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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by jay on December 31, 2002, at 5:41:22
This isn't news to most folks...as SRI's/SNRI's are associated with anxiety/panic, but docs *refuse* to treat properly with benzos. Anyhow..show your doc this story the next time they say Celexa *helps* panic/anxiety, and get what REALLY works..benzos.
http://www.medscape.com/viewarticle/442909Panic Attacks Associated With Citalopram
Heidi R. Brauer, MD, Paul W. Nowicki, MD, Glenn Catalano, MD, Maria C. Catalano, DO
South Med J 95(9):1088-1089, 2002. (c) 2002 Southern Medical AssociationPosted 12/20/2002
Abstract and Introduction
Abstract
Citalopram is the newest selective serotonin reuptake inhibitor (SSRI) available in the United States. It is currently approved by the Food and Drug Administration for the treatment of major depression. However, a number of studies have found it to be effective in the treatment of panic disorder as well. While there have been no previous case reports of citalopram inducing panic attacks in patients, this phenomenon has been reported with other members of the SSRI class of antidepressants. We present the case of a 61-year-old woman who had frank panic attacks after her citalopram dose was increased. She had had no history of anxiety symptoms. Anxiety abated completely upon discontinuance of citalopram therapy.Introduction
Citalopram hydrobromide (Celexa) is a selective serotonin reuptake inhibitor (SSRI) with established safety and efficacy in the treatment of depression.[1] Some citalopram studies have shown promising results in the treatment of panic disorder.[2] The most common side effects seen with citalopram use are nausea (21%), dry mouth (20%), somnolence (18%), insomnia (14%), and increased sweating (11%).[3]In a review of SSRI side-effect reports in Sweden, psychiatric symptoms were the second leading adverse reaction reported, occurring in 19.5% of patients.[4] The most common psychiatric side effect reported was "anxiety," which began, on average, 4 days after institution of treatment.[4] The development of anxiety and panic attacks during treatment with SSRIs has been well documented in the literature. Increased anxiety or the onset of panic attacks has been associated with sertraline,[5-7] fluoxetine,[8-12] paroxetine,[13,14] and fluvoxamine,[15] despite the fact that they all have some efficacy in the treatment of panic disorder.[16]
No case reports of increased anxiety or panic associated with citalopram treatment were found on MEDLINE. We now report the first known case of panic attacks induced by citalopram.
Case Report
The patient was a 61-year-old white woman hospitalized for revision of a popliteal bypass. Her medical history included major depression for 20 years, a myocardial infarction, peripheral vascular disease, three cerebrovascular accidents, type 2 diabetes mellitus, urinary incontinence, and a duodenal ulcer, which were all stable on admission. Her usual medications were clopidogrel (75 mg daily), enalapril (5 mg bid), digoxin (0.25 mg/day), warfarin (5 mg/day), metformin (1,000 mg bid), glipizide (10 mg orally tid), tolterodine (2 mg orally qd), metoprolol (50 mg orally bid), and enoxaparin (30 mg subcutaneously bid). Six weeks before admission, her antidepressant medication was changed from imipramine to citalopram (20 mg daily) without any anxiety symptoms or adverse effects. She denied any history of substance abuse. There was no family history of anxiety disorders.During her hospitalization, the patient complained of worsening depressive symptoms, including sleep difficulties, decreased interest, "a horribly depressed" mood and poor concentration. She denied anxiety symptoms, delusions, hallucinations, or suicidal ideations. Serum electrolyte values, complete blood count, thyrotropin level, and folate levels were within normal limits. Vitamin B12 level was low at 158.8 pg/mL, and she was given 1,000 µg of vitamin B12 intramuscularly that evening. Three days later, the citalopram dose was increased to 40 mg each morning. As needed, doses of zaleplon (5 mg qhs) were added for insomnia.
Four days after the citalopram dose increase, the patient reported worsening anxiety symptoms, and a day later, she began having panic attacks. These attacks were characterized by a feeling of "going crazy" with a "fear of losing control." She had bouts of shortness of breath, heart palpitations, accelerated heart rate, nausea, and perioral numbness. The attacks began abruptly, lasted between 3 and 5 minutes and continued for the next 2 days (approximately 5 attacks per day). Her cardiac and respiratory status were evaluated for any appreciable contribution to these symptoms, but none was identified. The increased dose of citalopram was believed to be the cause of the panic attacks, and it was withdrawn. She continued to report some anxiety but no accompanying physical symptoms for the first 24 hours after discontinuing citalopram therapy. After that, no further anxiety or panic was noted.
Discussion
The SSRIs have been found to be useful in the treatment of panic disorder.[16] However, SSRI therapy can give rise to a variety of adverse reactions, including generalized anxiety and panic attacks. The growing abundance of case reports of SSRI-induced panic attacks continues to implicate serotonergic neuronal overactivity in their origin.[17]Although increased anxiety and panic attacks have been associated with all SSRIs, we believe our report is the first documented account of citalopram-associated panic attacks. The anxiety and panic attacks appeared only after increasing the patient's initial citalopram dose, and they subsided quickly after the drug was withdrawn. All other medications remained unchanged except for the addition of zaleplon, which is not known to be a cause of anxiety or known to have an interaction with citalopram. Premarketing clinical trials found that zaleplon in short-term use was not associated with any significant adverse effects.[3] The patient continued to use zaleplon after discontinuance of citalopram therapy, without further panic attacks.
Our patient had nonspecific anxiety on day 4 and panic attacks on day 5 after increasing the dose of citalopram from 20 mg to 40 mg daily. Most anxiety reactions reported among patients receiving SSRIs occurred at a median time interval of 4 days.[4] When citalopram therapy was discontinued, our patient had no further panic attacks, likely because of citalopram's relatively short half-life of 33 hours.[18] This rapid disappearance of panic symptoms is also seen in patients taking other SSRIs with a relatively short half-life. In the previously reported cases of panic attacks associated with sertraline treatment,[5-7] the panic symptoms all abated quickly after the medication was discontinued. This is in stark contrast to fluoxetine and its active metabolite norfluoxetine, which have half-lives of 24 to 72 hours and 168 to 360 hours, respectively.[18] In two of the previously reported cases of panic attacks associated with fluoxetine therapy, the panic symptoms continued for more than 4 months after treatment was discontinued.[12]
In cases involving other SSRI-induced panic attacks, the use of benzodiazepines has been reported to relieve anxiety symptoms until the adverse effect of the SSRI wears off. This adjunctive therapy has been particularly useful with the SSRIs that have longer half-lives (such as fluoxetine/norfluoxetine), which take a considerable amount of time for complete excretion.
In conclusion, even though citalopram has been shown to be an effective agent in the treatment of panic disorder,[16] it may precipitate or worsen anxiety symptoms in some patients. Initiation of citalopram therapy should begin at a low dose and be increased at a slow rate to reduce the risk of exacerbation of anxiety or of inducing the onset of panic attacks.
References
Feighner J, Overo K: Multicenter, placebo-controlled, fixed dose study of citalopram in moderate-to-severe depression. J Clin Psychiatry 1999; 60:824-830
Wade AG, Lepola U, Koponen HJ, et al: The effect of citalopram in panic disorder. Br J Psychiatry 1997; 170:549-553
Physicians' Desk Reference. Montvale, NJ, Medical Economics Co, 54th Ed, 2000
Spigset O: Adverse reactions of selective serotonin reuptake inhibitors. reports from spontaneous reporting system. Drug Saf 1999; 20:277-287
Zinner SH: Panic attacks precipitated by sertraline. Am J Psychiatry 1994; 151:147-148
Varon J, Lechin AE, Taylor TV: "Impending death" and sertraline. J Emerg Med 1995; 13:246
Catalano G, Hakala SM, Catalano MC: Sertraline-induced panic attacks. Clin Neuropharmacol 2000; 23:164-168
Saran A, Halaris A: Panic attack precipitated by fluoxetine. J Neuropsychiatry Clin Neurosci 1989; 1:219-220
Marshall RD, Printz D, Cardena D, et al: Adverse events in PTSD patients taking fluoxetine. Am J Psychiatry 1995; 152:1238-1239
Louie AK, Lewis TB, Lannon RA: Use of low-dose fluoxetine in major depression and panic disorder. J Clin Psychiatry 1993; 54:435-438
Cookson J, Duffert R: Fluoxetine: therapeutic and undesirable effects. Hosp Med 1998; 59:622-626
Altshuler LL: Fluoxetine-associated panic attacks. J Clin Psychopharmacol 1994; 14:433-434
Lecrubier Y, Bakker A, Dunbar G, et al: A comparison of paroxetine, clomipramine and placebo in the treatment of panic disorder. Acta Psychiatr Scand 1997; 95:145-152
Ballenger JC, Wheadon DE, Steiner M, et al: Double-blind, fixed-dose, placebo-controlled study of paroxetine in the treatment of panic disorder. Am J Psychiatry 1998; 155:36-42
Sandmann J, Lorch B, Bandelow B, et al: Fluvoxamine or placebo in the treatment of panic disorder and relationship to blood concentrations of fluvoxamine. Pharmacopsychiatry 1998; 31:117-121
Sheehan DV: Current concepts in the treatment of panic disorder. J Clin Psychiatry 1999; 60(suppl 18):16-21
Nutt D, Lawson C: Panic attacks: a neurochemical overview of models and mechanisms. Br J Psychiatry 1992; 160:165-178
Nutt D: Antidepressants in panic disorder: clinical and preclinical mechanisms. J Clin Psychiatry 1998; 59(suppl 8):24-28
Sidebar: Key Points
The selective serotonin reuptake inhibitors (fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram) are now commonly used in the treatment of anxiety disorders.Fluoxetine, fluvoxamine, paroxetine, and sertraline have previously been associated with treatment emergent anxiety symptoms.
We describe the first reported case of the development of frank panic attacks during treatment with citalopram.
Posted by Ritch on December 31, 2002, at 9:30:45
In reply to Panic Caused By Celexa...Study!, posted by jay on December 31, 2002, at 5:41:22
Jay, that's an interesting article. I noted that she developed the panic attacks after a large dose increase. This has happened to me twice in the past (once with Prozac and once with Celexa). I found that 2.5mg of Prozac was anxiolytic, but when my seasonal depressions would start I would double it to 5.0mg. However, one time I was at the 5.0mg/day dosage and the depression was lifting and winter was nearly over and I experienced similar symptoms to that described in the article. I became out of breath easily, had difficulty breathing with the slightest exercise and that made me panicky because it felt like I was being "smothered". I dropped the dose in half and it resolved after a few days. With Celexa I started at 10mg and after a couple of weeks my depression was worsening and was told to double it to 20mg. Within two-three days I started to experience the same difficult breathing spells. I dropped it back to 10mg and it also resolved after a few days.
Posted by Sebastian on December 31, 2002, at 15:25:12
In reply to Panic Caused By Celexa...Study!, posted by jay on December 31, 2002, at 5:41:22
Thanks,
I had been wondering if I would have better success off the Zyprexa if I stoped the Celexa also.
Sebastian
Posted by sleepy lizard on December 31, 2002, at 22:30:47
In reply to Re: Panic Caused By Celexa...Study!, posted by Sebastian on December 31, 2002, at 15:25:12
I did not notice anxiety or panic increase on Celexa but did get it on Effexor and Wellbutrin. Remeron has not cause any anxiety or panic so far in two months.
Posted by linkadge on January 1, 2003, at 14:41:57
In reply to Re: Panic Caused By Celexa...Study!, posted by sleepy lizard on December 31, 2002, at 22:30:47
The only anxiety I get on Celexa is getting
over excited. I feel I can do really well on
a test or something, and then it's like my
brain is pushing me harder than I can go.Sometimes, on celexa, I forget to breathe.
I am just about asleep when I realize I havn't
breathed in like 20 seconds, I gasp for air,
then eventualy fall asleep.Interestingly, If I take a bit of remeron,
it's like my mind takes over the breathing
for me - big deep breaths in systematic mannor.Linkadge
Posted by Kam on January 1, 2003, at 15:09:45
In reply to Re: Panic Caused By Celexa...Study!, posted by linkadge on January 1, 2003, at 14:41:57
Well now I'm really concerned, I have panic attacks now and was prescribed lexapro which my doctor said was a newer drug similar to celexa. I certainly don't need to be any more anxious than I already am. I started the lexapro today, after the four other SSRI's I have tried I was really hoping this one would work, now after seeing it has caused panic in some, I'm not as hopeful as I was.
Posted by ZeeZee on January 1, 2003, at 16:55:57
In reply to Re: Panic Caused By Celexa...Study!, posted by Kam on January 1, 2003, at 15:09:45
Kam
I wish you all the best in your use of Lexapro. Many people do in fact respond well to Celexa, Lexapro and other SSRI's. However, they are notorious for increasing anxiety and panic intially, and for some it doesn't subside. I for one have not responded well to any of the SSRI's for that reason, and my dx is panic disorder. Benzo's are very helpful as are the MAOI's, so there are alternatives out there.
Keep us posted.Regards,
ZeeZee
Posted by Ritch on January 1, 2003, at 16:59:36
In reply to Re: Panic Caused By Celexa...Study!, posted by linkadge on January 1, 2003, at 14:41:57
> The only anxiety I get on Celexa is getting
> over excited. I feel I can do really well on
> a test or something, and then it's like my
> brain is pushing me harder than I can go.
>
> Sometimes, on celexa, I forget to breathe.
> I am just about asleep when I realize I havn't
> breathed in like 20 seconds, I gasp for air,
> then eventualy fall asleep.
>
> Interestingly, If I take a bit of remeron,
> it's like my mind takes over the breathing
> for me - big deep breaths in systematic mannor.
>
>
>
> Linkadge
Hi, that is an interesting post, and this is a little off the subject somewhat... but you brought up an interesting idea about "forgetting to breathe". I am not sure if this is a symptom of panic or not. I *think* it is related somehow. I know that when you panic the autonomic (automatic) functions of your body go haywire and it seems to me (from my panic experiences anyhow), that the Autonomic Nervous System just goes "asleep at the wheel" and you are temporarily given voluntary control of something you shouldn't have to think about and control consciously. That sounds strange, but that is what it *feels* like to me. Anyhow, there was something that I definitely noticed (related to breathing) with two different psychostimulants (along with the same other meds) with very different responses to breathing. Dexedrine seemed to make breathing MORE automatic and natural. It seemed free and easy and effortless. OTOH, with Ritalin I had the same exact response you describe above. My breathing would frequently pause for what seemed like a long time and then I would have to consciously make myself breathe (which was very annoying). Ritalin at a higher dose would make me tic as well. The tic involved involuntarily swallowing air and burping. I know it sounds weird, but when I took a single 5mg dose of Focalin once I couldn't stop doing it for nearly an hour-what a hassle! I don't understand the neurology behind that experience, but it certainly was strange. Sorry for the tangent....
Posted by Kam on January 1, 2003, at 17:12:21
In reply to Re: Panic Caused By Celexa...Study! » Kam, posted by ZeeZee on January 1, 2003, at 16:55:57
I am also taking xanax which actually works the best however I don't like the risk of becoming addicted. I am just very frustrated (as I am sure anyone with panic attacks are), that I keep going from drug to drug without success. I have a great deal of support from my friends, employer and husband, but even your closest friends don't understand what you are going through with this disorder unless they have it themselves, and I wouldn't wish this on anyone. If there were only that miracle pill out there!!
Posted by ZeeZee on January 1, 2003, at 21:37:03
In reply to Re: Panic Caused By Celexa...Study!, posted by Kam on January 1, 2003, at 17:12:21
Kam,
I wish there was a miracle pill, I'd be the first in line if there was!
I highly recommend cognitive behavioral therapy with a competent therapist, if you're not already doing this, as well as the use of the right benzo.You might also find relief with Nardil or Parnate, if you can find a competent physician who is willing to prescribe and monitor. Although they are frequently shunned by physicians MAOI's are in fact highly effective for panic disorder as well as the subsequent phobic avoidance.
However, this issue of dependence - I understand your concerns, I have the same ones - but using benzo's is really no different than a diabetic using insulin, or someone with epilepsy using neuroleptics. There's withdrawal from most of the AD's as well, but that doesn't make one an addict.
Sometimes the combination of CBT with the right benzo is just what it takes to help get this downward spiral going in reverse - back up. You need relief, and you need something that can help you quickly. You might talk to your doc about the use of Klonopin or one of the neuroleptics, like Neurontin. I'm on day 3 with Buspar, and I also use xanax, and St. John's Wort. Panic is infrequent for me, but the anticipatory anxiety and phobic avoidance are real killers.
Ask your doc why the push of the SSRI's? If that's all s/he's got I'd recommend you looking for a new doc.
I wish you all the best. Remember, you are not alone. There are many on this board who have been and currently are where you are right now, and that includes me.
Keep us posted.Regards,
ZeeZee
Posted by KAM on January 2, 2003, at 8:00:38
In reply to Re: Panic Caused By Celexa...Study! » Kam, posted by ZeeZee on January 1, 2003, at 21:37:03
Thank you for the info and support, I did go through six months of therapy about a year ago it was very helpful. The therapy was more for my prior long term verbally and physically abusive marriage, touched a little on the meds. I hadn't heard about Klonopin until I got on this site, I will research the med and keep that in mind should the Lexapro not work for me. This is a wonderful support system knowing that others are having similar trouble with meds. And yes you are correct the anticipatory is as bad as the panic itself ! I wish you the best of luck!!
Posted by worrier on January 2, 2003, at 20:37:56
In reply to Re: Panic Caused By Celexa...Study!, posted by KAM on January 2, 2003, at 8:00:38
> Just another comment from someone who has been where you are (and isn't very far removed from there now)..don't give up hope and don't be afraid of the xanax. It's been the only thing that has helped me at all. If it treats your problem, go for it. My father-in-law is an epileptic and at one point decided to stop taking his phenobarb because he feared becoming a "drug addict". You can guess what happened. Panic disorder is not that disimilar....uncontrollable abnormal brain activity, strikes at random,etc. You aren't using the drug to get high or whatever...just to gain some degree of control and normalcy. Be careful with the SSRIs...I know they work great for alot of people,but sometimes they make the whole anxiety/panic thing worse. Good Luck.
Posted by Kam on January 2, 2003, at 22:43:24
In reply to Re: Panic Caused By Celexa...Study! » KAM, posted by worrier on January 2, 2003, at 20:37:56
Thank you for your response, I am the type to let my headache go without a Tylenol. I do not like taking meds and now, (because of my prior abuse verbal and physical) I find myself in a whole new world. I am with the most amazingly wonderful man now and my "prior theropist" says the panic startet because I let the brick wall down that I had up for so long. My life was my son, I had at 20, he is now majoring in physics, wants to work at NASA one day. He is "in my world" the reason "I am". On the other side I am with a man (my husband now) who supports me and is soooo anti woman abuse, sometimes I feel I am not worthy of such a man. Again I Thank you, I only wish I had this support way back when. I just turned 40, my son is almost 20, I have some soooooooooooorrrrrrrrrrrrrry story's from his ewwwwwwwwwww can I say his father. The beauty of it all is he knows who was there for him, and that to me is ALL THAT MATTERS!!! Again, I thank you and I wish that I had this support, way back when, but am so excited that I have it now !!!!!!!!!!!!!! After all 40 is just the beginning !!!!!!!!!!!!!!!
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