Follow a person-centred approach to initiating antidepressants

• individual and prescriber’s expectations
• stepped-care and watchful-waiting for common mental health conditions
• effective non-pharmacological interventions (e.g. physical activity, self-help)
• drug effects and limitations (e.g. dose response) including dose ranges for treatment of different conditions (e.g. SSRI flat dose response effects for depression: meaning that ‘20’s plenty and 50’s enough’ – using standard doses of 20mg daily of citalopram/fluoxetine/paroxetine or 50mg daily of sertraline – to provide the full antidepressant effect,^40-42,44 or for neuropathic pain response TCAs at doses ≤75mg per day)³³
• the potential for short and long-term adverse drug effects e.g. nausea, agitation, sedation, sexual dysfunction (see section "Common adverse drug effects/harms from antidepressants" below).
• It is also important to discuss and consider how and when the antidepressant will be reduced and stopped in the future to minimise potential drug-related harms

Provide appropriate information about the condition (NHS Inform website), antidepressant treatment and stopping. The Choice and Medications website contains a variety of information and leaflets which may be helpful.

• The stepped-care approach should be used to help choose the most appropriate intervention - self-help, non-pharmacological, with or without antidepressant therapy.³⁶
• Consider that for 50% of individuals depressive symptoms can spontaneously resolve within 12 weeks of diagnosis.⁶⁸
• Less severe depression (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.^20,36

‘Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person's preference’.

• Moderate to severe depression. 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) below.^20,36

• The stepped-care approach should be used to help choose the most appropriate intervention; self-help, non-pharmacological with or without antidepressants,^37,38 in supporting individuals to achieve a reduction in anxiety symptoms and/or achieve remission, 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.^37,69

• Neuropathic pain. Tricyclic antidepressants (TCAs) and duloxetine demonstrate modest effects for the treatment of neuropathic pain (See the table below).³³
• Low back pain and sciatica. NICE indicates that ‘there was no evidence on the use of antidepressants for sciatica. The committee agreed that antidepressants were commonly prescribed for sciatica, and clinical experience suggests they may be of benefit in some people. The committee considered the potential for harm to be less than the harms of prolonged use of opioids.⁷⁰
• Chronic pain. The evidence for use of antidepressants (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine and sertraline) in chronic pain is conflicting. Antidepressants improved quality of life, pain, sleep and psychological distress compared with placebo.^71,72

* Response: usually defined as a ≥50% reduction in depression rating scale scores or remission.

# Withdrawal from study due to adverse drug effects

+ ≥50% reduction in pain intensity scores

^ ≥25% reduction in Yale Brown Obsessive Compulsive Scale