Develop a clear management plan collaboratively with the individual and carers where appropriate

Prescribers and individuals should aim to develop mutually supportive and constructive discussions when reviewing antidepressants and ongoing treatment needs. Where appropriate consider the fears and apprehensions associated with reducing/stopping antidepressant therapy and tailor treatment to the individual’s needs.

The stepped-care approach should be used to tailor the most appropriate intervention to the individual’s needs. This can be done according to the severity of the condition being treated, such as self-help resources or non-pharmacological interventions with or without antidepressant therapy.^36,37

Include realistic expectations and review dates that can be read coded for recall and pre-planned follow-up. 

Plan and agree follow up in relation to the condition being treated

In depression, it is a widely held belief that antidepressants do not exert their effects for four to six weeks. However, all antidepressants show a pattern of response and rate of improvement which is greater in the first one to two weeks.^18,20,73 Therefore, for those with no response at three to four weeks, review diagnosis; adherence with treatment; and where appropriate consider switching to an alternative antidepressant. Studies demonstrate that prescribers may change the antidepressant or optimise the dose at eight weeks, which creates a lag in treatment and may slow recovery.^5,21 Where appropriate, communicate changes in prescribing to the individual’s specialist in secondary care.

Agree, plan and record the criteria for reducing and stopping the antidepressant in the future, or if adverse drug effects become intolerable e.g. severe restlessness, more frequent thoughts of suicide or deliberate self-harm. Although younger people less than 25 years old are considered at greatest risk of antidepressant associated self-harm, there are multiple age, gender and regional effects that are associated with self-harm and suicide,^74,75 therefore these should also be explored.

Encourage people that are prescribed antidepressants, or any other medicine, to initiate open discussions regarding the appropriate continuation, reduction and discontinuation of pharmacological treatment. 

Review effectiveness, tolerability and adherence on an ongoing basis as part of a medication review, and where appropriate reduce the number and doses of medicines to minimise avoidable adverse effects and harms and to optimise adherence. Consider inviting individuals for proactive medication reviews. An example review invite letter is available here.

In relation to mental health and emotional distress, where appropriate complete and record a biopsychosocial assessment including:

• asking individuals directly about thoughts and/or plans of self-harm or suicide, and record severity as outlined in appropriate guidelines.^37,76
• consider and exclude physical causes of signs and symptoms including:
  • alcohol (FAST tool)
  • problem substance use
  • bereavement
  • organic disease as a cause for symptoms

As depression and other mental health conditions are associated with an increased risk of deliberate self-harm and suicide, ask the individual directly about any thoughts or plans for self-harm or suicide. Although some individuals may have suicidal thoughts when visiting their health professional, they may withhold and not share their thoughts.^11,77 Where healthcare professionals are uncomfortable asking directly about self-harm or suicide, the PHQ-9 assessment tool includes a self-harm question that may help facilitate and enable further discussion around this. As outlined in guidelines, such as the NICE depression guidelines, antidepressants may be appropriate in treating depression as part of the stepped-care model for the treatment of moderate to severe depression.³⁶ Continue to use and record the results of valid assessment tools such as PHQ-9, CORE 10 or other suitable rating scales to support continuity of care.