Millions of patients relying on antidepressants are being urged to meticulously check their medication following a manufacturing error that resulted in two different drugs being incorrectly packaged. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning that sealed packets of sertraline 100mg film-coated tablets may contain blister strips of citalopram 40mg.

Both sertraline and citalopram are classified as selective serotonin reuptake inhibitors (SSRIs), which are commonly prescribed to manage conditions such as depression, anxiety, and other mood disorders by increasing serotonin levels in the brain. However, inadvertently taking the wrong medication can lead to serious side effects, necessitating urgent medical attention.

Amarox Limited has initiated a precautionary recall for one specific batch of Sertraline 100mg film-coated tablets. This affected batch carries an expiry date of May 2028 and the batch number V2500425. Patients who have been prescribed sertraline from this batch are strongly advised to inspect their medication boxes to ensure they contain the correct drug, verifying that the blister strips' batch number and expiry date match those printed on the outer packaging.

Dr. Alison Cave, MHRA chief safety officer, emphasized, "If the blister strips inside the carton are labelled Citalopram 40mg, please contact your pharmacy as soon as possible." She further explained that patients who have accidentally ingested citalopram instead of, or in addition to, sertraline may experience heightened serotonergic side effects. These can manifest as nausea, headache, changes in sleep patterns, and mild anxiety. Those correctly prescribed sertraline 100mg and unaffected by this batch do not need to take further action.

The manufacturing company has, to date, received one complaint from an adult patient who reported experiencing a headache, subsequently identifying that their prescription wrongly included a strip of Citalopram tablets. The error is believed to have occurred during the secondary packing process of the strips into the cardboard packaging, as both drugs were manufactured at the same site. The affected batch was first distributed on November 28, 2025.

Healthcare professionals, including pharmacists, involved in dispensing antidepressants have been advised to contact any patients who may have received the incorrect medication and request its return. General practitioners and clinicians should also be informed of the mix-up to discuss treatment reviews and whether new prescriptions are needed for ongoing supply.

The MHRA has highlighted that certain patient groups require particular caution, including individuals over 65, those under 18, and patients with pre-existing heart or liver conditions. Any suspected adverse reactions resulting from this mix-up or other drug-related incidents should be reported through the MHRA's Yellow Card scheme. The MHRA has also instructed healthcare professionals to cease supplying the affected batch and return all remaining stock to their suppliers.

Over eight million patients in England are prescribed SSRIs to manage conditions such as depression, anxiety, and obsessive compulsive disorder. Sertraline is typically taken once daily at a consistent time, and taking an extra dose, even if a pill has been missed, can be dangerous.