Citalopram

Is citalopram safe?

For most adults with depression, yes, as long as the dose stays within the label and the prescriber knows about your heart and your other medicines. Citalopram, sold as Celexa in the US and Cipramil in the UK, is a selective serotonin reuptake inhibitor (SSRI). It is not addictive and was filled about 12.5 million times in the US in 2024.

What sets it apart from other SSRIs is its effect on heart rhythm. It lengthens the QT intervalQT prolongationA delay in the heart's electrical recovery between beats, seen on an ECG. Some medicines cause it, and in rare cases it leads to a serious heart rhythm problem.More in the glossary more than its close relative escitalopram, and in overdose that effect becomes a real danger. We score it 67, below escitalopram (71) and sertraline (72).

Why the dose is capped at 40 mg

Citalopram was once prescribed at up to 60 mg a day. In August 2011 the FDA said it should no longer be used above 40 mg, after studies showed a dose-dependent effect on the heart's electrical activity and no extra benefit for depression above 40 mg. The current Celexa label gives the numbers from a study in 119 healthy volunteers:

Daily dose	Average QTc increase vs placebo
20 mg	8.5 ms
40 mg (predicted)	12.6 ms
60 mg	18.5 ms

A rise of 10 to 20 milliseconds does nothing noticeable in most people. It matters when it stacks on other risks: a congenital long QT syndrome, a slow heart rate, low potassium or magnesium, recent heart attack, heart failure, or another drug that lengthens QT. Torsade de pointes, ventricular tachycardia and sudden death have been reported with citalopram after approval.

The US label sets a 20 mg maximum for people over 60, those with liver problems, poor CYP2C19CYP450 enzymesA family of liver enzymes that break down many medicines. When another drug or supplement speeds them up or slows them down, drug levels change.More in the glossary metabolisers and anyone taking a CYP2C19 inhibitor. The MHRA's 2011 rules are stricter in one respect: in the UK citalopram must not be combined with other QT-prolongingQT prolongationA delay in the heart's electrical recovery between beats, seen on an ECG. Some medicines cause it, and in rare cases it leads to a serious heart rhythm problem.More in the glossary medicines, which include several antipsychotics, antiarrhythmics such as amiodarone, tricyclic antidepressants and some antibiotics.

How well people tolerate it

In the label's short depression trials, 1,063 people took citalopram and 446 placebo:

Side effect	Citalopram	Placebo
Nausea	21%	14%
Dry mouth	20%	14%
Sleepiness	18%	10%
Sweating	11%	9%
Ejaculation disorder (men)	6%	1%

Sixteen per cent stopped because of side effects, twice the placebo rate, though doses in those trials went up to 80 mg. Nausea usually fades in the first weeks. Sexual side effects are more likely to last and are worth raising with the prescriber.

The boxed warning and other class risks

Like every US antidepressant, citalopram carries a boxed warningBoxed warningThe strongest safety warning the US FDA puts on a medicine's label, printed inside a black border at the top.More in the glossary: in short-term trials, antidepressants raised suicidal thoughts and behaviour in children, teenagers and young adults. Celexa is not approved for under-18s. Families should watch for agitation, worsening mood or talk of self-harm in the first months and after any dose change, and contact the prescriber the same day.

Other SSRI risks apply too. Serotonin syndromeSerotonin syndromeA reaction caused by too much serotonin in the body, usually from combining medicines that raise it. Symptoms range from shivering to high fever.More in the glossary can occur with tramadol, triptans, other antidepressants, lithium or St John's wort. Bleeding risk rises with aspirin, ibuprofen, naproxen and blood thinners. Low blood sodium is a concern in older people, and the drug can trigger mania in undiagnosed bipolar disorder.

Overdose: where citalopram differs most

Most SSRIs are forgiving in overdose. Citalopram is less so. In a 2004 review of 469 SSRI overdoses at an Australian toxicology unit, 68% of citalopram cases had a prolonged QTc, and the odds were five times those seen with sertraline. The current label warns that seizures and heart rhythm problems can be delayed and recommends prolonged heart monitoring.

Any overdose, even if the person feels fine, needs hospital assessment. In the US call Poison Help on 1-800-222-1222; in the UK call 111, or 999 if someone is drowsy, fitting or has palpitations. If anyone in the home is at risk of self-harm, ask the prescriber about smaller supplies.

Who should be careful

Talk to your doctor or pharmacist before starting citalopram, or before adding anything to it, if you:

• have a heart rhythm problem, a slow pulse, heart failure or a recent heart attack
• have low potassium or magnesium, or take diuretics
• take an antipsychotic, antiarrhythmic, methadone or certain antibiotics
• take omeprazole, cimetidine or another antidepressant
• are over 60, have liver disease, or are under 25
• have bipolar disorder, epilepsy or narrow-angle glaucoma
• are pregnant or breastfeeding

Stopping suddenly can bring dizziness, irritability and electric-shock sensations. The label advises tapering, and a lower score is no reason to stop a medicine that is working without talking to your prescriber.

How we scored it

Track record (90) and dependence (80) are strong. The overdose marginOverdose marginHow far a normal dose is from a harmful one. A wide margin means an accidental extra dose is unlikely to cause serious harm.More in the glossary (68) is the clearest gap with escitalopram and sertraline, because of citalopram's QT effect in large doses. Interactions (55) and regulatory warnings (45) reflect the 2011 dose restrictions, the QT drug combinations and the class boxed warningBoxed warningThe strongest safety warning the US FDA puts on a medicine's label, printed inside a black border at the top.More in the glossary.