Key messages

Clinicians should:

• Undertake proactive medicine reviews and create the opportunity for people to be directed to and access non-pharmacological and psychological interventions, which may be needed to achieve better longer-term outcomes (see Recommendations).
• Code clinical records for people receiving antidepressant prescriptions with the indication for antidepressant treatment (see Recommendations).
• Consider different strategies for reducing, tapering and stopping antidepressants where indicated. These should be considered and applied depending on individual preferences and need (see Reducing and stopping).
• Review diagnosis, adherence with treatment and where appropriate consider switching to an alternative antidepressant if no response to antidepressant treatment at three to four weeks. All antidepressants show a pattern of response and rate of improvement greatest in the first one to two weeks (see Recommendations).
• Use optimal doses of antidepressants where ‘20’s plenty and 50’s enough’. Selective serotonin re-uptake inhibitors (SSRIs) demonstrate a flat dose response curve for the treatment of depression. Standard daily doses of 20mg citalopram/fluoxetine/paroxetine, 50mg daily of sertraline or 10mg escitalopram provide optimal antidepressant effectiveness (see Purpose of this advice).
• Proactively review those on antidepressants and long-term antidepressants. As individuals may not be proactively reviewed and present only at times of crisis, this may lead to doses being inappropriately increased in response to crisis. Long-term antidepressant use is associated with the use of higher antidepressant doses (see Chart).

Depression

See Recommendations

• The stepped-care approach should be used to help choose the most appropriate intervention - self-help, non-pharmacological, with or without antidepressant therapy. 
• Consider that for 50% of individuals depressive symptoms can spontaneously resolve within 12 weeks of diagnosis.
• Less severe depression (i.e. PHQ-9 score <16), commonly referred to as mild depression, may respond better to non-pharmacological approaches as antidepressants are not effective for less severe illness.
• Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person's preference.
• Antidepressants are effective for reducing symptoms of moderate to severe depression and/or helping people achieve remission, especially in combination with non-pharmacological treatment and/or self-help, see Interventions to aid reduction of symptoms and recovery and Numbers needed to treat (NNT), and numbers needed to harm (NNH).
• Combining antidepressants for depression is not recommended. Non-specialist psychiatry prescribers should not initiate these combinations, unless on the advice of specialist services. People initiated on combinations by psychiatry should be reviewed by specialist services.
• For people with dementia, antidepressants demonstrate limited benefits in treating depression. However, for some individuals they may reduce depressive symptoms and improve general functioning.

Anxiety disorders

See Recommendations

• The stepped-care approach should be used to help choose the most appropriate intervention; self-help, non-pharmacological with or without antidepressants, see Interventions to aid reduction of symptoms and recovery.
• Different antidepressants demonstrate variable efficacy depending on which anxiety disorder is being treated – generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), etc.

Pain

See Recommendations

• Tricyclic antidepressants (TCAs) and duloxetine demonstrate modest effects in the treatment of neuropathic pain (See Numbers needed to treat (NNT), and numbers needed to harm (NNH)).
• Selective serotonin re-uptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and tricyclics antidepressants are not recommended in the management of lower back pain, with no evidence for the use of antidepressants in sciatica. 
• Antidepressants (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine and sertraline) can improve quality of life, pain, sleep and psychological distress compared with placebo in the treatment of chronic pain, however the evidence is conflicting.