SH CP 110

 Guidelines for the Management of

Depression in
Adults and Older People
Version 5

Summary

Keywords (minimum of 5)
Target Audience
Next Review Date:
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Sponsor:

The aim of the policy is to ensure support and

advice for staff dealing with depressive disorders
and to provide consistent advice and guidelines
across the health economy.
Depression, Depressive disorder, Antidepressant,
SSRI, Treatment Resistant Depression.
All healthcare professionals employed by
Southern Health NHS Foundation Trust
April 2017
Mental Health Drugs and Therapeutic Committee
Medicines Management Committee
April 2015
Dr Jasenka Matekovic, Consultant Psychiatrist
Prof. David Baldwin, University of Southampton
Stephen Bleakley, Deputy Chief Pharmacist
Dr Martyn Diaper, Medical Director

1. G
 uidelines for Management of Depression
in Adults and Older People
(jointly produced by Primary and Secondary Care)

Depressive Symptoms?
Start with Diagnostic Assessment (see Note 1)

Mild Depression (see Note 1)

Recent onset

Active monitoring, no antidepressant (AD)

Review within 2 weeks.
Helpful interim measures: education, short CBT course,
refer to local IAPT services, CBT and structured counselling,
problem solving, structured exercise programme /activity
scheduling and guided self-help CBT books on prescription
scheme (NICE)
Be alert to development of:
1. Persistent mild depression for more than 3 months, or longer
(dysthymia)
2. Moderate or severe depressive disorder

Consider:
1. Compliance
2. Therapeutic dose
3. Diagnosis and perpetuating factors (e.g. alcohol/drugs/
co-morbidity/psychosocial factors)
Then
1. Increase the dose OR
2. Switch to another AD (same or different class)

NO

Full
response to 2nd
adequate trial
of AD?

YES

SH00716 Communications Team January 2016

Consider referral to secondary care if no response to

2 adequate treatment courses with AD (see treatment
resistant guidelines)

Relapse or Recurrence

Consider immediate referral to Secondary Care

if any of these apply:
1. Considerable risk of suicide, harm to others or
severe self neglect
2. Psychotic symptoms
3. History of elation or mania
4. Significant cognitive impairment
5. Pregnancy for peri-natal advice
6. Psychiatric co-morbidity or complex presentation

1. Moderate to severe Depressive Disorder (DD)

2. Dysthymia, or persistent mild depression longer than 3
mths
3. Mild depression with a past Hx of more severe depression
and/or when it complicates the care of chronic physical
health problems
4. Patient preference for antidepressant
Acute treatment phase or Persistent mild depression
1. Dysthymia: consider antidepressant (AD) as 1st line
2. Moderate DD: 1st line AD

and/or CBT (if available)
3. Severe DD: AD and CBT (if available)
4. Review every 1-2 weeks for 4 - 6 weeks, and regularly
thereafter

No response
after 3-4 weeks
(up to 6 wks in older
person)
or
Partial response
at 6-8 weeks
(no more than 12 weeks
in older persons)

Full
response to AD?
(Symptoms and
Functioning)

Continuation phase (relapse prevention)

Continue same AD on the same dose for at least 6
months after remission. Review regularly once symptom
free. Then consider a gradual reduction in antidepressant

Maintenance phase (recurrence prevention)

To prevent long term recurrence in high risk cases
1. Multiple episodes (2 over 5 yrs, or 3 or more in total)
2. History of severe episode and/or suicidal risk
3. Persistent residual symptoms
4. P resence of other psychiatric disorders treatable with AD
(e.g. panic disorder, PTSD, OCD)
5. Presence of chronic medical condition (e.g. after stroke, MI)
The duration (at least 2 years or longer) depends on risk
factors
Maintain the same dose as for the acute phase
Consider specialist advice re need for maintenance

Note 1. Depressive Disorder (DD) ICD10:

At least 2 of the following:
1: Depressed mood for at least 2 weeks, most days, most of the time,
2: Loss of interest or pleasure,
3: Decreased energy or increased fatigability
Plus at least 2 of the following:
1. Low self-confidence
5. Agitation or retardation
2. Guilt or excessive self-reproach 6. Sleep disturbance
3. Suicidal thoughts or acts
7. Poor or increased appetite
4. Poor concentration or indecisiveness
Mild depression: 5 symptoms in total, and little disability.
Moderate depression: 6 or more symptoms, associated
significant disability.
* Consider use of rating scales to assess severity e.g. PHQ-9 or
HADS
DYSTHYMIA: At least two years of persistent mild depression.

Suicide risk factors in

depressed patients
Suicidal thoughts/
intentions/plans (ask
directly)
History of suicidal
behaviour
Family history of suicide
Comorbidity (alcohol
and other substance
abuse, schizophrenia,
personality disorder,
physical illness)
Hopelessness,
impulsivity,
Male, unemployed,
alone, stressful life
events and unsupported.

ANTIDEPRESSANT
Discontinuation
symptoms:
May include dizziness,
nausea, dysphoria,
paraesthesia, anxiety
and headaches.
Can occur when any
AD is abruptly stopped
or doses missed. Most
frequently reported
with paroxetine and
venlafaxine, and least
often with fluoxetine
and agomelatine. They
are usually mild and
self-limiting but can
occasionally be severe.
To stop AD: taper over
at least four weeks or
longer.
If SSRI withdrawal
proving difficult consider
switching to fluoxetine.

General Management
Always check the risk of suicide.
Begin AD treatment carefully, monitor patients closely, and
watch for signs of side effects, worsening symptoms, and
increased suicidality
All pts on ADs should be informed about duration of the
treatment, discontinuation symptoms, and that ADs are not
addictive
Close patient monitoring is important in early stage of
depression, even when not on AD
Those at risk of suicide or under 30 should be reviewed after 1
week of starting an antidepressant, and frequently thereafter.
There should be specific discussion and monitoring of possible
adverse effects early in treatment (initial worsening of anxiety/
agitation or the emergence of suicidal ideation) with all ADs.
Discuss the choice of drug and likely benefit/availability of
non-drug treatment and side effects.
Several therapeutic measures under Active Monitoring can also
be considered for other types of depression.
Psychosocial factors should be considered as predisposing,
precipitating and perpetuating factors.
Educate on a healthy diet/active lifestyle and appropriate
sleep pattern (esp. avoid oversleeping).

Cognitive Behavioural Therapy: has been recommended

by NICE:
6-8 CBT sessions in Mild depression
16 to 20 CBT sessions over 6-9 months in:
Moderate to severe depression: in problematic side
effects, lack of response to ADs, patients preference
Combination of AD and CBT considered in: Moderate and
Severe depression:
Group-based CBT for mild and moderate depression
CBT also recommended in: chronic, resistant, recurrent
depression and patients with residual symptoms.
CBT for people who have experienced 3 or more
previous episodes of depression.

These guidelines reflect the latest evidence and have been developed by primary, secondary and tertiary care services across the Hampshire
health economy. Clinicians are expected to consider the recommendations made in these guidelines. They do not override individual clinical
judgement made in consultation with the patient, carer or guardian.

References
NICE: Depression in adults. The treatment and management of depression in Adults (CG 90) October 2009. www.nice.
org.uk
Anderson et al. Evidence based guidelines for treating depressive disorders with antidepressants: A revision of the
2000 BAP guidelines. J Psychopharm 2008; 22: 343-396. www.bap.org.uk
Bauer et al. WFSBP guidelines for biological treatment of unipolar depressive disorders. Part 1: Update 2013. World J
Biol Psych 2013; 14: 334-385. www.wfsbp.org.uk

2. Prescribing Guidelines: Depression

Special Conditions
(if previous good response to an
AD-select in preference)

First line

Evidence
type

Second line

Evidence
type

Depressive Disorder

fluoxetine, citalopram **
sertraline

I
I

Different SSRI; mirtazapine,

venlafaxine***, lofepramine, tricyclics*

I for all

Older person (65+) (caution: sedation,

anticholinergic and sedative effects)

citalopram **, sertraline

mirtazapine, trazodone , lofepramine*

sertraline

venlafaxine***, duloxetine ,
paroxetine, escitalopram*,

citalopram**, paroxetine

Another SSRI e.g.escitalopram**or fluoxetine

Comorbid Social Anxiety Disorder

paroxetine, sertraline,
escitalopram**

Another SSRI or venlafaxine ***

I
I

Comorbid Post Traumatic Stress Disorder

sertraline, paroxetine

venlafaxine ***, mirtazapine

Comorbid Obsessive Compulsive Disorder

fluoxetine, sertraline

clomipramine*(another SSRI)

II
I

sertraline

other SSRI, mirtazapine, lofepramine

II

Prominent Sleep Disturbance

Avoid fluoxetine

mirtazapine, trazodone ,
TCAs*

agomelatine ****

Sexual Dysfunction
ADs induced

mirtazapine, reboxetine

II

agomelatine ****, moclobemide ,

vortioxetine

II
I

sertraline

Another SSRI, mirtazapine

II

Prostatism, Glaucoma
Avoid TCAs venlafaxine and paroxetine

citalopram**

II

Another SSRI, mirtazapine

III

#Significant risk of bleeding (consider PPI)

mirtazapine, trazodone

III

lofepramine, moclobemide ,

III

Warfarin treatment, monitor INR, increased

risk of bleeding consider PPI

mirtazapine, trazodone

III

reboxetine

III

fluoxetine

II

Another SSRI

II

sertraline, citalopram **

III

reboxetine , moclobemide

III

Renal Disease
adjust the dose according to severity

citalopram **

III

sertraline, moclobemide

III

Hepatic Disease
adjust the dose according to severity

paroxetine

III

citalopram **, sertraline

III

amitriptyline *

duloxetine

Bipolar Depression

See SHFT Bipolar Guidelines

Comorbid Generalised Anxiety Disorder

Comorbid Panic Disorder

Significant suicidal risk (avoid TCAs and

venlafaxine: give limited supply)

Cardiovascular Disease.
Avoid tricyclics and venlafaxine

Weight gain and type II diabetes concerns

Avoid tricyclics and mirtazapine
Epilepsy avoid TCAs, bupropion (all
antidepressants have the potential to lower
seizure threshold)

Comorbid neuropathic pain

Pregnancy and breastfeeding

see the psychotropic medication

in breastfeeding and pregnancy
consensus statement

Cost
The majority of antidepressents are less than 5 per month unless indicated as = 20-40 per month
Guide to prescribing table
Level of evidence: I: at least RCT(s), II: controlled trial(s), III: descriptive trial(s), IV; experts opinion (NICE criteria).
Cost has been taken into account in deciding 1st or 2nd line.
*Tricyclics (TCAs) serious risk in overdose. Titrate gradually. Avoid dosulepin (dothiepin). TCAs have a number of adverse
cardiac effects.
**Citalopram/escitalopram can increase the QTc interval and are contraindicated with other drugs which prolong QT
intervals.
***Venlafaxine. Monitor BP. Specialist supervision is required for patients who are on 300mg/ or more daily.
****Agomelatine: Test liver function before treatment then after 3,6,12 and 24 weeks of treatment, as clinically
appropriate afterwards.
#SSRIs and Venlafaxine increase the risk of bleeding, significantly more with addition of NSAIDs (including low dose aspirin).
The risk of gastric bleeding may decrease by adding a PPI.
Good practice points

Response to antidepresent treatment may take up to 4-6 weeks but most commonly occurs at week 1 or 2
Antidepressants should be continued for at least 6 months after treatment response.
Consider serotonin syndrome particularly with high dose SSRI, SNRI, TCAs antidepresent combinations and lithium. Symptoms include
sweating, tachycardia, fever, hyperreflexia, hypertension, nausea, diarrhea and altered mental state. Onset is usually early on.
Consider hyponatraemia with antidepressants, especially SSRIs. Symptoms include nausea, headaches, malaise, or stupor. Risk increased in
older and/or female patients.
Special consideration should be given to particular patient groups who are more likely to suffer side effects e.g. over 65, complex physical
problems, LD.
Cross Tapering/switching ADs: Caution required because of limited evidence, it should be determined by clinical needs. Adjust speed
according to response.

Approved Medicines Management Committee

Approved Basingstoke, Southampton & Winchester DPC
Approved Portsmouth APC
Review Date

3. Guidelines for Treatment Resistant Depression

(for use in specialist services only)
Definition: depression that has failed to show clinically meaningful improvement after treatment with at least two different
antidepressant agents prescribed in adequate dosage for adequate duration and with adequate affirmation of treatment
adherence.
Frequently results from inadequate dosage and inapproriate length of treatment with antidepressants or from the insufficient
use of the available therapeutic repertoire in cases of incomplete treatment response.(Adapted from the Maudsley Prescribing
Guidelines 11th edition 2012)
Level of
evidence
If SSRI or TCA has already been changed

Consider venlafaxine > 225mg/day (with close monitoring of BP)

Consider vortioxetine 10-20mg / day (5mg /day starting dose in over 65 years old)
Mindfulness based CBT should be considered in combination with first and second line treatment options for all
patients with recurrent depression
Consider referral to a mood disorder clinic in complex cases

II
I

First choice of antidepressant augmentation strategy:

Antidepressant*
SSRI or Venlafaxine + Mirtazapine (30-45 mg/day, watch for serotonin syndrome)
SSRI+ bupropion (up to 450mg/day, unlicensed use)
Antipsychotic + antidepressant (consider especially in psychotic depression) e.g.
Quetiapine 150-300 mg/day + SSRI/SNRI
Olanzapine + fluoxetine
Risperidone 0.5-3 mg/day + SSRI/SNRI
Aripiprazole 5-20 mg/day + SSRI/SNRI
Lithium, aim for plasma level between 0.4-1 mmol/l (refer to Lithium shared care guideline, monitor renal and thyroid
function regularly, watch for serotonin syndrome) + Antidepressant (most evidence supports Lithium + TCA)
Liothyronine sodium () 20-50 mcg/day + Antidepressant
If no significant improvement, consider other strategies from the first choice list

I
II
I
II
III
I
I
II

Second choice of antidepressant augmentation strategy:

Lamotrigine 200mg to 400 mg/day have been used (risk of rash which may be severe e.g. Stevens-Johnson Syndrome)
Buspirone up to 60 mg/day and SSRI, unlicenced and poorly tolerated
Pindolol 5 mg tds or 7.5 mg od (may speed up SSRI action but unlikely to increase efficacy)

II
III
II

Consider MAOIs, beware of toxicity in overdose in patients at high risk of suicide and potential for profound
interactions with foods.

Phenelzine for patients prepared to tolerate dietary resitrictions and women whose depression has atypical features
(monitor BP)

Electroconvulsive Therapy (ECT) - refer to ECT Policy (SHCP46):

Consider for patients with severe depression symptons after an adequate trial of other treatments has proven
ineffective and/or when the condition is considered to be potentially life-treatening. In pregnancy, in older or younger
people risks may be increased.
Balance the risks associated with anaesthetic, current co-morbidities, anticipated adverse events, particularly cognitive
impairment and the risks of not having treatment. Valid consent should be obtained in the patients with capacity.
Advance directives should be taken into account.
Consider a repeat course of ECT only for individuals who have severe depressive illness and who have previously
responded well to ECT. If they have not previously responded a repeat trial should be undertaken only after all other
options have been explored with the patient and, where appropriate, their carer or advocate.
Maintenance ECT is not recommended because longer term benefits and risks or ECT have not been clearly
established.

Other reported treatments which have been combined with antidepressants, not in order of preference:

L-Tryptophan 2-3 g tds (unlicensed)

Omega-3-triglycerides (EPA 1-2 g/day)
Pramipexole 0.125-5 mg/day
Nortriptyline +/- Lithium
Combine MAOI and TCA with extreme caution and close monioring for serotonin syndrome/ cardiac monitoring
Combine SSRI and TCA (watch for serotonin syndrome and drug interactions)
Venlaflaxine very high dose (up to 600 mg/day) use with extreme caution and close monitoring of BP/serotonin
syndrome/ cardiac monitoring
TCA high dose, formerly widely used - cardiac monitoring essential
Hormonal therapy eg, oestrogen, testosterone
Transdermal selegiline

IV