GGC Medicines


Adult Therapeutics Handbook

Management of Depression

Management of Depression

For further detail regarding the non-pharmacological therapies, continued care in the community, or antidepressant adverse effects see the 'Depression Treatment in Primary Care' guideline available on NHSGGC StaffNet, search in 'CNS' section.

Notes

Read the following before continuing to the flowchart.

  • If mild depression, antidepressant is not indicated (NICE CG23, Management of Depression in Primary and Secondary Care, December 2004).
  • Consider referral if there is a risk of suicide or the depression is severe (including psychotic symptoms).
  • If patient is very anxious or agitated, consider the use of benzodiazepines as an adjunct for a maximum of 2 weeks.
  • Agitation may be a side effect of antidepressant treatment and usually resolves after a few weeks.
  • MHRA has issued dose recommendations for citalopram due to risk of a dose-dependent QT interval prolongation. The maximum dose is 40 mg/day in adults and 20 mg/day in the > 65 years and people with reduced hepatic function. See www.mhra.gov.uk for more information on cautions and contraindications.

Flowchart - Management of depression

Make a positive diagnosis
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If an antidepressant is indicated check whether recurrence of depression or new diagnosis
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  • Recurrence of depression - Use previous antidepressant if it was effective unless there are new contraindications
  • New diagnosis - Fluoxetine, sertraline or citalopram (NHSGGC antidepressants of choice). These antidepressants are:
    • Safe in overdose.
    • Lower potential for withdrawal effects.
    • As effective as other antidepressants.
    • More cost-effective.
    • Citalopram is contraindicated in patients with QT interval prolongation and in combination with drugs known to prolong QT interval. See note above.
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If effective, continue for at least 6 months following recovery. Review regularly, however this may vary with individual needs.
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If no response after adequate trial (check concordance) or intolerable side effects:

  • (Another) formulary selective serotonin re-uptake inhibitor from the choices above or lofepramine
  • Mirtazapine or trazodone may be considered if night-time sedation is required

If no response also review diagnosis.
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If effective, continue for at least 6 months following recovery. Duration of treatment may vary depending on the severity of condition, see the 'Depression Treatment in Primary Care' guideline available on NHSGGC StaffNet for further detail. 
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If no response after adequate trial, or intolerable side effects:

  • Consider referral
  • Previously untried option from above
  • Duloxetine* / mirtazapine / venlafaxine**
  • Other tricyclic antidepressants

Notes:

*Duloxetine: Psychiatrist initiation only.

**Venlafaxine: Regular monitoring of BP as clinically appropriate. Prescribe the standard release preparation instead of the MR/XL preparations. Psychiatric supervision required for patients of daily doses of venlafaxine 300 mg and above and on initiation of a severely depressed patient.
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If effective, continue for at least 6 months following recovery