Depression in adults with a chronic physical health problem: recognition and management

Choice of antidepressants

If you decide to start taking an antidepressant, your healthcare professional should discuss with you which antidepressant is most suitable for you. They should take into account:

Some antidepressants cannot be taken alongside certain types of medication used to treat physical health problems. Your doctor should discuss the risks and benefits of particular antidepressants with you, and monitor you carefully.

You should usually be offered a type of antidepressant called a selective serotonin reuptake inhibitor (or SSRI for short). Ones called citalopram and sertraline are less likely to affect any other medication you are taking. If it is likely that an SSRI will affect your physical health problem or can't be taken alongside your other medication, you may be offered another type of antidepressant. Possibilities include mianserin, mirtazapine, moclobemide, reboxetine or trazodone.

Certain medicines should only be prescribed by a specialist mental health professional, including:

You should not be offered an antidepressant called dosulepin because it is associated with an increased risk of heart problems.

Starting treatment

Your healthcare professional should discuss any concerns you have about your medication. For example, they should explain that:

You should also be offered full written information about taking antidepressants.

If you are aged 30 or over and are not considered to be at increased risk of suicide, your healthcare professional should usually see you 2 weeks after starting treatment. You should then be seen every 2 to 4 weeks for the first 3 months, with less frequent appointments after that if the treatment is working.

There are some concerns about how young people respond to antidepressants in the early stages of treatment. So if you are under 30 you should usually be seen 1 week after starting an antidepressant, and then as often as needed after that.

If you are thought to be at risk of suicide, you should be seen 1 week after starting an antidepressant and then as often as needed, whatever your age.

If you get side effects when you first start taking an antidepressant but they are not too distressing, your healthcare professional should monitor you closely. If you prefer, your medication may be stopped or you can try a different antidepressant. If you are anxious or agitated or not sleeping very well, you may be offered another medicine called a benzodiazepine to take as well as your antidepressant – although you shouldn't usually take this for more than 2 weeks.

What happens if I don't feel better after taking an antidepressant?

If, at any stage of your antidepressant treatment, you have questions or you feel you are not getting better, you should go and see your healthcare professional and discuss your concerns.

If you don't feel any better after 2 to 4 weeks, they should check that you have been taking the medicine as prescribed. If you have been taking the correct dose but there's little or no improvement after 3 to 4 weeks of treatment, they may discuss increasing the dose of your medication with you. But if you have had distressing side effects, or if you prefer, you may be offered a different antidepressant.

If your symptoms have still not improved after you have completed your course of antidepressants, or the antidepressant is causing distressing side effects, your healthcare professional may discuss a range of options with you. These might include psychological treatment or trying a different antidepressant. When changing antidepressants, the dose should be increased gradually and you should be monitored carefully.

Stopping antidepressants

If an antidepressant has helped you, your healthcare professional should encourage you to continue taking it for at least 6 months after you feel better. This reduces the risk of your depression coming back. They should then discuss with you whether you need to stay on medication after this.

When it is time to stop taking your antidepressant, this should be done gradually over 4 weeks, although some drugs might need longer (such as paroxetine and venlafaxine). Fluoxetine can be stopped more quickly. You may have symptoms when you stop taking antidepressants or reduce the dose – these can include mood changes, restlessness, sleep problems, dizziness and stomach ache. Symptoms can also occur if you miss doses. These symptoms are usually mild and soon disappear. But they can sometimes be severe, especially if the antidepressant is stopped suddenly.

If you experience severe symptoms while your medication is being reduced or after you have stopped taking it, you should contact your healthcare professional. They might try you on your original dose, or try a similar antidepressant, before gradually reducing the dose again while monitoring your symptoms.