Starting citalopram, concerns/side effects...

[mcohen]

Hi all,

24/M. After years of worsening health anxiety, and years of not getting any treatment, I have given in and will be taking my prescription from the doctor from a few weeks ago to the pharmacy. My doctor prescribed 20mg Citalopram, specifically for the health anxiety.

One of the main reasons why it has taken me a few weeks to decide to go ahead is, I made the mistake of reading the 'side effects' of Citalopram online. The one that stood out as a concern is the risk of Sudden Adult Death Syndrome. From what I can gather the risks are very low - but the only bit worrying me is that in the past couple of months I've been getting surge sensations in my chest. I know realistically these are almost certainly from the anxiety, however there is a little part of me that thinks - is this an undiagnosed heart condition that could be exacerbated by the Citalopram.

This is a strange one for me as I have never really worried about my heart - my health anxiety largely revolves around fear of cancer.

Would be good to hear people's views, particularly anyone with a bit of knowledge about Citalopram. Would also be good to hear what to expect from the first few weeks, and months, of starting treatment, success stories etc.

[panic_down_under]

One of the main reasons why it has taken me a few weeks to decide to go ahead is, I made the mistake of reading the 'side effects' of Citalopram online. The one that stood out as a concern is the risk of Sudden Adult Death Syndrome.

Where did you read this as it isn't a listed side-effect? At very high doses well above its therapeutic dose range citalopram may affect the electrical system of the heart, but this is true of many medications, including quite a few heart meds. The only concern might come from taking a number of meds which have the same impact, but that is why meds have to be prescribed by a doctor. A major part of their job is taking such issues into account when selecting meds.


From what I can gather the risks are very low - but the only bit worrying me is that in the past couple of months I've been getting surge sensations in my chest. I know realistically these are almost certainly from the anxiety, however there is a little part of me that thinks - is this an undiagnosed heart condition that could be exacerbated by the Citalopram.

Anxiety can trigger such symptoms via several pathways, adrenaline surges; from the enteric nervous system (http://www.nytimes.com/2005/08/23/health/the-other-brain-also-deals-with-many-woes.html), the mini brain which controls the gut and to a considerable extent the brain, and also connects to and affects the heart and lungs via the vagus nerves; much more rarely through spasm of the main heart arteries during panic attacks. While unpleasant and scary these very rarely damage the heart (or any other organ).

Serotonergic antidepressants are mild anticoagulants which reduce the risk of having a heart attack, or ischemic stroke, although they may increase risks for the much less common haemorrhagic stroke.


This is a strange one for me as I have never really worried about my heart - my health anxiety largely revolves around fear of cancer.

There is evidence that serotonergic ADs can reduce cancer risk by, among other other means, stimulating the immune system to fight some cancers (https://www.sciencedaily.com/releases/2008/09/080911142620.htm)


Would also be good to hear what to expect from the first few weeks, and months, of starting treatment, success stories etc.

ADs typically take 3-12 weeks to kick-in with most beginning to see positive results around the 5-7 week mark. They have no direct effect on anxiety, or depression in the way say aspirin has on a headache. They work by stimulating the growth of new brain cells (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045/) (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels. The therapeutic response is produced by these new cells and the stronger interconnections they forge, not the meds directly, and they take time to bud, grow and mature. For a more detailed explanation see: How antidepressant drugs act (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025168/).

As for side-effects (SEs), these may range from not having any to sometimes severe reactions, especially during the first couple of weeks due to the increased serotonin activity. While it is often promoted as a 'feel good' neurotransmitter, serotonin is anything but. After a few weeks the increased activity triggers the downregulation of serotonin synthesis and expression and any SEs usually begin to ease, but they may return for a while after dose increases. The thing to always keep in mind is that while unpleasant, they are rarely harmful. The best way of minimizing SE severity is by starting on a low dose, for citalopram no more than 10mg, 5mg may be even better, and ramping the dose up by the same amount at 7-8 day intervals <-get the prescribing physician's okay before doing this if s/he has recommended a different approach.

[AntsyVee]

To add to everything Ian said, often it’s best to add some therapy and lifestyle changes like exercise to your medication regimen. Have you thought about that as well?

[mcohen]

Where did you read this as it isn't a listed side-effect? At very high doses well above its therapeutic dose range citalopram may affect the electrical system of the heart, but this is true of many medications, including quite a few heart meds. The only concern might come from taking a number of meds which have the same impact, but that is why meds have to be prescribed by a doctor. A major part of their job is taking such issues into account when selecting meds.

Anxiety can trigger such symptoms via several pathways, adrenaline surges; from the enteric nervous system (http://www.nytimes.com/2005/08/23/health/the-other-brain-also-deals-with-many-woes.html), the mini brain which controls the gut and to a considerable extent the brain, and also connects to and affects the heart and lungs via the vagus nerves; much more rarely through spasm of the main heart arteries during panic attacks. While unpleasant and scary these very rarely damage the heart (or any other organ).

Serotonergic antidepressants are mild anticoagulants which reduce the risk of having a heart attack, or ischemic stroke, although they may increase risks for the much less common haemorrhagic stroke.

There is evidence that serotonergic ADs can reduce cancer risk by, among other other means, stimulating the immune system to fight some cancers (https://www.sciencedaily.com/releases/2008/09/080911142620.htm)

ADs typically take 3-12 weeks to kick-in with most beginning to see positive results around the 5-7 week mark. They have no direct effect on anxiety, or depression in the way say aspirin has on a headache. They work by stimulating the growth of new brain cells (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045/) (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels. The therapeutic response is produced by these new cells and the stronger interconnections they forge, not the meds directly, and they take time to bud, grow and mature. For a more detailed explanation see: How antidepressant drugs act (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025168/).

As for side-effects (SEs), these may range from not having any to sometimes severe reactions, especially during the first couple of weeks due to the increased serotonin activity. While it is often promoted as a 'feel good' neurotransmitter, serotonin is anything but. After a few weeks the increased activity triggers the downregulation of serotonin synthesis and expression and any SEs usually begin to ease, but they may return for a while after dose increases. The thing to always keep in mind is that while unpleasant, they are rarely harmful. The best way of minimizing SE severity is by starting on a low dose, for citalopram no more than 10mg, 5mg may be even better, and ramping the dose up by the same amount at 7-8 day intervals <-get the prescribing physician's okay before doing this if s/he has recommended a different approach.

Thank you panic_down_under for your very detailed response - much appreciated. I cant seem to find the exact page where I read the risks - it was quite comprehensive, though if you search 'citalopram sudden death' it brings up results from several reputable sources. I believe it may be linked to Long QT syndrome. In terms of interactions with other medications - the only other medication I am on is doxycycline (long term).

Unfortunately I wont be able to see the doctor for at least a month so it's either a case of accept 20mg or delay treatment by a month to go back and request a lower dose.

Are side effects common/to be expected with Citalopram?

[mcohen]

To add to everything Ian said, often it’s best to add some therapy and lifestyle changes like exercise to your medication regimen. Have you thought about that as well?

Thanks for your response AntsyVee, I do feel like lifestyle changes would help. I used to be a lot more active and into exercise, quite consistent in fact, but nowadays the motivation just isn't there - I tell myself I will go to exercise and simply don't. Hopefully things will change with treatment.

[keta]

Hi I was on Citalopram twice , once for about couple of years and then again for about 5 years.
from what I remember from side effects - initial few days I felt increased anxiety , nervousness like feeling , was off food, tiredness ( so I used to take it in the evening), dry mouth , bit of increased sweating , jaw clenching and problems to orgasm , but it all improved with the time as my body got used to it.
i guess everyone reacts differently but over all no major health problems while I was on it .
If you do decide to take it maybe start with 10mg for first few days, but that’s just suggestion obviously you want to follow your doctors recommendations .
Any queations , feel free to ask

[panic_down_under]

I cant seem to find the exact page where I read the risks - it was quite comprehensive, though if you search 'citalopram sudden death' it brings up results from several reputable sources. I believe it may be linked to Long QT syndrome.

Prolonged QTc was what I was alluding to. It can be a concern for those with Congenital Long QT syndrome, or if taking many medications which prolong the interval.

The FDA reduced maximum citalopram dose from 60mg to 40mg when the QTc interval was discovered even though the data isn't clinically significant. To quote from van Haelst IMM (http://www.psychiatrist.com/_layouts/PPP.Psych.Controls/ArticleViewer.ashx?ArticleURL=/JCP/article/Pages/2014/v75n01/v75n0103.aspx), 2013:

In a thorough QT/QTc study of citalopram, a mean change in QTc interval of 8.5 milliseconds was found for 20 mg per day and 18.5 milliseconds for 60 mg per day. On the basis of these findings, the FDA stated that citalopram should no longer be prescribed at doses of greater than 40 mg per day and that the maximum citalopram dose is 20 mg per day in elderly patients.12 (http://www.fda.gov/drugs/drugsafety/ucm297391.htm) However, there is still no consensus whether an increase in QTc of this magnitude (< 20 milliseconds) for a dosage of 60 mg is clinically relevant.4 (http://doi.wiley.com/10.1111/bcp.12040), 28 (http://dx.doi.org/10.1016/j.amjmed.2011.12.002) The guidelines of the Committee for Proprietary Medicinal Products (CMPC) suggest that individual changes of QTc interval length need to be at least between 30 and 60 milliseconds from baseline to raise concern for potential risk of drug-induced arrhythmias.23-PDF (http://www.fda.gov/ohrms/dockets/ac/03/briefing/pubs/cpmp.pdf) Another commonly accepted threshold for a clinically significant drug-induced change in QTc length is even higher, with an increase = 60 milliseconds.28 (http://dx.doi.org/10.1016/j.amjmed.2011.12.002), 30 (http://dx.doi.org/10.1186/1744-859X-4-1)

Fwiw, I'm taking an AD which is so cardio toxic it has been removed from the British National Formulary (https://en.wikipedia.org/wiki/British_National_Formulary) and the UK drug regulator has recommended (http://webarchive.nationalarchives.gov.uk/+/http:/www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON084687) only psychiatrists and other special-care doctors be allowed to prescribe it to new patients. After 25 years on it at the maximum recommended dose my geriatric heart remains unaffected despite other issues putting it under more than usual stress.


In terms of interactions with other medications - the only other medication I am on is doxycycline (long term).

Doxycycline isn't a QTc prolonging med so there should be no issues.


Unfortunately I wont be able to see the doctor for at least a month so it's either a case of accept 20mg or delay treatment by a month to go back and request a lower dose .
Sigh. 20mg is the standard initial dose for those with depression, but starting at 10mg for the first week can make it easier for those with anxiety to stay on the med.


Are side effects common/to be expected with Citalopram?

Side-effects severity can range from none to severe with most experiencing mild to moderate severity. Unfortunately, there is no way of predicting how you will be affected.

[mcohen]

Hi I was on Citalopram twice , once for about couple of years and then again for about 5 years.
from what I remember from side effects - initial few days I felt increased anxiety , nervousness like feeling , was off food, tiredness ( so I used to take it in the evening), dry mouth , bit of increased sweating , jaw clenching and problems to orgasm , but it all improved with the time as my body got used to it.
i guess everyone reacts differently but over all no major health problems while I was on it .
If you do decide to take it maybe start with 10mg for first few days, but that’s just suggestion obviously you want to follow your doctors recommendations .
Any queations , feel free to ask

Thanks for sharing your experience of Citalopram Keta, from what I can gather an initial spike in anxiety is to be expected. I just hope I can dodge some of the worse side effects. Unfortuantely for me for the time being it's 20mg or 0 - I guess what will be will be.

[mcohen]

Prolonged QTc was what I was alluding to. It can be a concern for those with Congenital Long QT syndrome, or if taking many medications which prolong the interval.

The FDA reduced maximum citalopram dose from 60mg to 40mg when the QTc interval was discovered even though the data isn't clinically significant. To quote from van Haelst IMM (http://www.psychiatrist.com/_layouts/PPP.Psych.Controls/ArticleViewer.ashx?ArticleURL=/JCP/article/Pages/2014/v75n01/v75n0103.aspx), 2013:


Fwiw, I'm taking an AD which is so cardio toxic it has been removed from the British National Formulary (https://en.wikipedia.org/wiki/British_National_Formulary) and the UK drug regulator has recommended (http://webarchive.nationalarchives.gov.uk/+/http:/www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON084687) only psychiatrists and other special-care doctors be allowed to prescribe it to new patients. After 25 years on it at the maximum recommended dose my geriatric heart remains unaffected despite other issues putting it under more than usual stress.



Doxycycline isn't a QTc prolonging med so there should be no issues.

.
Sigh. 20mg is the standard initial dose for those with depression, but starting at 10mg for the first week can make it easier for those with anxiety to stay on the med.



Side-effects severity can range from none to severe with most experiencing mild to moderate severity. Unfortunately, there is no way of predicting how you will be affected.

That's very reassuring on the heart front, thank you panic_down_under. May be a stupid question but if someone was suffering from long QT syndrome, would they know about it e.g. would it manifest in symptoms? Hopefully I will dodge the more severe side-effects - the other one that concerns me alongside the heart is 'post ssri sexual dysfunction' i.e. not being able to get it up even post-treatment. I'm trying not to think too much about these weird and whacky symptoms.

[panic_down_under]

May be a stupid question

The only stupid questions are those never asked. :)


but if someone was suffering from long QT syndrome, would they know about it e.g. would it manifest in symptoms?

The most common symptom is fainting caused by the heart beating very fast, but inefficiently, sometimes for hours.

LQTS shouldn't be confused with the skipped beats and short lived accelerated heart rate of palpitations. These are normal, indeed necessary (https://www.nytimes.com/1989/01/17/science/in-heartbeat-predictability-is-worse-than-chaos.html), and a sign of a heart in good health. We tend to notice palpitations more than those without anxiety. Whether it's because anxiety triggers more of them, or simply because we monitor our bodies more closely is one of those subjects which promotes much discussion and not much enlightenment.


Hopefully I will dodge the more severe side-effects - the other one that concerns me alongside the heart is 'post ssri sexual dysfunction' i.e. not being able to get it up even post-treatment.

I'm not sure this is actually a thing, at least not directly caused by the med, and more likely due to psychological factors. There are ways of minimising sexual dysfunction while on the med, however, these include taking prescriptions medications in small doses such as buspirone (Buspar) and bupropion (Wellbutrin, Zyban), however, UK GPs appear to be unwilling to prescribe meds off-label so you may not be able to get them, unfortunately. :sad:


I'm trying not to think too much about these weird and whacky symptoms.

A very good idea. Our anticipations are almost always far worse than the reality and can sometimes ensure we develop them. An anxious mind is all too adept at generating the full symphony of symptoms for us if allowed to ruminate on potential side-effects.

[mcohen]

The only stupid questions are those never asked. :)



The most common symptom is fainting caused by the heart beating very fast, but inefficiently, sometimes for hours.

LQTS shouldn't be confused with the skipped beats and short lived accelerated heart rate of palpitations. These are normal, indeed necessary (https://www.nytimes.com/1989/01/17/science/in-heartbeat-predictability-is-worse-than-chaos.html), and a sign of a heart in good health. We tend to notice palpitations more than those without anxiety. Whether it's because anxiety triggers more of them, or simply because we monitor our bodies more closely is one of those subjects which promotes much discussion and not much enlightenment.



I'm not sure this is actually a thing, at least not directly caused by the med, and more likely due to psychological factors. There are ways of minimising sexual dysfunction while on the med, however, these include taking prescriptions medications in small doses such as buspirone (Buspar) and bupropion (Wellbutrin, Zyban), however, UK GPs appear to be unwilling to prescribe meds off-label so you may not be able to get them, unfortunately. :sad:



A very good idea. Our anticipations are almost always far worse than the reality and can sometimes ensure we develop them. An anxious mind is all too adept at generating the full symphony of symptoms for us if allowed to ruminate on potential side-effects.

Thank's again for a very thorough response panic_down_under. I feel reassured on the longQT front, having never in my life fainted. There has been a slight delay in being able to start treatment (should be able to start Citalopram by the end of the week), I'm now at a point where I'm looking forward to being able to start the medications (as opposed to nervous), as the health anxiety is continually getting worse, and manifesting in symptoms ever more similar to a panic attack.

[panic_down_under]

I'm now at a point where I'm looking forward to being able to start the medications (as opposed to nervous), as the health anxiety is continually getting worse, and manifesting in symptoms ever more similar to a panic attack.

The thing to always keep in mind is that while side-effects can sometimes be unpleasant and/or scary, they are rarely an indication of harm being done. It's just that serotonin has several functions in most organs of the body and SSRIs and other serotonergic ADs can sometimes affect these even more than the brain in the short term. After a while the extra serotonin activity should trigger the downregulation of serotonin synthesis and expression and the side-effects will then diminish, although they may return for a while after dose increases.

[mcohen]

The thing to always keep in mind is that while side-effects can sometimes be unpleasant and/or scary, they are rarely an indication of harm being done. It's just that serotonin has several functions in most organs of the body and SSRIs and other serotonergic ADs can sometimes affect these even more than the brain in the short term. After a while the extra serotonin activity should trigger the downregulation of serotonin synthesis and expression and the side-effects will then diminish, although they may return for a while after dose increases.

Hi panic_down_under, just thought I'd check in to say I am now on day 4 of Citalopram and, (touch wood!) haven't had any major side effects to report. So far the only side effects have been a general, but not extreme, rise in my anxiety and health anxiety, and a definite increase in tiredness.