What is the recommended method to taper citalopram safely in an adult?

How to Properly Wean Citalopram

Taper citalopram gradually over weeks to months by reducing the dose by 10–25% of the current dose every 1–2 weeks, with slower tapers (10% per month) for patients on treatment longer than one year, and never discontinue abruptly as this can trigger withdrawal symptoms including dizziness, flu-like symptoms, mood disturbances, and paresthesias. 1, 2, 3

Critical Safety Framework

Abrupt discontinuation of citalopram must be avoided. The FDA label explicitly warns that "abrupt discontinuation can be associated with certain symptoms" and recommends that "medication should be tapered, as rapidly as is feasible" when discontinuing treatment 1. Antidepressant discontinuation syndrome (ADS) commonly manifests as insomnia, flu-like symptoms, mood disturbances, dizziness, and paresthesias, with symptoms potentially lasting days to months 2.

Citalopram causes dose-dependent QTc prolongation, so patients should not exceed 40 mg/day during treatment, and maximum doses should be limited to 20 mg/day in patients over 60 years, those with hepatic impairment, or CYP2C19 poor metabolizers 1.

Standard Tapering Protocol

For Patients on Citalopram Less Than 1 Year

• Reduce by 10–25% of the current dose every 1–2 weeks 4, 2, 3
• For example, if a patient is on citalopram 40 mg/day:
  • Week 1–2: Reduce to 30 mg/day (25% reduction)
  • Week 3–4: Reduce to 22.5–24 mg/day (20–25% of current dose)
  • Week 5–6: Reduce to 17–18 mg/day (20–25% of current dose)
  • Continue this pattern until discontinuation 4

For Patients on Citalopram Longer Than 1 Year

• Reduce by 10% of the current dose per month to minimize withdrawal symptoms 5, 6
• This slower taper is better tolerated and reduces the risk of severe discontinuation symptoms 5
• The entire taper will likely require 6–12 months minimum, and possibly longer depending on patient tolerance 5, 2

Critical Tapering Principle

Always reduce by a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 5, 6. For instance, reducing 10% of 40 mg is 4 mg, but 10% of 10 mg is only 1 mg—this prevents the final steps from being too aggressive 5.

Identifying High-Risk Patients

Patients at higher risk for severe withdrawal symptoms include those who 7:

• Experience withdrawal symptoms with missed doses or non-compliance
• Had previous unsuccessful discontinuation attempts
• Are taking higher than minimum effective doses
• Have been on treatment for extended periods (>1 year)

For these patients, consider non-linear dose-reduction steps with even slower tapering schedules 7.

Managing Withdrawal Symptoms

Recognition of Withdrawal Symptoms

Monitor specifically for 2, 3:

• Somatic symptoms: Dizziness, light-headedness, nausea, vomiting, fatigue, lethargy, myalgia, chills, flu-like symptoms, sensory disturbances, sleep disturbances
• Psychological symptoms: Anxiety, agitation, crying spells, irritability, mood disturbances

Critical pitfall: Do not misdiagnose withdrawal symptoms as relapse of depression or physical illness, as this leads to unnecessary testing and treatment 3. Withdrawal symptoms typically emerge within days of dose reduction and are self-limiting, whereas relapse develops more gradually over weeks 2, 3.

Management Strategy

If withdrawal symptoms emerge 2, 3:

1. Restart the prior dose of citalopram that was tolerated
2. Taper even more slowly once symptoms resolve
3. Provide symptomatic management as needed
4. Reassure the patient that symptoms are usually transient 3

For mild symptoms, patient reassurance may be sufficient 3. For more severe symptoms, reinstituting the previous dose and slowing the taper rate is necessary 2, 3.

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 5, 6
• Monitor for withdrawal symptoms at each visit 5, 6
• Screen for emerging depression, anxiety, and suicidal ideation, especially during the initial weeks of dose changes 1
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge—the taper rate must be determined by patient tolerance, not a rigid schedule 5, 6

Adjunctive Strategies to Improve Success

Psychological Support

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated whenever possible 5, 8. Low-certainty evidence suggests that combining taper with preventive cognitive therapy or mindfulness-based cognitive therapy may result in successful discontinuation rates of 40–75% 8.

Patient Education

• Educate patients about the risks of continued antidepressant use versus benefits of discontinuation 5
• Provide clear, balanced information about potential withdrawal symptoms to normalize the process and reduce nocebo effects 9
• Explain that withdrawal symptoms in the final stages of tapering should not automatically be interpreted as relapse 9

Non-Pharmacological Support

Consider incorporating 5:

• Mindfulness and relaxation techniques
• Sleep hygiene education
• Exercise and fitness training

Special Populations

Elderly Patients (>60 Years)

• Maximum citalopram dose should be limited to 20 mg/day due to higher drug exposures 1
• Use lower starting doses (approximately 50% of adult starting dose) 4
• Consider more gradual tapers with smaller dose reductions 5

Patients with Hepatic Impairment

• Maximum dose should be limited to 20 mg/day 1
• Consider dose adjustments during tapering 4

Patients with Recurrent Depression

Nearly all discontinuation studies have been conducted in patients with recurrent depression (two or more prior episodes) 8. For patients with only one or no prior episodes, evidence is limited, but the same gradual tapering principles apply 8.

When to Refer to a Specialist

Immediate specialist referral is indicated for patients with 5:

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Realistic Expectations and Acceptable Outcomes

• The taper will likely take 6–12 months minimum, and possibly several years for some patients 5, 2
• Both complete discontinuation and achieving a reduced, functionally acceptable dose are acceptable outcomes based on patient goals and tolerance 5
• Never abandon the patient even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy as a legitimate outcome 5
• Success is defined by durability of the taper, not speed 5, 6

Common Pitfalls to Avoid

1. Never taper too quickly—research shows that even 10% reductions every 3 days resulted in only 24% of patients successfully completing withdrawal 5
2. Never use straight-line percentage reductions from the starting dose—this subjects patients to disproportionately large final decrements 5
3. Never discontinue abruptly—this is equivalent to suddenly stopping antihypertensives or antihyperglycemics and carries serious risks 5, 1
4. Do not confound withdrawal symptoms with relapse—withdrawal emerges within days of dose reduction, while relapse develops gradually over weeks 2, 3, 8