When Citalopram stops working... what next?

For many years now I've been on 30mg of Citalopram but recently I am coming to the conclusion that it's no longer effective. Most days I have that feeling of being on the edge of bursting into tears, along with uncontrollable health anxiety (see the poo-rifling elsewhere) and being utterly neurotic about Covid. Living alone with no work to go to leaves me with plenty of time to obsess about things, even to the point that a panic attack a fortnight ago saw me hospitalised. I can't talk to my family about it - they'd either be angry with me or just bewildered.

So, what's next? CBT seems to be ineffective for me too - I just can't make it work.

Last week, I went to the cemetery to look at my wife's grave and I have to admit, I did ask her if she wanted to swap places.

Any thoughts?

Sorry to hear that you've been struggling so much lately. I think it would be best to speak to your doctor to discuss the options. As you are currently on 30mg, you may be able to go up to 40mg, which is the usual maximum dose (although I think there are exceptions to this, depending on age and other health conditions). Failing that, you could be switched to a different medication. Also, maybe you could ask to be referred to a different therapist or even try a different type of therapy if CBT was ineffective for you before.

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Originally Posted by Pamplemousse

For many years now I've been on 30mg of Citalopram but recently I am coming to the conclusion that it's no longer effective.

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Given the times we're all under much higher stress and sometimes this means the negative stress impacts on the brain can overwhelm the positive effects of our AD. Increasing to the maximum 40mg might help and is the easiest and fastest option, but there are no guarantees.

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Most days I have that feeling of being on the edge of bursting into tears, along with uncontrollable health anxiety

...So, what's next? CBT seems to be ineffective for me too - I just can't make it work.

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Health anxiety is on the Obsessive-Compulsive Disorders spectrum and while as a generalisation no antidepressant is intrinsically better than any other, either generally or for a specific disorder, the exception to the rule seems to be the SSRI fluvoxamine (Luvox) and the TCA anafranil (Clomipramine) for OCD spectrum. If upping the citalopram isn't on the cards, or doesn't work then I think switching to anafranil is the better option, especially if there are other health issues as fluvoxamine interacts with many other meds which can complicate treatment. Anafranil also has the advantage of inhibiting noradrenaline/epinephrine reuptake in addition to serotonin.

BTW - A number of small scale studies have found the amino acid analogue supplement N-acetylcysteine (NAC) can reduce OCD intrusive and compulsive thought patterns and also boost the effectiveness of antidepressants for OCD and other OCD spectrum disorders [1]. There is a large scale multinational study currently underway to test this. NAC is generally a safe supplement with few side-effects. It is mostly used medically to protect the liver in cases of paracetamol, aka acetaminophen, overdose and has other medical uses. Doses of 1,800-3,000mg/day taken in 3 divided doses seems to work (start with one dose per day of around 500-600mg and increase by the same amount every 2-3 days to avoid triggering diarrhoea). NAC is best taken on an empty stomach about an hour before meals.

As an added bonus NAC may also reduce blood coagulation which seems to be one of the most serious symptoms of Covid-19 (Youtube, 7:57m)

HOWEVER, be aware that a study [2] found NAC (also Vitamin E) may increase the risk of lung cancer in smokers, or those with some specific lung diseases (note, it doesn't cause lung cancer, only maybe reduces the ability of the immune system to detect and destroy existing cancerous cells). This finding has been the subject of much debate because there are many other studies showing NAC protects against lung cancer so it is probably not the final word on the subject. FWIW, I'm a lung cancer survivor and have take NAC for over 14 years because it is the best thing I've found for reducing fluid build up in my remaining lung.

Seek your GP's advice before taking NAC. While it can be beneficial for asthmatics with fluid buildup in lungs, it may cause shortness of breath in some, so caution is needed if you have asthma. It is contraindicated for those taking nitroglycerin, vitamin K and some blood pressure meds.

References:

[1]
Couto JP, Moreira R. (2018)
Oral N-acetylcysteine in the treatment of obsessive-compulsive disorder: A systematic review of the clinical evidence.
Prog Neuropsychopharmacol Biol Psychiatry. Aug 30;86:245-254 (Abstract)

di Michele F, Siracusano A, Talamo A, Niolu C. (2018)
N-Acetyl Cysteine and Vitamin D Supplementation in Treatment Resistant Obsessive-compulsive Disorder Patients: A General Review.
Curr Pharm Des. 24(17):1832-1838 (Abstract)

Ghanizadeh A1,2, Mohammadi MR3,4, Bahraini S, etal. (2017)
Efficacy of N-Acetylcysteine Augmentation on Obsessive Compulsive Disorder: A Multicenter Randomized Double Blind Placebo Controlled Clinical Trial.
Iran J Psychiatry. Apr;12(2):134-141 (Abstract | Full text)

Oliver G, Dean O, Camfield D4, Blair-West S, et al (2015)
N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review.
Clin Psychopharmacol Neurosci. Apr 30;13(1):12-24 (Abstract | Full text - PDF)

[2]
Sayin VI1, Ibrahim MX, Larsson E, et al. (2014)
Antioxidants accelerate lung cancer progression in mice.
Sci Transl Med. 2014 Jan 29;6(221):221ra15 (Abstract | Full text - PDF)

And please reach out to us to talk, PM. You know you can always “PM” me :hugs:

You are not alone. Covid has us all stressed.

Thanks for all the replies so far - so informative and so kind.

As I write I'm watching the live Service of Remembrance from the National Arboretum, as today is the 75th anniversary of VJ day. It sort of puts my problems in perspective.

Your feelings and emotions still count PM,VDay was different to what you are experiencing.:bighug:
Take Care xx

Don’t give up, as there’s so many different medications you can try. Talk to your dr about upping your dose or switching to a new medication. Or it may be that all that’s happening around you has affected your mental health and you’re having a bit of a blip.