Citalopram Discontinuation and Sleepwalking

Discontinuation Syndrome

Citalopram discontinuation syndrome is characterized by dizziness, fatigue, lethargy, general malaise, myalgias, chills, headaches, nausea, vomiting, diarrhea, insomnia, imbalance, vertigo, sensory disturbances, paresthesias, anxiety, irritability, and agitation, according to the American Academy of Child and Adolescent Psychiatry 1, 2.
Citalopram has a relatively lower risk of discontinuation syndrome compared to paroxetine, fluvoxamine, and sertraline, which are more commonly associated with withdrawal symptoms, as noted by the American Academy of Child and Adolescent Psychiatry 1.

SSRIs, including citalopram, have been shown to induce or exacerbate REM Behavior Disorder (RBD) during active treatment, along with tricyclic antidepressants and MAOIs, according to the American Geriatrics Society 3.
RBD involves complex, often violent motor behaviors during sleep with loss of normal REM sleep atonia, which is distinct from typical sleepwalking (a non-REM parasomnia), as described by the American Geriatrics Society 3.
Sleepwalking has been reported with alcohol and barbiturate withdrawal, suggesting that withdrawal states from CNS-active medications can trigger parasomnias, as noted by the American Geriatrics Society 3.

If sleepwalking occurs after stopping citalopram, consider whether the patient has a personal or family history of parasomnias, as this would increase susceptibility, according to the American Geriatrics Society 3.
The American Academy of Sleep Medicine recommends implementing environmental safety measures, such as removing dangerous objects, padding surfaces around the bed, using heavy window coverings, and considering placing the mattress on the floor, if sleepwalking occurs after citalopram discontinuation 3.
The American Geriatrics Society suggests considering polysomnography if episodes are recurrent or severe to evaluate for RBD or other primary sleep disorders 3.
The American Academy of Sleep Medicine recommends evaluating for underlying sleep disorders, such as sleep apnea, which can trigger parasomnias when untreated, if sleepwalking occurs after citalopram discontinuation 3.

Paroxetine (Paxil) is consistently identified as having the highest risk of withdrawal symptoms, with withdrawal symptoms being more likely and more severe compared to other SSRIs 4
The American Academy of Family Physicians notes that older guidelines suggesting 10-14 day tapers are inadequate for long-term therapy, and recommends gradual dose reduction rather than abrupt cessation, although the specific citation for this is not provided, a similar recommendation is made by the FDA for paroxetine 4

Fluvoxamine is grouped with paroxetine as a "shorter half-life SSRI" with higher withdrawal rates, and withdrawal symptoms are common with fluvoxamine 4
Venlafaxine (SNRI, not pure SSRI) has higher discontinuation rates due to adverse effects compared to SSRIs as a class 5
Withdrawal symptoms are especially severe with venlafaxine 4

Antidepressant discontinuation syndrome is characterized by symptoms including dizziness, fatigue, lethargy, general malaise, myalgias, chills, headaches, nausea, vomiting, diarrhea, insomnia, imbalance, vertigo, sensory disturbances, paresthesias, anxiety, irritability, and agitation 6
These symptoms typically occur following missed doses or abrupt discontinuation of shorter-acting SSRIs, particularly paroxetine, fluvoxamine, and sertraline 6

Avoid combining fluoxetine with MAOIs due to risk of serotonin syndrome 7
Use caution when combining fluoxetine with other serotonergic agents, including triptans, tramadol, other SSRIs, and certain supplements 7

The patient's symptoms of hives, insomnia, and arm paresthesias while on the medication suggest adverse reactions or early serotonin syndrome features, which can complicate the withdrawal picture 8

Implement supportive care, including benzodiazepines for severe anxiety/agitation if needed, though use cautiously given potential for another withdrawal syndrome, and patient education that sensory disturbances are a known withdrawal phenomenon that typically resolves, even if taking longer than expected 8

Check for serotonin syndrome features, including hyperreflexia, clonus, muscle rigidity, or tremor, which would indicate ongoing serotonergic toxicity rather than simple withdrawal, and these symptoms can be easily misidentified as relapse of the underlying anxiety disorder, but the sensory component points more toward medication effects 8