These guidelines are for the managementof mild to moderate depression in adults and the older patient using antidepressant therapy and considering other treatment options.
Treatment with antidepressants:
The goal of treatment is to get well. Continuation of treatment is important to prevent relapse. The benefits of antidepressants increase with the severity of depression and are uncertain at the mildest severity. Antidepressants are an effective treatment for moderate depression when prescribed at an adequate dose and for a period of at least 4-6 weeks to achieve improvement. Expectation of treatment and early side effects should be discussed with patient together with a management plan of treatment. Patients should be warned against suddenly stopping medication. Older people require longer treatment and may respond more slowly.
Patients should be monitored:
for suicide risk
to assess side effects are tolerated
to ensure compliance with treatment
Frequency depends on clinical assessment.
Important points
Ensure adequate dose - titration of dose may be necessary
Continuing treatment for at least 6-9 months once effective medication and dose level has been achieved
Patients with incomplete recovery may require longer treatment
Patients with recurrent episodes may require maintenance therapy after recovery
Lower doses of antidepressants should be considered for the older patient (refer to BNF)
Withdrawal of treatment
Slowly reduce doses over a minimum of 4 weeks and advise not to stop medication suddenly
Discontinuation symptoms (including gastrointestinal and somatic distress) may appear within 1-14 days of stopping treatment and usually improve within a week
Important to distinguish between withdrawal and relapse (assessment tools helpful)
Choosing an antidepressant
familiarise oneself with small number of drugs within each therapeutic class
be guided by efficacy and tolerability of previous response to antidepressant treatment
if no response to adequate dose and duration choose another class of medication
main factors in primary care
impact of likely side effects
likely toxic effects
likely interactions
patient preference