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DrRussMD, Board Certified MD
Category: Medical
Satisfied Customers: 65671
Experience:  Board certified Internal medicine and Integrative medicine. Many years of experience all areas.
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Ok Please only answer if you are a UK Medic with a specialist

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Ok Please only answer if you are a UK Medic with a specialist aka Psychiatrist or have a special interest in Mental Health Issues.

I have been depressed for the last 6 months. I started on Fluxoetine and reacted baldly to this. I was placed on Citalopram 20mg and increased to 40mg.

Recently, I have been acutely unwell and in a bad frame of mind. I have been to the GP and he has given me two options: To increase my Citalopram to 60mg. To reduce my Citalopram and to start Sertraline.

I was quite interested in augmenting my treatment with a drug to add in. I have researched it extensively on the internet. I note that Lithium has a good augmenting effect on treatment resistant depression. I was told that Lithium is only prescribed by Psychiatrists and regular blood levels are needed to check for toxicity. I also suggested Bupropion as I have noted from my research an effective augmenting effect on Treatment Resistant Depression. I am told that in the UK, I don't know if this is accurate but Bupropion is only indicated for smoking cessation.

I am concerned that increasing my Citalopram to 60mg is dangerous, and likely to cause QT prolongation. I am concerned that starting a new SSRI is dangerous for me in my current state of mind, and reducing the dose could be very detrimental to my mental health. Is Citalopram 60mg an off label treatment, as I looked at the BNF and found 40mg was the maximum dose indicated.

What are my other options??????

You know, I try everything to become well. I go to counselling, CBT and play positive Hypnotherapy before bed. I eat well, exercise, and extensively read about my subject and the guidelines.

My last question is to do with ECT. I am quite motivated to do it. What is the criteria within the UK. Can I just request this or do I have to get a Psychiatric Referral??
I am a double board certified doctor also degreed in psychology as well as internal medicine and integrative medicine, based in the US but have worked in the UK arena as well.

In fact I would not use lithium, and I would not first add another medication.

This is always more dangerous than increasing the dose of a drug that you tolerate well.

Does this make sense so far?
Customer: replied 4 years ago.

Ok I understand. Please go on

Both citalopram and sertraline have a good side effect profile and are generally well tolerated.
In fact sertraline has a wide dosing range that is well tolerated, so it is a very good choice, and safe compared to any of your other ideas.

Lithium the way it is used in conventional medicine is very problematic, but very effective for bi polar disorder. I would not want to risk the thyroid problems or the kidney problems for depression.

A little house keeping here

Have you had
thyroid studies
vitamin D levels checked
magnesium levels checked?

If so please provide me with the values
simply use reply to expert to respond ...I realize it might take a while
Customer: replied 4 years ago.

Yes I am aware of the Vitamin D levels and Magnesium levels affecting depression. I haven't had them checked. But for a few months I took Vitamin B12, Vitamin D and Magnesium supplementation plus a multivitamin. It had no effect on my mood, so I stopped it.


I had my thyroid checked and it was underactive. I am now being treated with 25mcg of Levothyroxine. I also have a low testosterone count and they are not currently treating that, as they are hoping the correction of the thyroid will correct the other problems.


I am quite concerned that although I tolerate Citalopram well 60mg will give me prolonged QT intervals. I want to know if 60mg is off label use because on looking at the BNF 40mg is the maximum here in the UK


I am also worried Setraline, although I have noted the good profile of the drug and its effectiveness for me, I am worried with the way I feel currently I may end up taking my own life while reducing the dose, and consequently reducing my serotonin and norepinephrine levels. I think it will make me feel like crap.


Thats why I want to add in a mood stabilser, because Im scared about increasing the Citalopram and even more scared about reducing my SSRI before starting another one.


I control my suicidal thoughts and ideations with 40mg Citalopram but am not sure how I would cope without it.


I have also been suggested to use a sedative antihistimine to correct sleep issues to improve my mood

first of all it is a miss conception that increasing the dose of the citalopram is going to make the incidence of that side effect any more likely. If you don't get it at 40 you are not likely to get it at 60.

So that is a fear rather than a reality.

Magnesium orally is often not well absorbed, which is why you have to get your blood levels 2.5 or higher. This can take a year or longer with the best oral supplements.

Thyroid should optimally be treated such that the TSH is around .5 to 1, but the normal says up to 4.5 which is actually quite hypothyroid.

It is likely that even 1.5 is hypothyroid for you, and I suspect you are under treated.

Again, misconception here, you do not have to reduce citalopram and be off of it before starting sertraline.

It appears you are spending a lot of time trying to manage your case in your own mind, which scars you...but the fact is that adding another drug before optimizing the drug you are on, or a single agent, and optimizing these other factors, would not be indicated unless there is some emergency here...IE: optimal dosing has not worked and you are suicidal. That would need, ideally medication adjustment in the hospital.

So, I would say that your doctor, [except for the magnesium, D, thyroid perhaps] is on the right track. But I would also check into these other factors as soon as possible.

If you have not had maximal drug therapy, and you have not by any means, then ECT would not be indicated in either the US or UK, unless again, there is an emergent reason for it as described.

Let me know if you have more questions; use reply to expert.

This is a complex subject, and of course it is not a simple matter for your GP to handle. I would suggest to him that at least a referral for at least one visit to a specialist with more training is in order.

Please do not forget a positive rating.

Customer: replied 4 years ago.

Attachment: 2013-12-05_165310_ecg.pdf


This is a copy of my ECG I had. Do you think its appropriate to increase the dose to 60mg based on this tracing?

Your EKG looks fine.
Let me know if you have more questions; use reply to expert.
Please do not forget a positive rating.
Customer: replied 4 years ago.

So, in relation to dosage, what is the maximum Citalopram you prescribe in USA because I've read a lot of articles indicating it is now only 40mg

It can go to 60 but there is no more proven efficacy.

So that is why I would go to sertraline, as the effective dosing range is much more flexible.

However, as I understand it, your doctor has given you this option.

Let me know if you have more questions; use reply to expert.
Please do not forget a positive rating.
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