Citalopram Safe at Higher Doses?

There’s a new study recently published in the American Journal of Psychiatry (AJP) which seems to cast doubt on the FDA warning against using Citalopram doses higher than 40 mg a day, PsychiatryOnline | American Journal of Psychiatry | Evaluation of the FDA Warning Against Prescribing Citalopram at Doses Exceeding 40 mg. I’m always alert to new information which has the potential to change my clinical practice. I’ve posted about the FDA warning, which can be found at link, Drug Safety and Availability > FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses.

What I think this new study does is create an opportunity for a meaningful risk to benefit ratio conversation between doctor and patient. Most often it will be between primary care providers and patients because primary care physicians actually write most of the prescriptions for antidepressants. I wonder how confident they feel about this new information.

I’m not sure whether this should change my practice right now. I think further study is needed. I asked several colleagues for their views and only one replied. The data used by the researchers in the AJP study is not identical to that which was used by the FDA to generate the warning. That might be important to know. You have to understand quite a bit about how to evaluate research studies in order to make sense of what to do with this new information by Zivin and colleagues.

The conclusions reached by the FDA and Zivin et al need not be mutually exclusive. And the decision to stick with views by either one could be defended. Patients and their doctors need to know how to discuss them without getting bogged down in the biostatistics. It might be helpful to remember that there’s more to the treatment of depression than pills, for one thing. Evidence-based psychotherapies include but are not limited to Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT).

It’s also important to know when to diagnose major depression and when not to diagnose it. Diagnostic classification manuals and depression rating scales can be helpful, along with common sense and a trusting relationship with patients.

Doctors could also practice saying “I don’t know”, and “We don’t have all the answers yet,” in front of a mirror before going into the consultation room.

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