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Ask the Mental Health Expert Archives 2001-2004

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Citalopram for Depression

Q. I have been taking Citalopram (Cipramil, Celexa), one 20 mg tablet a day, for six weeks now, for the treatment of depression and anxiety. It seems to be working, but I have some questions.

Is it true that the use of this medicine is limited to six to twelve months, or it can be taken for a long time on a regular chronic manner? Is there a discontinuation/withdrawal syndrome? Is it dangerous? How can I avoid it? Is there a risk of hypomania? What is it? What is the problem with grapefruits or grapefruit juice and this medicine? Do you recommend taking the more modern Escitalopram (Cipralex, Lexapro) instead of Citalopram? What uses is it better for?

A. There is no absolute or mandated limit as to how long Citalopram--or any antidepressant--may be used; each case must be weighed according to the risks and benefits of continued use for the specific patient. Several studies of citalopram suggest that it has continued antidepressant benefit, and is well-tolerated, for as long as long as 28 months (see Klysner et al, Br J Psychiatry. 2002 Jul;181:29-35; and Franchini et al, Psychiatry Res. 2001 Dec 15;105(1-2):129-33).

Discontinuation syndromes may be seen with many SSRI type medications (e.g., Celexa, Paxil, Zoloft). These usually occur when medication is stopped suddenly or over just a few days, rather than gradually being discontinued over, say, 4-6 weeks. These syndromes may be unpleasant, but are very rarely life-threatening. Usually, the person complains of symptoms such as nausea, vomiting, muscle aches, headache, and insomnia. These problems may be avoided very simply--don't stop the medication suddenly.

Hypomania-abnormally elevated mood or excitation, falling short of full-blown mania-may occasionally be seen with the use of any antidepressant, in susceptible individuals. This is probably a much bigger problem in individuals with bipolar disorder, rather than unipolar depression, but antidepressant-induced hypomania may rarely be seen even in the unipolar depressed patient.

Rates of antidepressant-induced hypomania/mania are hard to establish for many reasons, but in general, this may be seen in from roughly 3-20% of bipolar patients (see Goldberg et al, J Clin Psychiatry. 2002;63:791-795 for review). Rates are probably lower in those with unipolar depression. Regarding grapefruit juice: large quantities of it (probably more than a glass per day) inhibit an enzyme system (called CYP 3A4) that breaks down many medications, including some antidepressants. This may lead to larger-than-expected blood levels of medications, including several antidepressants that are metabolized via CYP 3A4 (mainly located in the intestine).

Citalopram is metabolized by several enzymes, including but not limited to CYP 3A4; in theory, its levels could be increased by drinking large quantities of grapefruit juice. Finally, despite a good deal of hype surrounding the new formulation, Escitalopram--basically, the active isomer of Citalopram--I am not yet convinced it has major therapeutic advantages over the original formulation.

Some data suggest that Lexapro may have a somewhat faster onset of action than conventional Citalopram; possibly slightly fewer side effects; and perhaps slightly greater efficacy based on certain rating scales-but for my money, the jury is still out. (For a review, see Bender K, Psychiatric Times (Advances in Psychiatric Medicine), June 2002).

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November 2003

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