Target groups for review
Antidepressants: Quality prescribing - a guide for improvement
This may vary depending on practice populations and prescriber preferences, however, we would advise that the following groups should be considered for review. The Scottish Therapeutics Utility (STU) is available in all general practices in Scotland to allow case finding and identification of the higher risk groups below.
Potential groups of people that receive antidepressants and may benefit from being prioritised for a regular, proactive medicines review:
1. People receiving the same antidepressant continuously, long-term (≥2 years)
2. Older adults (≥65 years) and/or frail adults
- Receiving a SSRI plus antiplatelet/NSAIDs/DOAC/warfarin without gastro-protection, due to the increased risk of gastric bleed with this combination.
- Receiving >1 defined daily dose per day of citalopram (>20mg per day) or escitalopram (>10mg per day) due to QTc prolongation
- Diagnosed with dementia,
- Antidepressants may provide limited effects for depression
- Receiving antidepressants for behavioural and psychological symptoms of dementia
- Receiving TCAs and other anticholinergics – reduce the anticholinergic drug burden, to reduce the risk of falls and confusion
3. People receiving combinations
- Antidepressant plus long-term benzodiazepines (≥8 weeks) and/or z-drugs (B-Z)
- B-Z are associated with an increased risk of depressive symptoms, paradoxically worsen anxiety, and reduce the effectiveness of psychological treatments. Review reducing B-Z use prior to assessing antidepressant need where appropriate.
- B-Z prescribing and use is associated with use of higher doses of SSRIs
- Combination antidepressant treatment e.g. mirtazapine with SSRI/SNRI. There is a lack of evidence demonstrating the efficacy of this combination to treat depression. People initiated on combinations by psychiatry should be reviewed by specialist services.
- Higher risk of QTc prolongation combinations:
- Citalopram or escitalopram or TCAs plus: methadone, antipsychotics, quinine, some antinausea medicines, etc
QTc prolongation see Proactively reviewing antidepressants for more information.