Use in Children and Adolescents
There have been some reports of efficacy of citalopram in children. Maud and Stein (1996) described one case of a prepubertal girl with obsessive-compulsive disorder who responded to 40 mg citalopram within 10 weeks and remained well for an additional 3 months thereafter. More significant is an open-label trial of citalopram in children and adolescents (). In this naturalistic treatment study, 23 subjects (mean age 13 years) meeting DSM-III-R criteria for obsessive-compulsive disorder were treated over the course of 10 weeks with a combination of citalopram and inpatient or outpatient cognitive-behavioral therapy. Exclusion criteria included psychosis, neurologic or medical disorders, and alcohol or substance abuse. Citalopram was started at 10 mg/day and increased gradually as tolerated. The mean daily dose of citalopram was 37.0 mg, with 20 of the 23 patients maintained on 40 mg, 2 patients on 20 mg, and 1 patient on 10 mg/day. Y-BOCS scores (either adult version or children’s version in subjects younger than 15 years) dropped from a mean at entry of 30.1 to 20.9 at the study conclusion (P<0.001), representing a reduction of 29% overall. This included 4 children who experienced a reduction of greater than 50% and 14 children with “moderate improvement,” liberally defined as greater than 20% reduction in Y-BOCS score. The medication was generally well tolerated. Of the 23 children, 13 experienced mild side effects that remitted within the first few weeks, including dry mouth, headaches, and tremor. Two subjects experienced some agitation necessitating dose reduction, and one individual developed erectile difficulty.
Use in the Elderly
Citalopram appears to be extremely well tolerated by elderly subjects. Several meta-analyses have been conducted on data from open and double-blind studies. These studies have suggested that young patients experience equal or perhaps even higher frequency of adverse events than do the elderly. Dencker and Hopfner Petersen (1989) found that reduced sleep duration and reduced salivation were significantly more common in younger subjects in their analyzed sample of 800 depressed patients. In contrast, Elsborg (1991) found side effect profiles to be essentially the same when controlled for age, with the exception of significantly more dizziness in the older subjects. However, notwithstanding the benign profile, serum concentrations of citalopram and metabolites increase linearly with age (). Similarly, clearance decreases and half-life is increased by up to 50% (). Allowing for this difference, a daily dose of 20 mg is considered sufficient for elderly patients, adjusting upward to a maximum of 30 mg daily if necessary.
Use in Pregnancy
As with all psychotropic agents, there is relatively little information available on safety during pregnancy. Because all antidepressants cross the placenta, the potential for teratogenicity and fetal and neonatal toxicity is present for all available agents. Thus, the decision to use any antidepressant during pregnancy must be made with extreme caution, after careful consideration of treatment alternatives and potential risks and benefits. When antidepressant treatment is warranted, the favorable side effect and safety profile of the SSRIs render them a good choice. Currently, fluoxetine is the best-studied agent; several studies suggest no associated increase in major birth defects with fluoxetine, although there may be elevated rates of spontaneous abortions and perinatal complications (). Given the lesser state of knowledge on citalopram exposure, the need for use should be carefully evaluated on the merits of each case. There are two reports of excessive somnolence, decreased feeding, and weight loss in two infants exposed to citalopram during lactation (Forest Pharmaceuticals Inc. 1998). There are two published reports on the excretion of citalopram in breast milk; these suggest that nursing infants receive no more than 5% of the maternal dose, adjusting for weight (). Infant serum level was 1/15 the maternal trough concentration in the one case in which this was directly studied (). Thus, available data suggest that the relative dose of citalopram ingested by a nursing infant is comparable with that of fluoxetine and higher than those of fluvoxamine, sertraline, and paroxetine (). Taken together, citalopram is probably a poorer choice than some of the other SSRIs for nursing mothers.
Selections from the book: “Current treatments of obsessive-compulsive disorder” (2001).