Can't dump citalopram

Hi all,

I was on 20mg citalopram for about three years and gradually reduced my dose to 5mg. Going to zero from there proved to be a problem. Tinnitus, "humming" in my body - not unbearable but unpleasant. The second time I "relapsed," I went back to a 2,5mg dose, which I realize is pretty ridiculous, but it worked just fine. After about a week on 2,5mg, I decided to go off again. Like a clockwork, on the third day of zero, the discontinuation effects roared back today.

I'm okay with staying on an SSRI if need be, but I want to be done with citalopram. My doctor prescribed sertraline a while ago, so today - about 60 hours since my last mini dose of citalopram - I took a quarter of a 25mg sertraline pill, which was probably a stupid idea; I should just make up my mind and then stay the course.

Anyway, I'm a bit at a loss about what to do now. Here are some questions:

1. If I stay on SSRIs, my understanding is that I should be able to switch from citalopram to sertraline without a washout period, especially since my doses are so tiny. Does this sound correct?

2. Is there any harm in staying on those tiny doses of citalopram/sertraline for another while? Maybe it'll be easier to quit when the world in general is a bit less crazy than right now. I have to say that I'm in a good place mentally right now, and I feel like some of the sexual side effects I had on 20mg citalopram have subsided, so I'd rather not go back up unless my anxiety comes back.

3. If I decide to quit now, how long do those darn effects possibly last? I can't believe I had ZERO problems going from 20 to 10mg, but that those last milligrams are so tough...

Thanks for reading this mess! :)

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Originally Posted by Justus

1. If I stay on SSRIs, my understanding is that I should be able to switch from citalopram to sertraline without a washout period, especially since my doses are so tiny. Does this sound correct?

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Yes. A washout is not generally not required when switching between SSRIs, though some care may be needed when switching from fluoxetine (Prozac) because of its very long half-life. You could probably have switched from 20mg citalopram to 20mg sertraline with few issues. Going to/from the TCAs is usually not a problem either though it is best done via a short cross-taper than an overnight switch. The only ADs for which a washout is mandatory is the MAOIs and you're unlikely to encounter them (which may not be a good thing as they can be very effective).

However, sertraline may not be the best SSRI to switch to if the intention is to do so only for a short while before weaning off. The problem is sertraline has an even shorter half-life than citalopram, about 24 h vs 36 h. Fluoxetine would be better as it has a half-life of up to 6 days and that of its active metabolite norfluoxetine, which does most of the work, is up to 16 days, so it takes about a month for fluoxetine to be completely metabolised and eliminated and nearly 3 months for its metabolite. That provides a very slow taper compared to citalopram.

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2. Is there any harm in staying on those tiny doses of citalopram/sertraline for another while? Maybe it'll be easier to quit when the world in general is a bit less crazy than right now.

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The potential issue with staying on sub therapeutic doses for extended periods is that it may increase the risk of antidepressant poop-out.

Antidepressants 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 (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 this requires a minimum level of the med in the system to initiate and sustain.

The problem with taking sub/borderline therapeutic doses is neurogenesis may be interrupted whenever the antidepressant 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 long periods may create a similar situation as stopping and restarting the med. While the neurogenesis interruptions may only be of short duration, they will likely occur much more frequently.

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I have to say that I'm in a good place mentally right now, and I feel like some of the sexual side effects I had on 20mg citalopram have subsided, so I'd rather not go back up unless my anxiety comes back.

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There are ways of easing SSRI induced sexual dysfunction.

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3. If I decide to quit now, how long do those darn effects possibly last? I can't believe I had ZERO problems going from 20 to 10mg, but that those last milligrams are so tough...

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It's the last bit that is always the hardest. It's like falling off a ladder, the first metre and a half are no problem, but the last 0.5mm is a doozy! As for the likely duration, unfortunately, this is a 'how long is a piece of string question' which can only be answered with "it depends." It could be a few days, or some weeks. I suggest you discuss this with your GP and there are ways of treating the withdrawal symptoms. Perhaps a low dose of diazepam for a week for the tinnitus. It might help with the "humming" too.