What is the recommended tapering schedule for citalopram 20 mg to avoid discontinuation symptoms?

Citalopram 20mg Weaning Process

For citalopram 20mg, taper gradually over several weeks to months by reducing the dose by 10% of the current dose every 1-2 weeks, continuing down to very small doses (as low as 2-5mg) before complete cessation to minimize discontinuation syndrome. 1

Tapering Schedule

The FDA-approved label recommends gradual dose reduction rather than abrupt cessation, with monitoring for discontinuation symptoms throughout the process. 1 While specific tapering schedules are not mandated, the following approach synthesizes best available evidence:

Initial Reduction Phase

• Start by reducing from 20mg to 18mg (a 10% reduction) and maintain for 1-2 weeks 2
• Citalopram is a shorter-acting SSRI requiring careful attention during dose changes 2
• Monitor closely during the first 24-48 hours after each dose reduction 2

Continued Tapering

• Continue reducing by 10% of the most recent dose every 1-2 weeks (e.g., 18mg → 16mg → 14mg → 13mg → 12mg, etc.) 3
• Recent evidence suggests hyperbolic tapering (reducing by a fixed percentage rather than fixed amount) better accounts for the nonlinear relationship between dose and serotonin transporter occupancy 3
• The total taper duration should be several weeks to months, not the traditional 2-4 weeks recommended in older guidelines 3

Final Doses Before Cessation

• Do not stop at the lowest commercially available tablet strength (typically 10mg) 3
• Continue tapering to doses as low as 2-5mg or even lower before complete cessation 3
• This may require splitting tablets, using liquid formulations, or compounding 3
• The final step from a very low dose to zero represents a significant change in receptor occupancy and should not be rushed 3

Discontinuation Syndrome Recognition

Citalopram discontinuation syndrome can occur following missed doses or abrupt cessation, though it is less severe than with paroxetine 2. Common symptoms include:

• Physical symptoms: Dizziness, fatigue, lethargy, myalgias, chills, headaches, nausea, vomiting, diarrhea, insomnia, imbalance, vertigo, sensory disturbances, paresthesias 2, 4
• Psychological symptoms: Anxiety, irritability, agitation, crying spells 2, 4
• Symptoms typically emerge within days of dose reduction and can last days to months 5

Management of Withdrawal Symptoms

If intolerable symptoms develop, immediately reinstate the previous well-tolerated dose and then taper more slowly 1, 5. This is the FDA-recommended approach and should be implemented without delay.

Symptomatic Management

• Mild symptoms can be managed with reassurance that they are typically transient 4
• For more severe symptoms, resuming the prior dose is necessary 1, 5
• After restabilization, resume tapering at a slower rate (e.g., 5% reductions every 2-4 weeks instead of 10% every 1-2 weeks) 5

Distinguishing Withdrawal from Relapse

• Withdrawal symptoms typically begin within days of dose reduction, while relapse develops more gradually over weeks 5
• Withdrawal includes physical symptoms (dizziness, paresthesias, flu-like symptoms) that are uncommon in depression relapse 4, 5
• Consider using standardized symptom rating scales to differentiate 2

Special Considerations and Monitoring

High-Risk Patients

• Patients on higher doses or with lower clearance of citalopram are at increased risk for discontinuation syndrome 6
• The 20mg dose represents a moderate risk level 6
• Very slow tapering is recommended for all patients, regardless of perceived risk 6

Monitoring Schedule

• Schedule follow-up appointments every 1-2 weeks during active tapering 7
• More frequent monitoring may be needed for patients experiencing symptoms 7
• Continue monitoring for several months after complete cessation, as protracted withdrawal symptoms can persist 2

Drug Interactions During Tapering

• Avoid combining with MAOIs or other serotonergic drugs during the taper 2
• Be cautious with drugs that prolong QT interval, though this is less concerning at lower doses 2
• Citalopram has minimal CYP450 interactions compared to other SSRIs 2

Common Pitfalls to Avoid

• Do not use the traditional 2-4 week taper to therapeutic minimum doses—this approach shows minimal benefit over abrupt discontinuation 3
• Do not stop at 10mg (the lowest common tablet strength)—continue tapering to much lower doses 3
• Do not mistake withdrawal symptoms for depression relapse and restart full-dose treatment unnecessarily 4, 5
• Do not ignore patient reports of withdrawal symptoms—these are real physiological phenomena requiring dose adjustment 5