Starting and monitoring antidepressant treatment

Starting and Monitoring antidepressant treatment

When an antidepressant is to be prescribed in routine care, it should be a selective serotonin reuptake inhibitor (SSRI), because SSRIs are as effective as tricyclic antidepressants and are less likely to be discontinued because of side effects.

• explore any concerns the person has about taking medication and provide information, including:
  • the gradual development of the full antidepressant effect
  • the importance of taking medication as prescribed and the need to continue beyond remission
  • potential side effects and drug interactions
  • the risk and nature of discontinuation symptoms (particularly with drugs with a shorter half-life, such as paroxetine and venlafaxine)
  • the fact that addiction does not occur
    
    
• for people who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly, for example every 2-4 weeks in the first 3 months, and then at longer intervals if response is good
  
  
• for people who are considered to be at increased risk of suicide or are younger than 30 years, normally see them after 1 week and then frequently until the risk is no longer clinically important
  
  
• if a person experiences side effects early in treatment, provide information and consider:
  • monitoring symptoms closely if side effects are mild and acceptable to the person or
  • stopping or changing to a different antidepressant if the person prefers or
  • in discussion with the person, consider short-term concomitant treatment with a benzodiazepine if anxiety, agitation and/or insomnia are problematic (except in people with chronic symptoms of anxiety); this should usually be for no longer than 2 weeks in order to prevent the development of dependence
    
    
• people who start on low-dose TCAs and have a clear clinical response can be maintained on that dose with careful monitoring
  
  
• If the person's depression shows no improvement after 2 to 4 weeks with the first antidepressant, check that the drug has been taken regularly and in the prescribed dose
  
  
• if response is absent or minimal after 3-4 weeks of treatment with a therapeutic dose of an antidepressant, increase support and consider:
  • increasing the dose in line with the summary of product characteristics (SPC) if there are no significant side effects or
  • switching to another antidepressant if there are side effects or if the person prefers
    
    
• if there is some improvement by 4 weeks, continue treatment for another 2-4 weeks. Consider switching antidepressants if:
  • response is still not adequate or
  • there are side effects or
  • the person prefers to change drug

For more detailed guidance then refer to full NICE guideline (1).

Specific advice if monitoring after switching antidepressant treatment (4):

Advising people

Ensure the person knows the monitoring they can expect after the switch, by whom, and when. Advise people at their review appointment on aspects such as the:

• time required for treatment to be effective - it may take a minimum of 4 to 6 weeks for the efficacy of the switch to be seen (4)
• discuss the possibility of side-effects and that discontinuation symptoms may be associated with the switch
  • discontinuation symptoms may include:
    • restlessness
    • trouble sleeping
    • unsteadiness
    • sweating
    • stomach problems
    • feeling as if there’s an electric shock in your head
    • feeling irritable, anxious or confused
• discuss the risks of serotonin syndrome and symptoms and signs
  • clinical presentation ranges from mild to life-threatening. Possible clinical features include:
    • autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, sweating, shivering and diarrhoea)
    • neuromuscular hyperactivity (tremor, rigidity, myoclonus, clonus and hyperreflexia)
    • altered mental state (agitation, confusion, mania and coma)
• risk of relapse, and that medication may be needed for 6 months or longer (if relapse risk is higher) even after remission of symptoms
• non-addictive nature of antidepressants
• management of missed or extra doses and the risks associated with stopping an antidepressant
  • patient advice re: missed or extra doses
    • It's important not to miss any of your doses, as this could make your treatment less effective.
    • You may also get withdrawal symptoms as a result of missing a dose of the medicine.
    • If you do miss 1 of your doses, skip the missed dose and take your next dose at the usual time. Do not take a double dose to make up for the dose you missed.
    • If you take more tablets than prescribed, contact your GP or NHS 111 as soon as possible for advice
  • patient advice re:stopping antidepressants
    • Talk to your doctor before you stop taking antidepressants. It's important that you do not stop taking antidepressants suddenly.
    • Once you're ready to come off antidepressants, your doctor will probably recommend reducing your dose gradually over several weeks – or longer, if you have been taking them for a long time.
    • This is to help prevent any withdrawal symptoms you might get as a reaction to coming off the medicine. These include:
      • restlessness
      • trouble sleeping
      • unsteadiness
      • sweating
      • stomach problems
      • feeling as if there's an electric shock in your head
      • feeling irritable, anxious or confused
    • Withdrawal symptoms are often mild and get better on their own. However, some people have withdrawal symptoms that are severe and last for several months or more.
    • Coming off antidepressants too soon can cause your condition to return. Stopping before you have been taking them for 4 weeks may mean the medicine has not had a chance to work.
• availability of self-help groups, and how and from whom to seek urgent support

Reference:

1. NICE (April 2018). Depression
2. Anderson IM et al (2000). Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol, 14, 3-20.
3. MeReC Briefing (2005); 31:1-8.
4. NHS Specialist Pharmacy Service (February 2023). Monitoring a person during and after antidepressant switching
5. NHS Advice (accessed February 21st 2023). Antidepressant treatment - missed doses or stopping treatment