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improvement. In the beginning of the treatment certain patients may experience increased anxiety, which will disappear during continued treatment. Therefore, it is very important that you follow exactly your doctor’s orders and do not stop the treatment or change the dose without consulting your doctor.

Z Thoughts of suicide and worsening of your depression or anxiety disorder

If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself. These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer.

You may be more likely to think like this:

•    If you have previously had thoughts about killing or harming yourself.

•    If you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant.

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Use in children and adolescents under 18 years of age

Citalopram Tablets should normally not be used for children and adolescents under 18 years. Also, you should know that patients under 18 have an increased risk of side-effects such as suicide attempt, suicidal thoughts and hostility (predominantly aggression, oppositional behaviour and anger) when they take this class of medicines. Despite this, your doctor may prescribe citalopram for patients under 18 because he/she decides that this is in their best interests. If your doctor has prescribed Citalopram Tablets for a patient under 18 and you want to discuss this, please go back to your doctor. You should inform your doctor if any of the symptoms listed above develop or worsen when patients under 18 are taking Citalopram Tablets. Also, the long-term safety effects concerning growth, maturation and cognitive and behavioural development of Citalopram Tablets in this age group have not yet been demonstrated.

Other medicines and Citalopram

Medicines may affect the action of other medicines and this can sometimes cause serious adverse reactions. Please tell your doctor or pharmacist if you are taking or have taken any other medicines (including those purchased without prescription) during the last 14 days. This includes other medicines for depression (see Do not take Citalopram Tablets above).

•    The herbal remedy St John’s wort (Hypericum perforatum). This should not be taken at the same time as Citalopram Tablets.

•    Monoamine oxidase inhibitors (MAOIs). These should not be taken at the same time as Citalopram Tablets (see Do not take Citalopram Tablets above).

Tell your doctor if you are taking any of the following medicines:

•    Linezolid (an antibiotic).

•    Sumatriptan (used to treat migraine) or tramadol (a pain killer). If you feel unwell when using these medicines with Citalopram Tablets you should see your doctor.

•    Lithium (used to prevent and treat mania) and tryptophan (an anti-depressant)

•    Pimozide (a neuroleptic). This should not be taken at the same time as Citalopram Tablets (see Do not take Citalopram Tablets above).

•    Imipramine and desipramine (used to treat depression).

•    Medicines containing selegiline (used to treat Parkinson’s disease)

•    Cimetidine (used to treat stomach ulcers).

•    Mefloquine (used to treat malaria).

•    Bupropion (used to treat depression).

•    Medicines known to affect the blood platelets (e.g. anticoagulant drugs used to treat or prevent blood clots; aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac used as painkillers and some antipsychotic drugs and tricyclic antidepressants).

•    Metoprolol, a beta blocker used to treat migraine, some heart conditions and high blood pressure. The effects of either drug could be increased, decreased or altered.

•    Neuroleptics (used in the treatment of schizophrenia).

Do not take Citalopram if you take medicines for heart rhythm problems or medicines that may affect heart's rhythm, e.g. such as class IA and III antiarrhythmics, antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol), tricyclic antidepressants, certain antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV, pentamidine, anti-malarial treatment particularly halofantrine), certain antihistamines (astemizole, mizolastine). If you have any further questions about this you should speak to your doctor.

Taking Citalopram Tablets with food and drink

Citalopram can be taken with or without food (see section 3 "How to take Citalopram Tablets'").

As with all antidepressants, it is sensible to avoid drinking alcohol whilst receiving treatment although Citalopram has not been shown to increase the effects of alcohol.

Pregnancy, breast-feeding and fertility Pregnancy

Ask your doctor or pharmacist for advice before taking any medicine. If you are pregnant, think you might be pregnant, or are trying to become pregnant, tell your doctor. Do not take Citalopram Tablets if you are pregnant unless you and your doctor have discussed the risks and benefits involved.

Make sure your midwife and/or doctor know you are on Citalopram Tablets. When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Citalopram Tablets may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately. Also, if you take Citalopram Tablets during the last 3 months of your pregnancy and until the date of birth you should be aware that the following effects may be seen in your newborn: fits, being too hot or cold, feeding difficulties, vomiting, low blood sugar, stiff or floppy muscles, overactive reflexes, tremor, jitteriness, irritability, lethargy, constant crying, sleepiness or sleeping difficulties. If your newborn baby gets any of these symptoms please contact your midwife and/or doctor immediately.

Breast-feeding: Ask your doctor or pharmacist for advice before taking any medicine.

If you are breast-feeding, ask your doctor for advice. You should not breast-feed your baby when taking Citalopram Tablets because small amounts of the medicine can pass into the breast milk.

Fertility: Citalopram has been shown to reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet.

Driving and using machines: Citalopram may have side effects like dizziness and lack of concentration. You should not drive or operate machinery if affected.

Citalopram Tablets contain lactose: These tablets contain lactose. If you have been told that you have intolerance to some sugars, contact your doctor before taking these tablets.

3. How to take Citalopram Tablets

Always take Citalopram Tablets exactly as your doctor has told you. You should check with your doctor or pharmacist if you are not sure.

Swallow the tablets whole. Do not crush them. The tablets can be taken either in the morning or in the evening, before or after a meal.

The usual oral dose is:

Adults

Depression: The usual dose is 20 mg per day. This may be increased by your doctor to a maximum of 40 mg per day.

Panic Disorder: The starting dose is 10 mg per day for the first week before increasing the dose to 20-30 mg per day. The dose may be increased by doctor to a maximum of 40 mg per day.

Elderly patients (above 65 years of age): The starting dose should be decreased to half of the recommended dose, e.g. 10-20 mg per day. Elderly patients should not usually receive more than 20 mg per day.

Children and adolescents (< 18 years): This medicine is not recommended for children. For further information, please see section 2, Before you take Citalopram Tablets

Patients with special risks: Patients with liver complaints should not receive more than 20 mg per day.

Patients with kidney disease: No dosage adjustment is required in mild or moderate kidney impairment. In severe renal impairment, your doctor may adjust your dose.

How and when to take Citalopram Tablets: Citalopram Tablets is taken every day as a single daily dose. Citalopram Tablets can be taken any time of the day with or without food. Swallow the tablets with a drink of water. Do not chew them (they have a bitter taste).

Duration of treatment: Like other medicines for depression and panic disorder these tablets may take a few weeks before you feel any improvement. Continue to take Citalopram Tablets even if it takes some time before you feel any improvement in your condition. The duration of treatment is individual, usually at least 6 months. Continue to take the tablets for as long as your doctor recommends. Do not stop taking them even if you begin to feel better, unless you are told to do so by your doctor. The underlying illness may persist for a long time and if you stop your treatment too soon your symptoms may return. Patients who have recurrent depression benefit from continued treatment, sometimes for several years, to prevent the occurrence of new depressive episodes. Never change the dose of the medicine without talking to your doctor first.

If you take more Citalopram Tablets than you should: If you take too many of these tablets or someone else takes your tablets, contact your doctor or hospital emergency department immediately. Do this even if there are no signs of discomfort or poisoning. Try to take any tablets left with you and also the container, as this will allow easier identification of the tablets. Some of the signs of an overdosage could be life-threatening.

Symptoms of overdosage may include:

If you forget to take Citalopram Tablets: If you forget to take a dose, take it as soon as you remember, then go on as before. Do not take a double dose to make up for a forgotten dose.

If you stop taking Citalopram Tablets: Do not discontinue your tablets without consulting your doctor or pharmacist. Abrupt discontinuation of medication may lead to certain side-effects. Stopping this medicine quickly may cause symptoms such as dizziness, nausea and numbness or tingling in hands or feet, sleep disturbances (vivid dreams, nightmares, inability to sleep), feeling anxious, headaches, feeling or being sick, sweating, feeling restless or agitated, tremor, feeling confused or disorientated, feeling emotional or irritable, diarrhoea (loose stools), visual disturbances, fluttering or pounding heartbeat (palpitations). These are usually non-serious and disappear within a few days. When you have completed your course of treatment, the dose of Citalopram Tablets is usually reduced gradually over a couple of weeks.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

4. Possible side effects

Like all medicines, Citalopram Tablets can cause side effects, although not everybody gets them.

Serious side effects

Stop taking Citalopram Tablets and seek medical advice immediately if you

have any of the following symptoms:

•    Difficulty in breathing.

•    Swelling of the face, lips, tongue or throat that causes difficulty in swallowing or breathing.

•    Severe itching of the skin (with raised lumps).

•    Fast, irregular heartbeat, fainting which could be symptoms of a life-threatening condition known as torsades de pointes.

•    Condition known as SIADH (syndrome of inappropriate secretion of antidiuretic hormone)

•    Liver inflammation (hepatitis)

•    Bleeding (e.g. vaginal, gastrointestinal, skin and soft tissue bleeding)

If you notice any of the following symptoms you should contact your

doctor immediately as your dose may need to be reduced or stopped:

•    You start having fits for the first time or fits that you have suffered from in the past become more frequent.

•    Your behaviour changes because you feel elated or over excited.

•    You experience high fever, agitation, confusion, trembling or abrupt contractions of muscles. These may be signs of a rare condition called serotonin syndrome.