopram), stop their medication prior to undergoing gastric sleeve surgery?

Should You Stop Celexa Prior to Gastric Sleeve Surgery?

No, you should not stop Celexa (citalopram) prior to gastric sleeve surgery—in fact, continuing antidepressant therapy is critical because bariatric surgery patients face increased risks of depression, anxiety, and suicidal ideation postoperatively. 1, 2

Mental Health Risks Take Priority

The most important consideration here is not the medication itself, but rather the mental health status of the patient:

• Candidates for bariatric surgery with histories of significant depression or mental health conditions must be assessed by a mental health professional with expertise in obesity management prior to surgery. 1

• Surgery should be postponed in patients with severe depression or suicidal ideation until these conditions have been sufficiently addressed—not by stopping medication, but by optimizing treatment. 1

• Patients who undergo metabolic surgery are at increased risk for worsening or new-onset depression, anxiety disorders, substance abuse, and suicidal ideation. 1

• The American Diabetes Association emphasizes that assuming weight loss will resolve depression is not recommended, and antidepressant use is only slightly reduced after bariatric procedures. 2

Medication Management Strategy

Preoperative Phase

• Continue Celexa through the perioperative period unless there are specific contraindications unrelated to the surgery itself. 2

• Ensure psychiatric stability before proceeding with surgery—this means the patient should be on an effective, stable antidepressant regimen, not discontinuing therapy. 1

• Document current mental health status and medication effectiveness as part of the preoperative psychiatric evaluation. 1

Postoperative Medication Absorption Considerations

While gastric sleeve surgery does alter medication absorption, the impact is generally less severe than with gastric bypass since intestinal anatomy remains intact:

• Gastric sleeve surgery alters medication absorption through reduced gastric volume, accelerated gastric emptying, and changes in pH environment, though the impact is generally less severe than with gastric bypass. 2

• Extended-release and enteric-coated formulations may have unpredictable absorption after bariatric procedures—standard immediate-release citalopram tablets are preferable. 2

• Alternative formulations such as liquid preparations or sublingual options may provide more reliable absorption if standard tablets prove inadequate postoperatively. 2

• Citalopram has favorable pharmacokinetic properties with linear kinetics and is well-tolerated, making it a reasonable choice for continuation through bariatric surgery. 3

Postoperative Monitoring Protocol

Intensive psychiatric surveillance is mandatory after bariatric surgery:

• Individuals with preoperative psychopathology should be assessed regularly following metabolic surgery to optimize mental health management and ensure psychiatric symptoms don't interfere with weight loss. 1

• Monitor for clinical effectiveness of the antidepressant postoperatively—watch for return of depressive symptoms that might indicate inadequate absorption. 2, 4, 5

• For drugs with a narrow therapeutic index, plasma drug levels, patients' clinical outcomes, and laboratory markers need to be monitored closely. 4

• Patients should be followed up frequently and treated in accordance with their response to drug therapy. 4

Common Pitfalls to Avoid

Critical Error: Discontinuing Antidepressants Preoperatively

• Do not discontinue citalopram abruptly—the FDA label warns that symptoms associated with discontinuation include anxiety, irritability, mood changes, restlessness, sleep changes, headache, sweating, nausea, dizziness, electric shock-like sensations, shaking, and confusion. 6

• A gradual reduction in dose rather than abrupt cessation is recommended whenever possible if discontinuation is truly necessary. 6

• Stopping antidepressants in anticipation of surgery creates unnecessary psychiatric destabilization in a patient population already at high risk for mental health complications. 1

Medication-Specific Considerations

• Citalopram has important cardiac considerations (QT prolongation risk), but this is a reason for ECG monitoring, not discontinuation. 6

• The maximum recommended dose is 40 mg/day due to QT prolongation risk, with 20 mg/day maximum for patients over 60 years of age. 6

• Research suggests bupropion may be associated with greater weight loss after bariatric surgery compared to SSRIs, but switching medications perioperatively introduces unnecessary risk. 7

Practical Algorithm

For a patient currently stable on Celexa preparing for gastric sleeve surgery:

1. Continue current Celexa dose through surgery 2
2. Ensure preoperative psychiatric evaluation confirms stability 1
3. Use immediate-release formulation (not extended-release) postoperatively 2
4. Schedule psychiatric follow-up within 2-4 weeks postoperatively 1
5. Monitor for return of depressive symptoms suggesting inadequate absorption 2, 4
6. Consider liquid formulation if absorption concerns arise 2
7. Maintain long-term psychiatric surveillance given elevated risk profile 1

The goal is psychiatric stability through the perioperative period, not medication discontinuation. The anatomical changes from sleeve gastrectomy are manageable with appropriate monitoring and formulation adjustments if needed, but the mental health risks of stopping antidepressants are immediate and potentially severe. 1, 2