Effective antidepressant medication reviews: Key points for practice and community pharmacists

Clinical pharmacist Maleeha Erum offers a practical guide on what practice and community pharmacists should cover in antidepressant medication reviews

Depression is one of the most common mental health conditions in the UK, impacting quality of life, daily function and physical health. Management requires a holistic, person-centred approach, combining psychological therapies, lifestyle changes and, when appropriate, antidepressants.

As prescribing of antidepressants continues to rise, pharmacists play an increasingly important role in ensuring safe, effective use.

GP practice pharmacists play a key role, carrying out medication reviews, monitoring response and side effects, and coordinating timely dose adjustments or switches when needed. Their access to full clinical records and ability to conduct follow up reviews systematically enhances safety, supports treatment optimisation and enables more personalised care.

Community pharmacists are also uniquely placed to support adherence, identify deterioration and provide continuity of care through regular prescription screening and the New Medicine Service (NMS).

The place of antidepressants in depression management

NICE guidelines on depression in adults recommend that antidepressants should be considered as part of a stepped-care model. They are not routinely recommended for mild depression, where psychological and self-help interventions are preferred. However, antidepressants play a central role in the management of:

• Moderate to severe depression.
• Mild depression when other interventions are unsuitable, ineffective or declined.
• Depression associated with significant functional impairment.
• Relapse prevention, especially in recurrent depression.
• Depression in the context of chronic physical health conditions.

The decision to use medication should be based on shared decision-making, exploration of patient preferences, previous treatment response, comorbidities, likely side-effects and practical considerations such as dosing convenience.

Pharmacists support this decision-making by providing information, exploring concerns, and reinforcing expectations around treatment duration and onset of effect.

Principles of prescribing antidepressants

When prescribing is appropriate

NICE recommends antidepressants in:

• Moderate to severe depressive episodes.
• Mild depressive symptoms with marked functional impairment.
• Failure of psychological interventions.
• High-risk individuals, including those with chronic medical conditions where depression worsens prognosis.
• Recurrent depression, where long-term maintenance therapy may be needed.

Choice of antidepressant

SSRIs remain the first-line option for most patients due to favourable tolerability and safety in overdose. Common first-line choices include:

• Sertraline – particularly preferred in cardiovascular disease.
• Citalopram / escitalopram – well tolerated; must consider QT prolongation risks.
• Fluoxetine – long half-life and lower withdrawal risk.
• Paroxetine – generally avoided first-line because of higher withdrawal burden.

If SSRIs are ineffective or not tolerated, alternative options include:

• Tricyclic antidepressants (TCAs) – generally second line due to toxicity in overdose, although they may be appropriate in specific cases such as chronic pain.
• SNRIs (venlafaxine, duloxetine) – useful when low energy is prominent or where comorbid neuropathic pain exists.
• Mirtazapine – particularly helpful for patients with poor sleep or appetite due to its sedative profile at lower doses.
  • Lower doses (e.g., 15 mg) are more sedating because of strong antihistamine effects.
  • Higher doses (30–45 mg) become less sedating and more activating, driven by greater noradrenergic activity. This is an important counselling point, as many patients assume higher doses will cause more drowsiness.

• Monoamine oxidase inhibitors (MAOIs) – reserved for specialist settings due to extensive food and drug interactions.

Duration of therapy should be a minimum of six months after symptom improvement, and for recurrent or high-risk cases, treatment may continue for 2 years or longer, depending on clinical need.

Initiating treatment and patient counselling

When antidepressants are initiated, pharmacists play a vital role in preparing patients for what to expect.

Key points include:

• Time to effect: Antidepressants typically take 2–4 weeks to show benefit. This is to set realistic expectations for patients and prevent premature discontinuation.
• Early side effects: Gastrointestinal (GI) upset, agitation, sleep disturbance, headaches – often settle within 1–2 weeks.
• Withdrawal symptoms: If stopped abruptly, patients may experience dizziness, electric-shock sensations (‘brain zaps’), flu-like symptoms or insomnia.
• Do not stop suddenly: Emphasise the importance of planned dose reduction.
• Need for early GP review:
• Within 1 week if under 25 years or at risk of self-harm.
• Within 2 weeks for most adults.
• Safety-netting: Patients should be informed about warning signs of worsening depression, suicidal thoughts, or severe side effects, and advised on when and how to seek urgent help. This proactive guidance helps reduce risk and supports patient engagement in ongoing care.

Older adults require additional caution when starting antidepressants. They may respond more slowly, often taking up to six weeks to see benefit, and are more sensitive to early side effects such as agitation, GI upset, insomnia and dizziness. SSRIs also carry a higher risk of hyponatraemia and falls in this group, especially where polypharmacy is present. A ‘start low, go slow’ approach is recommended to help minimise these side effects, with early review within 1–2 weeks and regular monitoring thereafter.

Specific cautions

Pharmacists should be alert to:

• Hyponatraemia risk with SSRIs (particularly older adults).
• Increased bleeding risk with SSRIs in those on NSAIDs, anticoagulants.
• QT prolongation with citalopram/escitalopram.
• Hypertension with SNRIs.
• Overdose toxicity with TCAs.
• Serotonin syndrome with serotonergic combinations.
• Pregnancy and breastfeeding considerations.

The role of pharmacists in early and ongoing reviews

Early reviews (New Medicine Service and initial follow-up)

Community pharmacists are often the first point of contact after initiation. Early review should assess:

• Adherence and any practical barriers by asking open ended questions. For example: Have you been taking your medications? What time of the day do you usually take your medications? Is there anything that can make you miss your dose?
• Tolerance of side effects and whether they are settling. Discuss common early side effects and how they are affecting the patient. Encourage patients to report new or worsening effects but offer reassurance that many are transient. Potential side effects include nausea, sleep problems, agitation and headaches.
• Mood changes, including any signs of worsening depression. Ask simple non-judgemental questions such as: How have you been feeling? Any changes in sleep, appetite, motivation? Any thoughts of self-harm? Assessing these signs early helps detect inadequate response or deterioration and prompts timely GP review if needed.
• Realistic expectations about onset of action. Reinforce that antidepressants usually take 2–4 weeks to show benefit.

If the patient reports minimal benefit after several weeks, significant side effects or new concerns, pharmacists should recommend GP review for potential dose optimisation or switching.

Ongoing monitoring

Patients should be reviewed around 4–6 weeks after initiation and then periodically, depending on response. Pharmacists should explore:

• Improvements in mood, sleep, appetite and energy. The Patient Health Questionnaire-9 (PHQ-9) can be used before initiating and after to monitor improvement.
• Any missed doses or irregular dosing.
• New medications that might interact. These include serotonergic drugs like tramadol, drugs that can increase bleeding such as NSAIDs or anticoagulants, and drugs associated with QT prolongation such as amiodarone, sotalol, clarithromycin and erythromycin. St John’s Wort (herbal remedy) is also serotonergic.
• Alcohol or recreational drug use.
• Practical advice on dosing – for example, SSRIs are generally taken in the morning, mirtazapine often taken in the evening.

Identifying issues through community pharmacy interactions

Community pharmacists can identify potential concerns much earlier than other clinicians because they see patients frequently.

Important warning signs include:

• Missed collections – may indicate worsening depression, low motivation, or withdrawal after stopping.
• Erratic picking up of antidepressants.
• Bulk collection of previously uncollected prescriptions (suggesting inconsistent use).

These patterns are opportunities to gently explore how the patient is coping.

Opening up supportive conversations can reveal early signs of relapse or poor response.

This might include questions like: How are you getting on with your medication? Have you noticed any changes in how you’re feeling? Are you finding the treatment helpful so far?

Young people with long-term conditions

Young people with chronic illnesses, such as diabetes, or asthma, are at increased risk of depression and may:

• Struggle with adherence.
• Experience more sensitivity to early side effects.
• Need closer follow-up.

Any concerns should be escalated quickly, especially in those under 25.

Supporting ethnic minority communities

In some cultures, mental health remains highly stigmatised. People from certain ethnic groups or those living in deprived areas may:

• Avoid discussing symptoms.
• Present with physical complaints instead of mood symptoms. For example they may describe feeling ‘tired all the time’ or ‘not well’ or having ‘recurrent headaches’ rather than talking about sadness or low mood, because discussing emotional difficulties is considered shameful in their culture.
• Decline psychological therapies – because of stigma around seeing a mental health professional, or because therapy is not culturally familiar.
• Feel embarrassed about taking antidepressants.
• Struggle more with adherence due to Language barriers, misunderstanding dosing instructions.

Pharmacists must adopt a sensitive, culturally informed approach, ensuring:

• Privacy and discretion.
• Non-judgemental language.
• Recognition that patients may not volunteer symptoms.
• Active encouragement to seek help early.
• Vigilance for hidden non-adherence.

Supporting these groups proactively helps reduce health inequalities and ensures equitable mental health care.

Supporting patients during discontinuation

Stopping antidepressants should be gradual. This involves:

• Tapering over at least 4 weeks. Refer to guidelines for specific recommended durations.
• Longer tapering for drugs with high withdrawal risk (paroxetine, venlafaxine).
• Educate on normal versus concerning withdrawal symptoms. Initial light headedness, headache, sweating, insomnia or sleep disturbance can be expected and should settle down within1-2 weeks. However, concerning symptoms include severe mood deterioration, suicidal thoughts or persistent functional impairment warrant urgent review with the GP. Patients may sometimes interpret temporary withdrawal effects as evidence that they are ‘addicted’ or ‘can’t cope without the medication’. Pharmacists should reassure patients that physical dependence is different from addiction, and these sensations usually reflect neurochemical adjustment rather than true addiction.
• Practical support. Provide a clear, written tapering schedule and explain that small, stepwise dose reductions are safer than abrupt discontinuation. Encourage patients to keep a symptom diary during tapering to track any changes in mood, sleep or side effects.
• Safety netting. Early GP or pharmacist review is appropriate if withdrawal symptoms are severe, persistent, or impacting daily life. Encourage coping strategies, such as regular sleep, gentle exercise, stress management and support networks, to help manage mild withdrawal effects.
• Encourage planned stopping with GP oversight.

Maleeha Erum is a senior clinical pharmacist at East Merton Primary Care Network

Sources and further reading

• Baldwin D et al. Evidence-based pharmacological treatment of generalized anxiety disorder. Int J Neuropsychopharmacol 2011;17(5):747–68
• Coupland C et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551
• Coupland C et al. Antidepressant use and risk of cardiovascular outcomes in people aged 20 to 64: cohort study using primary care database. 2016 BMJ 352:i350
• Davies J and Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects. Addict Behav 2019;97:111-21
• Fava G et al. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: systematic review. Psychother Psychosom 2015;84(2):72-81
• MHRA. Drug Safety Update. Citalopram and escitalopram: QT interval prolongation. 2014
• NHS England. Community pharmacy advanced service specification: NHS new medicine service. 2025
• NHS Specialist Pharmacy Service (SPS). Switching strategies for antidepressants. 2024
• NHS SPS. Deprescribing of antidepressants for depression and anxiety. 2023
• NICE. Depression in adults: treatment and management [NG222]. 2022
• NICE. Medicines associated with dependence or withdrawal symptoms: safe prescribing and management. [NG215]. 2022
• NICE Clinical Knowledge Summary. Depression. 2023
• Royal College of Psychiatrists Stopping antidepressants. 2024
• Shrestha P et al. Paroxetine. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
• Taylor D et al. The Maudsley Prescribing Guidelines in Psychiatry (14th edition). Wiley-Blackwell. 2021