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Nov 13, 2020
6 min read

Citalopram withdrawal: recognizing symptoms

Citalopram is a drug approved by the FDA for treating depression, sometimes sold under the brand name Celexa. Citalopram may also be prescribed off-label to treat other mental health conditions. Citalopram carries a black box warning from the FDA. Citalopram may increase suicidal thoughts in children, teens, and young adults under the age of 25. If you have thoughts of suicide, call the National Suicide Prevention Hotline at 800-273-8255. They are available 24 hours a day. As with all antidepressants, some patients may experience withdrawal symptoms.

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

What is Celexa?

Celexa is the brand name of citalopram, a selective serotonin reuptake inhibitor (SSRI) used primarily for treating depression. It is also available generically. SSRIs work by preventing nerve cells from reabsorbing a neurotransmitter called serotonin, making more of it available to the brain. We don’t know exactly why they work, but decades of research have shown they can relieve symptoms of depression in many patients. 

Healthcare providers also prescribe citalopram off-label for generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, panic attacks, eating disorders, and several other conditions.

Citalopram should not be confused with the similarly named medication, escitalopram (brand name Lexapro; see Important Safety Information).

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Why stop treatment?

Many medications have side effects. With citalopram, for most patients, they’re rare and tend to be mild. However, for some patients, the side effects may be strong enough to outweigh any relief they feel.

In some cases, the patient may simply be feeling better and no longer have the need to take it. Major depressive disorder (MDD) is temporary, and the duration of a given episode can vary.

In other cases, patients may not have any side effects but don’t improve after some weeks and wish to try a different treatment. Switching to a monoamine oxidase inhibitor (MAOI) from an SSRI requires at least two weeks to pass between medications.

Switching to another SSRI is an easier transition. Even though they all act similarly, just because one SSRI doesn’t work isn’t an indication that another won’t. A 2008 study of adolescents who didn’t respond to their initial SSRI treatment found just over 40% responded favorably to a change in SSRI or a switch to venlafaxine (brand name Effexor; see Important Safety Information). With the addition of cognitive behavioral therapy, that number increased to 54.8% (Brent, 2008).

Serotonin syndrome is a rare condition caused by too much serotonin in the system. Serotonin syndrome can result from an overdose of an SSRI or by combining two or more medications that both affect serotonin levels. It is one of the rare occasions when your healthcare provider may wish to end treatment more abruptly.

We’ll talk about the side effects you might encounter with citalopram and what might happen when discontinuing treatment. Never abruptly stop treatment on your own—always do it under the guidance of your healthcare provider. 

Side effects of citalopram

SSRIs are well-tolerated by most people, and side effects tend to be temporary. Even when persistent, they’re usually mild enough to be outweighed by the benefits. The most common adverse effects that cause patients to stop SSRI treatment are (Bull, 2002):

  • Drowsiness
  • Anxiety
  • Headache
  • Nausea

Other side effects of citalopram can include (MedLine Plus, n.d.):

  • Dry mouth
  • Heartburn
  • Lower sex drive
  • Difficulty ejaculating
  • Heavy menstruation
  • Loss of appetite, weight loss
  • Constipation
  • Stomach pain
  • Frequent peeing
  • Sleepiness
  • Muscle or joint pain

Some of the above can also be signs of serotonin syndrome. Specific symptoms can also include (Ables, 2010):

  • Agitation
  • Unusual sweating
  • Diarrhea
  • Fever over 100.4°F
  • Overactive reflexes
  • Twitching, shivering, or tremors
  • Incoordination
  • Loss of inhibitions
  • Confusion
  • Euphoria
  • Eye spasms

Untreated, severe serotonin syndrome cases can lead to kidney failure, blood clots, organ failure, and death. If you feel you might have overdosed or are experiencing multiple symptoms above, call your healthcare provider or local poison control center immediately. 

Citalopram seems to be the most well-tolerated SSRI. The incidence of specific side effects varies between different SSRIs, though. For example, dry mouth and sweating were reported more frequently by patients taking citalopram versus fluoxetine (brand name Prozac; see Important Safety Information). The opposite was the case regarding drowsiness and anxiety (Ferguson, 2001). Sometimes one side effect may be more tolerable to a given patient than another.

Citalopram withdrawal symptoms

Stopping treatment with any antidepressant medication runs the risk of antidepressant discontinuation syndrome (ADS), a collection of withdrawal symptoms. Not every patient will experience them, but with SSRIs, they are usually mild. Typically they start within ten days of stopping medication or reducing the dose, with symptoms fading in two to three weeks (Jha, 2018).

SSRI discontinuation symptoms can include (Jha, 2018):

  • Anxiety
  • Insomnia, vivid dreams, and nightmares
  • Anger or irritability, mood swings
  • Flu-like symptoms, such as chills or fever
  • Sweating
  • Shortness of breath
  • Heart palpitations
  • Higher blood pressure
  • Fatigue, tiredness
  • Nausea
  • Vomiting
  • Diarrhea
  • Abdominal pain or bloating
  • Tingling, “pins and needles” sensations
  • Dizziness
  • Headache
  • Muscle spasms or tremors
  • Tinnitus, ringing in the ears
  • Eye twitching
  • Hallucinations

When withdrawal effects are severe, restarting medication or another SSRI usually alleviates them in two to three days (Jha, 2018).

“Brain zaps”

During SSRI withdrawal, some patients reported a curious symptom that came to be known as “brain zaps,” among many other descriptions. We don’t know what causes these sensations, described by patients as feeling like an electric shock in the brain lasting a second or two. Some describe the feeling starting in the brain and coursing through the body to the fingers and toes. 

Some also hear a sound when they happen. 

This symptom first came to light in the late 1990s and early 2000s, when patients began reporting them in internet forums. At the time, some thought the terms might have been creative ways of describing unfamiliar sensations such as vertigo or tinnitus (Christmas, 2005). 

There hasn’t been much clinical research into brain zaps. What we’ve learned so far comes from analyzing patients’ self-reported experiences, often in anonymous forums. It appears that, like many other symptoms, they’re more common in patients who abruptly stop taking their medication versus those who slowly taper off (Papp, 2018).

Withdrawal or relapse?

Some antidepressant withdrawal symptoms may appear similar to a return of the initial condition. Determining which one is occurring can be challenging to diagnose. There are different categories a return of symptoms can fall into (Fava, 2019):

  • A relapse happens when the original episode hasn’t fully resolved, and symptoms gradually return to their initial level as treatment stops.
  • A recurrence is when a new episode with symptoms at the previous level happens. Recurrences can occur weeks, months, or years after treatment.
  • A rebound is when symptoms return very quickly when the medication stops or the dose is lowered, at a level much more intense than they were before treatment. 

Withdrawal side effects can include entirely new symptoms and are temporary. And, of course, what appear to be symptoms could be entirely unrelated. You shouldn’t immediately assume that, for example, a set of flu-like symptoms are due to withdrawal. You might, after all, actually have the flu. It’s essential to stay in contact with your healthcare provider during the process, reporting any adverse effects you might be experiencing. 

Preventing or minimizing withdrawal symptoms

While there’s no 100% way to prevent withdrawal effects, you don’t want the idea of withdrawal itself to cause anxiety. Knowing what symptoms could happen and that they’re likely temporary goes a long way to making them more tolerable. The likelihood of withdrawal symptoms is lower in patients taking antidepressants with longer half-lives (how long they remain in the system after discontinuing). Citalopram is considered low-risk for withdrawal effects among the SSRIs (Henssler, 2019).

There are proactive measures that you and your healthcare provider can take before and during withdrawal (Jha, 2018):

  • Diet and exercise
  • Psychotherapy, such as cognitive behavioral therapy (CBT)
  • Switching from citalopram to fluoxetine (brand name Prozac), an SSRI with a much longer half-life
  • Medications to alleviate specific withdrawal effects, such as sedatives for insomnia or benzodiazepines for anxiety

Never stop any medication cold turkey. It is essential to consult with your healthcare provider before discontinuing any medication and follow their medical advice. Barring the rare emergency such as an allergic reaction or serotonin syndrome, your prescriber will want to lower your dose gradually. Current guidelines from the American Psychiatric Association recommend gradually reducing over several weeks. However, a recent study suggested that an even slower reduction over months would minimize adverse effects to a much greater degree (Hurley, 2019).

References

    
    
    
    
    
  1. Ables, A., & Nagubilli, R. (2010). Prevention, Recognition, and Management of Serotonin Syndrome. American Family Physician; 81(9):1139-1142. Retrieved from https://www.aafp.org/afp/2010/0501/p1139.html
  2. Brent, D., Emslie, G., Clarke, G., Wagner, K. D., Asarnow, J. R., Keller, M., et al. (2008). Switching to Another SSRI or to Venlafaxine With or Without Cognitive Behavioral Therapy for Adolescents With SSRI-Resistant Depression. Jama, 299(8), 901. doi: 10.1001/jama.299.8.901. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/1028633 
  3. Bull, S. A., Hunkeler, E. M., Lee, J. Y., Rowland, C. R., Williamson, T. E., Schwab, J. R., & Hurt, S. W. (2002). Discontinuing or Switching Selective Serotonin-Reuptake Inhibitors. Annals of Pharmacotherapy, 36(4), 578-584. doi: 10.1345/aph.1a254. Retrieved from https://journals.sagepub.com/doi/abs/10.1345/aph.1a254
  4. Christmas, D. M. (2005). ‘Brain shivers’: From chat room to clinic. Psychiatric Bulletin, 29(6), 219-221. doi: 10.1192/pb.29.6.219. Retrieved from https://www.cambridge.org/core/journals/psychiatric-bulletin/article/brain-shivers-from-chat-room-to-clinic/642FBBAE131EAB792E474F02A4B2CCC0/core-reader 
  5. Fava, G. A., & Cosci, F. (2019). Understanding and Managing Withdrawal Syndromes After Discontinuation of Antidepressant Drugs. The Journal of Clinical Psychiatry, 80(6). doi: 10.4088/jcp.19com12794. Retrieved from https://www.psychiatrist.com/JCP/article/Pages/understanding-and-managing-antidepressant-withdrawal-syndromes.aspx 
  6. Ferguson, J. M. (2001). SSRI Antidepressant Medications: Adverse Effects and Tolerability. The Primary Care Companion to The Journal of Clinical Psychiatry, 03(01), 22-27. doi: 10.4088/pcc.v03n0105. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/
  7. Henssler, J., Heinz, A., Brandt, L., & Bschor, T. (2019). Antidepressant withdrawal and rebound phenomena. Deutsches Aerzteblatt Online. doi: 10.3238/arztebl.2019.0355. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637660/
  8. Hurley, D. (2019). Avoiding Withdrawal Syndrome for SSRIs Requires Months, Not Weeks, and a More Gradual Curve, Paper Concludes. Neurology Today, 19(8), 41-47. doi: 10.1097/01.nt.0000558056.34793.96. Retrieved from https://journals.lww.com/neurotodayonline/subjects/Headache,%20Facial%20Pain/Fulltext/2019/04180/Avoiding_Withdrawal_Syndrome_for_SSRIs_Requires.4.aspx
  9. Jha, M. K., Rush, A. J., & Trivedi, M. H. (2018). When Discontinuing SSRI Antidepressants Is a Challenge: Management Tips. American Journal of Psychiatry, 175(12), 1176-1184. doi: 10.1176/appi.ajp.2018.18060692. Retrieved from https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2018.18060692
  10. MedlinePlus. (2018). Citalopram: MedlinePlus Drug Information. Retrieved on Nov. 1, 2020 from https://medlineplus.gov/druginfo/meds/a699001.html
  11. Papp, A., & Onton, J. A. (2018). Brain Zaps: An Underappreciated Symptom of Antidepressant Discontinuation. The Primary Care Companion For CNS Disorders, 20(6). doi: 10.4088/pcc.18m02311. Retrieved from https://www.psychiatrist.com/PCC/article/Pages/brain-zaps.aspx