4.3.3 Selective serotonin re-uptake inhibitors

Following a review of the safety and efficacy of Selective serotonin re–uptake inhibitors (SSRIs) for the treatment of depression in children and adolescents, the CSM has advised (December 2003) that the SSRIs citalopram, escitalopram, paroxetine and sertraline, and the related antidepressant venlafaxine are contraindicated in those aged under 18 years. Fluvoxamine should also not be used to treat depression in these individuals because there is insufficient information on safety and efficacy.

MHRA Drug Safety Update (December 2011)

Citalopram and escitalopram: QT interval prolongation

Citalopram and escitalopram are contraindicated in patients at greatest risk of QT interval prolongation, such as those with:

  • Congenital long QT syndrome
  • Known pre-existing QT interval prolongation
  • In combination with other medicines that prolong the QT interval; these include (but note that this is not an exhaustive list)
    • Class IA and III antiarrhythmics (e.g. amiodarone, dronedarone, quinidine)
    • Antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol)
    • Tricyclic antidepressants
    • Some antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV, pentamidine, antimalaria treatment—particularly halofantrine)
    • Some antihistamines (astemizole, mizolastine)
    • Some antiretrovirals (e.g. ritonavir, saquinavir, lopinavir)

Patients taking concomitant medications known to increase plasma levels of escitalopram and citalopram may require a dose reduction. Drugs known to increase plasma concentrations of escitalopram and citalopram include some antiretroviral medications, and omeprazole and cimetidine.

Details of specific interactions can be found in the individual Summaries of Product Characteristics.

The balance of benefits and risks of citalopram and escitalopram should be considered carefully; caution is advised in patients with pre-existing risk factors for QT interval prolongation, for example:

  • Congestive heart failure
  • Recent myocardial infarction
  • Bradyarrhythmias or predisposition to hypokalaemia or hypomagnesaemia because of concomitant illness or medicines

Note that the maximum daily doses for citalopram and escitalopram are restricted – see individual drug entries.

  • Tablets 5mg, 10mg, 20mg (£1.03 = 10mg daily)



  1. Escitalopram maximum adult daily dose: 20mg daily
  2. In adults aged > 65 years and adults with hepatic impairment the maximum daily dose of escitalopram is 10mg daily
  3. See prescribing guidance notes above
  • Tablets 50mg, 100mg (£0.85 = 100mg daily)


  • Capsules 20mg (£0.57 = 20mg daily)
  • Oral solution 20mg in 5ml (£2.64 = 70ml)


  • Tablets 10mg, 20mg, 40mg (£1.20 = 20mg daily)
  • Oral dropsSF 40mg in 1ml (4 drops may be considered equivalent to 10mg tablet) (£3.63 = 15ml)



  1. Citalopram maximum adult daily dose: 40mg daily
  2. In adults aged > 65 years and adults with hepatic impairment the maximum daily dose is 20mg daily
  3. 4 oral drops (8mg) is equivalent in therapeutic effect to 10mg tablet
  4. See prescribing guidance notes above
  • Tablets 5mg, 10mg, 20mg (£27.72 all strengths = one daily)


  1. NICE TA367: Vortioxetine is recommended as an option for treating major depressive episodes in adults whose condition has responded inadequately to two antidepressants within the current episode. (November 2015)


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