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Establishing whether a person needs to switch their antidepressant

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Topics: Mental health and illnessSwitching

Prior response, side-effects, new contraindications, and current symptoms may make an antidepressant switch necessary. When it is, establish shared goals.

Contents
  1. Discuss issues and experiences
    1. Inadequate response
    2. Side-effects
    3. New contraindications and interactions
    4. Current symptoms
  2. Agree goals
    1. Share decisions
  3. Choosing a new medicine, planning the switch, and monitoring
  4. Individual switches

Discuss issues and experiences

You should adopt a shared approach from the beginning in establishing whether a person might benefit from switching their antidepressant. Discuss existing issues and experiences, and how medicines fit in with a typical day. Points to consider include the following:

Inadequate response

Discuss with the person and/or their carer whether their current antidepressant is effective after they have adhered to a therapeutic dose, for an appropriate duration.

Side-effects

Discuss with the person and/or their carer any side-effects they have experienced (such as weight gain or reduced libido). Abrupt withdrawal should be avoided unless the person experiences a serious side-effect.

New contraindications and interactions

People may develop a new contraindication to their existing antidepressant or they may start a new medication that interacts with their existing antidepressant. Establish whether this is the case.

Current symptoms

Establish current symptoms, particularly where treatment has failed previously. Consider using an evidence-based tool, such as PHQ-9 (Patient Health Questionnaire-9), HADS (Hospital Anxiety and Depression Scale) or BDI-II (Beck Depression Inventory-II) to assess. It can be unsafe for some people to remain untreated for extended periods of time.

Agree goals

Use a shared decision making approach to agree the purpose of the switch with your patient and what will be achieved from it.

Share decisions

Discuss with the person and/or their carer the purpose of the switch and what you’re trying to achieve. Consider:

  • what matters to them
  • any concerns they have
  • the extent of the side-effects they could tolerate
  • whether a trial period without an antidepressant might be useful

Choosing a new medicine, planning the switch, and monitoring

After you’ve agreed that a switch is necessary, you’ll need to choose a medicine to switch to, and then agree a strategy and monitoring approach.

Choosing an antidepressant to switch a person to

Where a need to switch antidepressant is established, appraise the options to identify what's suitable for the person. For complex switches: consult an expert.

Planning and agreeing an antidepressant switching strategy

Where the need for an antidepressant switch is established and you've agreed with the individual what to switch to, you can then plan and implement the switch.

Monitoring a person during and after antidepressant switching

Review people at appropriate time points; advise on what to expect and report; and beware of the possibility of discontinuation and serotonin syndromes.

Individual switches

We have advice on how to switch between individual antidepressants of different types. Browse our collection below.