NICE guidelines for timing of initial review of non-suicidal patients: Within 1 week for people less than 30 years of age who have been started on an antidepressant. Within 2 weeks for anyone else. Subsequent reviews every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered.

QOF guidelines: not earlier than 10 days after and not later than 56 days

Initial Review

 

Are you getting any side effects?

o    Drowsiness

o    dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures.

o    Anxiety agitation insomnia

o    Sexual disfunction

§  Is it effective?

§  GAD & PHQ

Ensure the following is covered during the review

·         call us if you have any problems

·         need to take the antidepressant for at least 6 months after recovery

·         antidepressant is not addictive

·         Do not stop it suddenly

·         May affect your ability to drive

Reassess:

·         The risk of suicide

·         Any safeguarding concerns

·         Any stresses that may contribute to depression such as:

o    Employment or financial worries.

• Poor living conditions.
• Problems with interpersonal relationships (e.g. partner children or parents).
• Lack of social support.

·         Assess the benefits of any psychological interventions.

 

§  Assess continuation or taper off:

o    Continue treatment for at least 6 months following remission

o    Someone who has had only one episode should stay on medication for at least six months to a year

o    Someone who has had two episodes -If strong family history of depression, or one of those episodes was so severe that their life was impacted significantly in some way - stay on medication indefinitely.

o    Patients with three or more episodes have a 90% chance of relapse

IF TAPERING

§  Discuss antidepressant withdrawal symptoms

§  Create a plan

§  Send email with all info (see page 6)

IF NOT TAPERING

§  Read Code

§  Are you getting any side effects?

o    Drowsiness

o    dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures.

o    Anxiety agitation insomnia

o    Sexual disfunction

§  Is it effective?

§  GAD & PHQ

Ensure the following is covered during the review

·         call us if you have any problems

·         need to take the antidepressant for at least 6 months after recovery

·         antidepressant is not addictive

·         Do not stop it suddenly

·         May affect your ability to drive

 

 

 

Assessing the risk of suicide

 

Directly ask about suicidal thoughts and intent. Do not avoid the word 'suicide'. Ask:

§  Do you ever feel that life is hopeless and not worth living?

§  Do you ever think about suicide?

§  Have you made any plans for ending your life?

§  Do you have the means for doing this available to you?

§  What has kept you from acting on these thoughts?

o    Follow up on 'not really' answers.

·         Identify risk factors that increase the risk of suicide, particularly previous attempts at suicide or self-harm, or a feeling of hopelessness.

·         Assess adequacy of social support and current personal circumstances.

·         Identify factors that reduce the risk of suicide, including good social support and responsibility for children.

Managing adverse effects

·         Suicidal thoughts and suicide attempts — all antidepressants have been associated with an increase in suicidal thoughts and suicide attempts in adolescents and young adults, and people with a history of suicidal behaviour. The absolute risk is thought to be small, however people who have higher risk should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed. (NICE states that this must be balanced against more recent findings that the risk of clinically important suicidal behaviour is highest in the month before starting antidepressants and decreases thereafter. NICE state that it is not clear whether the increase in suicidal thoughts or behaviour is a direct result of taking an antidepressant or the timing of when the person asked for help.) 

·         Anxiety, agitation, or insomnia — if these are problematic, consider short-term (usually less than 2 weeks) concomitant treatment with a benzodiazepine.

·         Persistent, severe, or distressing adverse effects may be managed by:

o    Dose reduction and re-titration (if possible).

o    Switching antidepressants to an antidepressant less likely to cause that adverse effect.

·         Sexual dysfunction — sexual dysfunction is a common symptom of depression, all antidepressants can cause sexual dysfunction to varying degrees (most commonly serotonin reuptake inhibitors). If erectile dysfunction is a problem, sildenafil maybe considered.

·         Hyponatraemia may occur with all antidepressants, especially in elderly people. The onset is usually within 30 days of starting treatment and is not considered to be dose related.

o    Consider hyponatraemia if the person develops dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures.

o    If hyponatraemia is suspected, stop the antidepressant and manage according to the severity and duration of symptoms, and state of hydration.

·         Mild and transient adverse effects such as nausea induced by SSRIs may be managed by explanation, reassurance and, if necessary, dose reduction and re-titration.

Antidepressant withdrawal

Antidepressants work by altering the levels of neurotransmitters — chemical messengers that attach to receptors on neurons (nerve cells) throughout the body and influence their activity. Neurons eventually adapt to the current level of neurotransmitters, and symptoms that range from mild to distressing may arise if the level changes too much too fast — for example, because you've suddenly stopped taking your antidepressant. They're generally not medically dangerous but may be uncomfortable.

Among the newer antidepressants, those that influence the serotonin system — selective serotonin reuptake inhibitors (SSRIs, now commonly known as SRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) — are associated with a number of withdrawal symptoms, often called antidepressant or SRI discontinuation syndrome. Stopping antidepressants such as bupropion (Wellbutrin) that do not affect serotonin systems — dopamine and norepinephrine reuptake inhibitors — seems less troublesome over all, although some patients develop extreme irritability.

Having discontinuation symptoms doesn't mean you're addicted to your antidepressant. A person who is addicted craves the drug and often needs increasingly higher doses. Few people who take antidepressants develop a craving or feel a need to increase the dose. (Sometimes an SRI will stop working — a phenomenon called "Prozac poop-out" — which may necessitate increasing the dose or adding another drug.)

Antidepressant withdrawal can look like depression Discontinuation symptoms can include anxiety and depression. Since these may be the reason you were prescribed antidepressants in the first place, their reappearance may suggest that you're having a relapse and need ongoing treatment. Here's how to distinguish discontinuation symptoms from relapse: ·         Discontinuation symptoms emerge within days to weeks of stopping the medication or lowering the dose, whereas relapse symptoms develop later and more gradually. ·         Discontinuation symptoms often include physical complaints that aren't commonly found in depression, such as dizziness, flulike symptoms, and abnormal sensations. ·         Discontinuation symptoms disappear quickly if you take a dose of the antidepressant, while drug treatment of depression itself takes weeks to work. ·         Discontinuation symptoms resolve as the body readjusts, while recurrent depression continues and may get worse. If symptoms last more than a month and are worsening, it's worth considering whether you're having a relapse of depression.

Neurotransmitters act throughout the body, and you may experience physical as well as mental effects when you stop taking antidepressants or lower the dose too fast. Common complaints include the following:

·         Digestive. You may have nausea, vomiting, cramps, diarrhea, or loss of appetite.

·         Blood vessel control. You may sweat excessively, flush, or find hot weather difficult to tolerate.

·         Sleep changes. You may have trouble sleeping and unusual dreams or nightmares.

·         Balance. You may become dizzy or lightheaded or feel like you don't quite have your "sea legs" when walking.

·         Control of movements. You may experience tremors, restless legs, uneven gait, and difficulty coordinating speech and chewing movements.

·         Unwanted feelings. You may have mood swings or feel agitated, anxious, manic, depressed, irritable, or confused — even paranoid or suicidal.

·         Strange sensations. You may have pain or numbness; you may become hypersensitive to sound or sense a ringing in your ears; you may experience "brain-zaps" — a feeling that resembles an electric shock to your head — or a sensation that some people describe as "brain shivers."

 

Half-lives
Drug	Half out of body in	99% out of body in
Paroxetine	24 hours	4.4 days
sertraline	26 hours	5.4 days
escitalopram	27 to 32 hours	6.1 days
citalopram	36 hours	7.3 days
fluoxetine	Four to six days	25 days
venlafaxine	5 hours	1 day
duloxetine	12 hours	2.5 days

 

Depression questionnaires

o    PHQ-9

§  A score of 12 is the recommended threshold for considering intervention.

o    HADS

§  Ascore of 10 is the recommended threshold for considering intervention.

o    BDI-II

§  A score of 20 is the recommended threshold for considering intervention.

 

Send this advice email (or letter by post) to the patient

Dear Mr/Mrs

Here is some advice to help you come off your antidepressant.

Take your time.  Before discontinuing your antidepressant, you should feel confident that you're functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don't try to quit while you're under stress or undergoing a significant change in your life, such as a new job or an illness.

Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you're taking, how long you've been on it, your current dose, and any symptoms you had during previous medication changes. It's also a good idea to keep a "mood calendar" on which you record your mood (on a scale of one to 10) on a daily basis.

Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it's often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.

Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It's been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.

Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you'll probably be reassured that they're just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you're taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.

You may want to involve a relative or close friend in your planning. If people around you realize that you're discontinuing antidepressants and may occasionally be irritable or tearful, they'll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.

Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn't been tested in a clinical trial.

Check in with your clinician one month after you've stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.

Our tapering schedule will depend on which antidepressant you're taking, how long you've been taking it, your current dose, and any symptoms you had during previous medication changes. Below is a chart with sample tapering schedules for some of the most popular antidepressants. However, depending on how you respond to each dose reduction, you may want to taper more gradually using smaller dose reductions, longer intervals between dose reductions, or both. If you experience discontinuation symptoms after a particular dose reduction, you may want to add back half the dose — or all of it — and continue from there with smaller dose reductions. There are no hard and fast rules for getting off antidepressants, other than that the approach should be individualized! Some people can taper off an antidepressant in a matter of weeks, while others may take months.

 

Suggested dose reductions for tapering off antidepressants
Drug	Starting dose (mg)	1st dose reduction (mg)	2nd dose reduction (mg)	3rd dose reduction (mg)	4th dose reduction mg)
Fluoxetine	60 mg	40	30+	20	10++
Paroxetine	60	40	30	20	10
Sertraline	200	150	100	75	50
Citalopram	40	30	20	10
escitalopram	20	15	10	5
Venlafaxine	300	225	150	75	37.5
duloxetine*	90	60	30	20
bupropion*	300	200	150	100
+Alternate 40 mg one day and 20 the next to get the equivalent of 30 mg per day. ++Take 20 mg every other day to get the equivalent of 10 mg per day. *Pill should not be cut. Source: https://www.health.harvard.edu/diseases-and-conditions/