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Citalopram is the most commonly prescribed antidepressant in Germany — around one million people take it daily. It belongs to the class of selective serotonin reuptake inhibitors (SSRIs) and is primarily used for depression and anxiety disorders.
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This article is for information and does not replace psychiatric advice. Never stop citalopram or change the dose on your own initiative. If you are having suicidal thoughts: in Germany, Telefonseelsorge 0800 111 0 111 (free, 24/7); in the UK, Samaritans 116 123 (free, 24/7).
Citalopram belongs to the group of selective serotonin reuptake inhibitors (SSRIs) and is one of the most prescribed antidepressants in Germany. It is used for depression, panic disorders, and anxiety disorders. One important feature: citalopram prolongs the QT interval on the ECG in a dose-dependent way – which makes regular cardiac checks necessary and limits the maximum dose to 40 mg.
| Property | Details |
|---|---|
| Active substance | Citalopram (as citalopram hydrobromide) |
| ATC code | N06AB04 |
| Drug class | Selective serotonin reuptake inhibitor (SSRI) |
| Available forms | Tablets 10 mg, 20 mg, 40 mg; drops |
| Half-life | approx. 36 hours |
| Onset of action | Increased drive after 1–2 weeks; mood lift after 2–4 weeks |
| Bioavailability | approx. 80% |
| Intake | 1× daily, independent of meals |
| Maximum dose | 40 mg/day (20 mg if >65 years, hepatic impairment, CYP2C19 poor metaboliser) |
| Prescription only | Yes |
| Special feature | Dose-dependent QT prolongation! ECG recommended. |
To understand how citalopram works, it helps to look at the brain: nerve cells communicate via messenger substances that are released into the so-called synaptic cleft. After the signal is transmitted, these messengers are normally taken up again by the releasing nerve cell – a process called reuptake. Serotonin is one of these messengers, which in depression and anxiety disorders is often present at too low a concentration.
Citalopram selectively blocks the serotonin transporter (SERT) – the protein responsible for the reuptake of serotonin. With the transporter blocked, serotonin remains longer in the synaptic cleft and can stimulate the downstream receptors for longer. The result: increased serotonin activity in the brain.
This is the question that occupies almost all patients at the start of therapy. The answer is pharmacologically interesting: the increase in serotonin in the synaptic cleft actually happens immediately – the SERT is blocked after the very first tablet. But the actual antidepressant effect only arises through an adaptation (desensitisation) of the receptors. The brain initially responds to the persistently raised serotonin with a counter-regulation – it reduces the sensitivity of its own receptors. Only when this adaptation is complete does the full therapeutic effect unfold. That takes 2–4 weeks.
In this settling-in phase, side effects can even intensify while the antidepressant effect is still absent. This is medically normal and not a sign that the medication is not working. Important: anyone who develops suicidal thoughts in this phase must contact their doctor immediately or call a crisis line (in Germany, Telefonseelsorge 0800 111 0 111, free, 24/7; in the UK, Samaritans 116 123, free, 24/7).
Chemically, citalopram consists of two mirror-image molecules: the S-enantiomer and the R-enantiomer. In pharmacology this is called a racemate. The antidepressant effect comes almost exclusively from the S-enantiomer. The R-enantiomer contributes little to the effect but is partly responsible for some of the QT prolongation. For this reason the pure S-enantiomer was developed as a separate substance: escitalopram – the same antidepressant effect, half the dose, a somewhat lower QT risk.
Citalopram is used for various mental health conditions, with depression and panic disorder being the main indications. The basic principle across all indications: start low, increase slowly. In panic disorders in particular, a low starting dose of 10 mg in the first week is important – increasing the dose too quickly can initially intensify the anxiety.
| Indication | Starting dose | Target dose | Maximum dose |
|---|---|---|---|
| Depression | 20 mg | 20–40 mg | 40 mg (20 mg in older people) |
| Panic disorder | 10 mg (1st week) | 20–40 mg | 40 mg |
| Anxiety disorder (GAD) | 10–20 mg | 20–40 mg | 40 mg (off-label) |
| Obsessive-compulsive disorder | 20 mg | 20–40 mg | 40 mg (off-label) |
| Older patients (>65) | 10 mg | 10–20 mg | 20 mg! |
| Hepatic impairment | 10 mg | 10–20 mg | 20 mg! |
The side effects of citalopram follow a typical time course that patients should know – because anyone who knows what is coming can handle it better and does not break off therapy prematurely.
In the first 1–2 weeks, adjustment reactions are to the fore. Nausea is the most common complaint – it affects over 10% of patients and disappears on its own in most after 1–2 weeks. Headaches, sleep disturbances, and inner restlessness are also common. An important warning: in the first weeks, drive can increase before the mood lift sets in. In patients with suicidal thoughts this can temporarily raise the risk – close contact with the doctor in this phase is essential.
From the second week, the mood lift usually begins. The nausea eases. Now it becomes clear whether the dose is sufficient or needs adjusting – a doctor's appointment in this phase makes sense. Anyone who feels no improvement after 4–6 weeks should talk to their doctor about a dose adjustment or a change of substance.
The most frequently underestimated long-term side effects are sexual dysfunction and emotional blunting. Sexual side effects – loss of libido, orgasm problems, erection problems – affect 40–70% of patients according to studies. They are often not raised spontaneously, because the topic is uncomfortable. Yet there are options: dose reduction, a switch to bupropion or mirtazapine, or a so-called "drug holiday" at the weekend – all of which should be discussed openly with the doctor.
Emotional blunting – the feeling of no longer really feeling anything, neither joy nor sorrow – is another common long-term complaint. Some patients experience it as worse than the original depression. Here too: speak up, don't stay silent. Sometimes a dose reduction is enough, sometimes a change of substance is the better solution.
| Side effect | Frequency | Note |
|---|---|---|
| Nausea | Very common (>10%) | Usually in week 1–2, then improves |
| Dry mouth | Common | Drink plenty of water, sugar-free sweets |
| Sweating | Common | Especially at night – often persistent |
| Sleep disturbances / fatigue | Common | Adjust the intake time (morning vs. evening) |
| Sexual dysfunction | Very common (40–70%) | Loss of libido, orgasm problems, erection problems. Talk to your doctor! |
| Weight gain | Common | On average 2–5 kg in 6–12 months |
| Emotional blunting | Common | The feeling of no longer really feeling anything. Talk to your doctor! |
| QT prolongation | Dose-dependent | Check ECG, especially above 20 mg |
| Increased bleeding risk | Class effect | Serotonin in platelets reduced by 80% |
| Brain zaps (when stopping) | Common | Electric shock-like sensations – a typical withdrawal symptom |
Stopping citalopram is for many patients the most difficult phase of the entire therapy. Up to 56% of patients develop symptoms when stopping – from mild to severe. This is not because citalopram "is addictive" but because of physiology: the brain has adapted over months to the raised serotonin level and responds to the sudden withdrawal with a counter-reaction.
Brain zaps are the best-known and eeriest withdrawal symptom: a brief electric shock-like sensation in the head, often triggered by eye movements. They arise because serotonin receptors recalibrate when stopping and briefly react overactively in the process. Brain zaps are unpleasant but not dangerous – and they disappear if you taper slowly enough.
The most important principle: the more slowly you taper, the milder the symptoms. Patients who stop abruptly risk severe withdrawal syndromes. Patients who reduce gradually over weeks and months can often stop symptom-free.
This can be explained pharmacologically: the serotonin-transporter blockade does not behave linearly with the dose. At 20 mg, over 80% of the transporters are already blocked. At 10 mg it is still about 70%. But when you reduce from 10 mg to 5 mg, the blockade falls off much more sharply – and the brain feels the change more intensely than with the reduction from 40 to 30 mg. This explains why the last milligrams are the hardest. Drops here allow particularly fine dosing steps and are very valuable in this phase.
| Withdrawal symptom | Description | Duration |
|---|---|---|
| Brain zaps | Electric shock-like sensations in the head, often on eye movement | Days to weeks |
| Dizziness | Sometimes so strong that standing up is difficult | Days to weeks |
| Irritability / mood swings | Often confused with a relapse of the depression! | Days to months |
| Flu-like symptoms | Aching limbs, sweating, chills | Days |
| Nausea / diarrhoea | Gastrointestinal symptoms | Days |
| Sleep disturbances / nightmares | Very vivid, intense dreams | Weeks |
| Paraesthesias | Tingling, numbness in hands and feet | Days to weeks |
| Phase | Dose | Duration | Note |
|---|---|---|---|
| Phase 1 | 40 mg → 30 mg | 2 weeks | Use drops for precise dosing |
| Phase 2 | 30 mg → 20 mg | 2 weeks | – |
| Phase 3 | 20 mg → 15 mg | 2 weeks | Symptoms often appear for the first time here |
| Phase 4 | 15 mg → 10 mg | 2 weeks | – |
| Phase 5 | 10 mg → 5 mg | 2–4 weeks | The most critical phase! Reduce very slowly |
| Phase 6 | 5 mg → stop | 1–2 weeks | Alternatively: 5 mg every other day |
| Phase | Dose | Duration |
|---|---|---|
| Phase 1 | 20 mg → 15 mg | 2 weeks |
| Phase 2 | 15 mg → 10 mg | 2 weeks |
| Phase 3 | 10 mg → 5 mg | 2–4 weeks |
| Phase 4 | 5 mg → stop | 1–2 weeks |
This combination is alarmingly common: patients take citalopram daily – and reach for the ibuprofen tablet from the medicine cabinet for headaches, back pain, or joint pain. Without knowing that they are taking on a massive bleeding risk. The brite interaction check detects this combination automatically.
| Painkiller | Risk with citalopram | Recommendation |
|---|---|---|
| Ibuprofen / diclofenac | 12-fold increased GI bleeding risk | Avoid! If unavoidable: only short-term + pantoprazole |
| Low-dose aspirin (blood thinning) | 5-fold increased bleeding risk | Only with a compelling indication + pantoprazole |
| Paracetamol | No increased bleeding risk | First choice for pain on an SSRI |
| Metamizole (Novalgin) | No increased bleeding risk | An alternative – but with its own risks (agranulocytosis) |
The rule is easy to remember: anyone taking citalopram or another SSRI should use paracetamol as the standard painkiller and use ibuprofen only in absolute exceptions and always with stomach protection. Keep this information available for your treating doctors too – not every doctor who prescribes a painkiller knows that you are also taking an SSRI. So keep a complete medication list.
