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SSRI (Selective Serotonin Reuptake Inhibitor) Pregnancy: Avoid in first trimester (cardiac defects — weak signal). If used in third trimester, neonatal abstinence syndrome possible. Use lowest effective dose; discuss risk-benefit. Sertraline preferred SSRI in pregnancy.

Citalopram

Brand names: Cipramil

Adult dose

Dose: Depression / anxiety: 20mg OD initially; usual maintenance 20–40mg OD. Maximum 20mg OD in patients over 65, or taking omeprazole/cimetidine (CYP2C19 inhibitors), or with hepatic impairment.
Route: Oral
Frequency: Once daily (morning or evening)
Max: 40mg OD (adults under 65); 20mg OD (over 65, hepatic impairment, CYP2C19 inhibitors)
MHRA 2011 safety alert: citalopram causes dose-dependent QT prolongation — maximum dose must not exceed 40mg (adults) or 20mg (elderly, hepatic impairment, CYP2C19 inhibitors). Baseline ECG recommended if pre-existing QTc prolongation or risk factors. Allow 4–6 weeks for antidepressant effect.

Paediatric dose

Route: Oral
Frequency: Once daily
Max: Not applicable
Not licensed under 18 years in UK. Not recommended — insufficient evidence for efficacy and safety in children and adolescents. Seek specialist child and adolescent psychiatry opinion.

Dose adjustments

Renal

eGFR 20–50: no adjustment needed. eGFR <20: use with caution — limited data.

Hepatic

Mild-moderate: maximum 20mg OD. Severe hepatic impairment: avoid.

Clinical pearls

  • QT prolongation is dose-dependent — never exceed 40mg in adults or 20mg in elderly. Check ECG at baseline if cardiac risk factors
  • Hyponatraemia: check sodium in elderly patients on SSRIs, especially in first 3 months — SSRIs can cause SIADH; may present as confusion or falls
  • Antidote: no specific antidote for SSRI overdose; cyproheptadine 8–12mg oral used for mild-moderate serotonin syndrome (serotonin antagonist)
  • Discontinuation syndrome: taper slowly over 4+ weeks — abrupt stopping causes dizziness, electric-shock sensations ('brain zaps'), nausea

Contraindications

  • Concomitant MAOIs (serotonin syndrome — 14-day washout required)
  • Concomitant pimozide or QT-prolonging drugs
  • Known QT prolongation or congenital long QT syndrome
  • Hypersensitivity to citalopram

Side effects

  • Nausea (common — first 1–2 weeks)
  • QT prolongation (dose-dependent — MHRA warning)
  • Insomnia or somnolence
  • Dry mouth
  • Sexual dysfunction (common — reduced libido, anorgasmia)
  • Sweating
  • Hyponatraemia (SIADH — particularly in elderly)
  • Serotonin syndrome (overdose or interaction)
  • Increased suicidality (under-25s — monitor closely)

Interactions

  • MAOIs — contraindicated (serotonin syndrome)
  • Pimozide — contraindicated (additive QT prolongation)
  • Omeprazole, cimetidine (CYP2C19 inhibitors) — increase citalopram levels; reduce maximum dose to 20mg
  • Tramadol — serotonin syndrome risk
  • Lithium — additive serotonin syndrome risk; monitor

Monitoring

  • ECG (QTc) — before starting and if dose increased (especially in elderly or with risk factors)
  • Sodium (particularly in elderly — SIADH screening)
  • Mood and suicidality (first 4 weeks — especially under-25s)
  • Sexual function review

Reference: BNFc; BNF 90; MHRA Drug Safety Update 2011 (QT Citalopram); NICE CG90 (Depression). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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