How should I taper citalopram 20 mg and start sertraline 50 mg?

How to Taper Citalopram 20 mg and Start Sertraline 50 mg

You should taper citalopram gradually over 4-6 weeks using hyperbolic dose reductions down to very small doses (as low as 2.5 mg or less) before complete cessation, and only begin sertraline after citalopram is fully discontinued to avoid overlapping serotonergic medications and minimize withdrawal symptoms. 1, 2

Critical Understanding: Why Standard Tapering Fails

• Citalopram (like all SSRIs) requires hyperbolic tapering, not linear tapering, because receptor occupancy decreases in a non-linear fashion as doses are reduced 2
• Standard guidelines recommending 2-4 week tapers down to half the minimum therapeutic dose show minimal benefit over abrupt discontinuation and are often not tolerated by patients 2
• Never use alternate-day dosing (e.g., taking 20 mg every other day) as this causes severe fluctuations in receptor occupancy and dramatically increases withdrawal symptoms, even at standard doses 3

Recommended Tapering Protocol for Citalopram 20 mg

Week 1-2: Initial Reduction

• Reduce to 15 mg daily for 1-2 weeks 1
• Monitor for withdrawal symptoms including dizziness, fatigue, nausea, anxiety, sensory disturbances, and flu-like symptoms 1, 4

Week 3-4: Second Reduction

• Reduce to 10 mg daily for 1-2 weeks 1
• Continue daily monitoring for withdrawal symptoms 1

Week 5-6: Third Reduction

• Reduce to 5 mg daily for 1-2 weeks 1
• This step is critical—do not skip to complete cessation from 10 mg 2

Week 7-8: Final Reduction

• Reduce to 2.5 mg daily for 1-2 weeks 1
• This very low dose is essential because hyperbolic tapering requires reaching doses far below minimum therapeutic levels to minimize receptor occupancy fluctuations 2

Week 9: Complete Discontinuation

• Stop citalopram completely after the 2.5 mg phase 1
• Wait at least 3-5 days after complete cessation before starting sertraline to ensure citalopram clearance 4

Starting Sertraline After Citalopram Discontinuation

Timing

• Begin sertraline only after citalopram is fully discontinued for at least 3-5 days 4, 5
• Do not overlap these medications, as both are serotonergic and increase the risk of serotonin syndrome 6

Initial Sertraline Dosing

• Start sertraline at 25 mg daily for the first week, not 50 mg 6
• Increase to 50 mg daily after 1 week if the 25 mg dose is well-tolerated 6
• This staged approach minimizes the risk of serotonin syndrome, which can occur even at the lowest therapeutic dose of 25 mg 6

Mandatory Monitoring Requirements

During Citalopram Taper

• Weekly contact for the first month of tapering 6
• Monitor for withdrawal symptoms that typically appear within 1-3 days of each dose reduction 1
• Common symptoms include dizziness (most frequent), muscle tension, chills, confusion, insomnia, nausea, and anxiety 1, 4, 7

During Sertraline Initiation

• Weekly contact for the first month after starting sertraline 6
• Monitor for serotonin syndrome symptoms: mental status changes, agitation, confusion, tremors, autonomic hyperactivity 6
• Highest risk period is the first 24-48 hours after each dose increase 6

Managing Withdrawal Symptoms

If Withdrawal Symptoms Emerge

• Do not mistake withdrawal for depression relapse—this is a common pitfall that leads to unnecessary long-term medication continuation 1, 4
• If symptoms are severe, return to the previous dose and slow the taper rate further 1, 5
• The taper may need to be paused and restarted when the patient is ready 1
• Consider extending each dose reduction phase to 2-3 weeks instead of 1-2 weeks 5

Symptomatic Management

• Provide reassurance that withdrawal symptoms are typically transient 4
• For severe symptoms, reinstitute the previous dose and taper even more slowly 5
• Symptoms can last days to months, with different symptoms having different durations 5

Critical Pitfalls to Avoid

• Never taper faster than 10% per month for patients on long-term SSRI therapy 8
• Never use alternate-day dosing as a tapering strategy—this causes severe receptor occupancy fluctuations 3
• Never start sertraline while still tapering citalopram—complete the taper first 6, 4
• Never skip the very low dose phase (2.5 mg)—hyperbolic tapering requires reaching doses far below therapeutic minimums 2
• Never assume the patient is safe on sertraline 50 mg just because they tolerated 25 mg—serotonin syndrome risk increases with dose escalation 6

Special Considerations

• Patients on higher doses of citalopram or with lower drug clearance have higher risk of withdrawal symptoms 7
• The entire process from starting the citalopram taper to reaching sertraline 50 mg will take approximately 10-12 weeks minimum 1, 5
• If the patient has been on citalopram for more than 1 year, consider an even slower taper (10% per month or slower) 8