Low Dose Citalopram

I've heard reports and anecdotes suggesting that the standard dosing for SSRIs is often higher than it needs to be, and that taking lower doses - somewhat below standard recommendations, not quite "microdosing" - can be just as effective, but with less pronounced side effects.

Has anyone's experience here borne that out?

I've recently started Citalopram at a dose of 5mg. The standard recommendation is 20mg for adults. It's only been 6 days, but the side effects have been fairly obvious even at this small dose - jaw clenching, sweating, etc. It seems crazy that doctors often recommend just jumping straight in at 20mg. I'm planning to stick to 5mg for the time being. If there's no progress after six weeks or so, I'll consider increasing up to 10mg.

I will report back.

I did okay on 10mg citalopram for a couple of months, but eventually decided I wanted to switch up to 20mg. That said, I was never hit all that badly by side effects.

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Originally Posted by Waldenpond

I've heard reports and anecdotes suggesting that the standard dosing for SSRIs is often higher than it needs to be, and that taking lower doses - somewhat below standard recommendations, not quite "microdosing" - can be just as effective, but with less pronounced side effects.

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There is a lot of evidence that, with a few exceptions, ADs need to block 80% of the serotonin (or noradrenaline/norepinephrine (NA) for NA reuptake inhibitors) transporters to initiate and sustain the therapeutic response. The dose range recommendations are based on this.

The other thing to consider is that ADs have no direct effect on anxiety, or depression in the way say benzodiazepines do on anxiety, or aspirin on headaches. They work by stimulating the growth of new brain cells (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 themselves and this requires a minimum level of the med in the system to initiate and sustain. See also: Depression and the Birth and Death of Brain Cells (PDF) and How antidepressant drugs act.

The problem with taking sub/borderline therapeutic doses is neurogenesis may be interrupted whenever AD plasma levels drop below the amount needed to sustain it which could lead to the second issue, the growing evidence antidepressants become progressively less effective every time they are stopped and restarted. Two studies, Amsterdam JD, 2016 and Amsterdam, 2009 found the likelihood of antidepressants working after each restart drops by between 19-25% (see also: Bosman RC 2018; Amsterdam JD, 2009; Leykin Y, 2007); Paholpak S, 2002). Taking a low dose for months may create a similar situation as stopping and restarting it. While the neurogenesis interruptions may only be of short duration, they will probably occur much more frequently.

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It seems crazy that doctors often recommend just jumping straight in at 20mg.

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That's because many of them are clueless about psyche disorders due to limited training. Many GPs know much more about treating diseases they rarely see in their practices whereas their waiting rooms are often full of patients with anxiety disorders and/or depression, diagnosed or not. Sigh! :sad:

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I'm planning to stick to 5mg for the time being.

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I wouldn't, but...

I'm actually going to increase to 10mg in the next few days (currently day 8), since that is still below standard - I hadn't realised 20mg was the standard therapeutic dose for Citalopram.

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Originally Posted by Waldenpond

I'm actually going to increase to 10mg in the next few days (currently day 8), since that is still below standard - I hadn't realised 20mg was the standard therapeutic dose for Citalopram.

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The rule of thumb on dose increases (or decreases) is to not raise the dose earlier than 5 times the half-life of the med as it takes that long for plasma levels to stabilize to a steady-state. For citalopram this is 35 hours x 5 = 175 h/8 days. Increasing the dose earlier may trigger more severe side-effects, however, delaying the increase won't significantly lessen any side-effects spike triggered by it no matter how long the delay.

I took 10mg Citalopram (day 11) this morning and noticed a significant increase in agitation and anxiety within an hour or so.

Toughed it out unsuccessfully for an hour but then succumbed and took 4mg Diazepam and a glass of red wine (very sensible) and felt better within the hour. The whole thing was probably a self-fulfilling prophecy of sorts.

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Originally Posted by Waldenpond

took 4mg Diazepam and a glass of red wine (very sensible)

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Unfortunately, not so sensible. :weep: Alcohol has the same affect on hippocampal neurogenesis as cortisol and BZDs. Even moderate drinking can reduce hippocampus neurogenesis by nearly half (see also: Morris SA, 2010; Crews FT, 2003).

Also, the alcohol-BZD combo is potentially lethal as both are brainstem depressants and among other basic functions the brainstem produces the breathing reflex. 4mg diazepam and a single glass or wine is unlikely to be a problem, but at high doses there is a risk of asphyxiation, especially during sleep.

Plus, alcohol and ADs can be problematic for some. On some days they might be able to drink a herd of alcoholic elephants under the table without raising a sweat, on others a small drink may turn their legs to rubber, so be extra cautious until you work out how the combination effects you.

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The whole thing was probably a self-fulfilling prophecy of sorts.

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Citalopram is absorbed relatively slowly only reaching peak plasma levels some 4 hours after being taken so at least some of the heightened agitation and anxiety 1 hour after taking the dose may have been the anxious mind at play. :sad:

Giving up. Side effects unbearable. Sure, things might improve, but it feels as though these drugs are actually damaging me. (I've seen suggestions that the therapeutic effects of SSRIs are brought about by brain irritation). I'm going to try Propranolol now, which I've never tried before. I'm hopeful that blocking the adrenaline response could be key.

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Originally Posted by Waldenpond

Giving up. Side effects unbearable. Sure, things might improve, but it feels as though these drugs are actually damaging me.

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That is a pity. Maybe try dropping the dose back to 5mg and then after a few days raising it by only 2.5mg for a week, or two. Citalopram is available in liquid form which makes increasing the dose by small increments fairly easy.

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(I've seen suggestions that the therapeutic effects of SSRIs are brought about by brain irritation).

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Antidepressants reverse the brain damaging effects of stress hormones. They don't work by brain irritation, whatever that is, however, the extra serotonin activity initially may cause emotional irritation/agitation until bio-feedback reduces serotonin synthesis and expression, in some areas of the brain to well below baseline.

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I'm going to try Propranolol now, which I've never tried before. I'm hopeful that blocking the adrenaline response could be key.

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Beta-blockers reduce the adrenaline surge of the flight-or-fight response, but don't directly target anxiety. If your anxiety is expressed mostly by such surges then propranolol may be effective, but less so for more generalised anxiety.

I've been on propranolol for a variety of different reasons over the years; it was quite good for migraines (especially the aura), but when it comes to anxiety it can take the physical edge off panic attacks and that's more or less it. From bitter experience, it can also wreak havoc with your ability to sleep if you're already feeling nervous, too. Back when I was dealing with some medical matters (not anxiety related) and a hospital phobia, I landed up going without sleep for 60 hours on two separate occasions, which has never happened before or since. If you really think propranolol will work for you, I'd strongly advise requesting the slow-release stuff and taking it first thing in the morning.