How to talk to patients about starting antidepressants

Depression is a common mental health condition, affecting 3.8% of the global population, including 5% of adults​[1]​. In the UK, approximately 1 in 6 adults experience depression, and it tends to affect more women than men​[2,3]​. This difference in gender prevalence could be attributed to factors such as increased reporting, genetic influences, psychosocial traits, susceptibility to stress and environmental factors​[3]​. However, only 15% of women and 9% of men receive treatment for depression​[4]​.

The severity of depression can vary from mild to severe, based on symptoms and their impact on functioning[5]. Individuals who have experienced trauma or severe life stressors are at a higher risk of developing depression. Depressive episodes are characterised by:

• Symptoms (which may vary in frequency and intensity);
• Duration of the disorder;
• The impact on personal and social functioning​[5]​.

In response to a recent increase in antidepressant use and the associated scrutiny of side effects experienced by many patients, the Royal College of Psychiatrists has taken a stance. Stressing that depression can be a potentially life-threatening condition, the college recommends a comprehensive approach to treatment, often involving a combination of self-help strategies, therapy and medication​[6]​. While acknowledging the significance of antidepressants in therapy for numerous patients, pharmacists should make sure to consider the broader spectrum of treatment options. Guidance from the National Institute for Health and Care Excellence (NICE) on depression in adults recognises this diversity and highlights various approaches​[5]​.

This article summarises the relevant information and advice for pharmacists to provide to patients and carers about antidepressant treatment, recognising the importance of shared decision making and taking a person-centred approach.

Antidepressant medication

Antidepressants are effective at reducing the symptoms of moderate-to-severe depression that has persisted for two years or more, or mild depression that has persisted for longer than three months, particularly when used in combination with talking therapies​[5,6]​.

There are several major classes of antidepressant drugs:

• Selective serotonin reuptake inhibitors (e.g. citalopram, fluoxetine, sertraline);
• Serotonin and noradrenaline reuptake inhibitors (e.g. venlafaxine);
• Tricyclic antidepressants (e.g. amitriptyline, trimipramine);
• Monoamine oxidase inhibitors (e.g. phenelzine, moclobemide)​[7]​.

Some antidepressant drugs, such as mirtazapine, vortioxetine and reboxetine, do not fit neatly into any of these categories but are available and often initiated in secondary care​[5]​.

NICE guidance summarises treatment options for depression; pharmacists may find the tables in the guidance useful when comparing non-pharmacological interventions and antidepressants​[5]​.

Before an antidepressant is prescribed, a patient’s concurrent physical or mental health comorbidities, response to previous treatment and suicide risk all need to be considered​[8]​. When starting an antidepressant, the first few weeks of treatment can be challenging, as there is an increased risk of agitation, anxiety, hopelessness or even suicidal ideation. Consulting with the patient and carer (where appropriate) using shared decision making principles, considering their views on treatment outcomes and providing advice on when to seek support is therefore important. Antidepressant medication usually starts to work within two to four weeks, but many patients see some effects sooner​[5,9]​.

Involving patients and carers (where appropriate) in discussions and considering their beliefs and values over their care and treatment for depression is vital in driving the shared decision making agenda.

Common misconceptions about antidepressants and how to address them

Many people turn to social media and other websites for information about antidepressants. Some online sources are accurate, but many are not, and misinformation can affect adherence to treatment. Pharmacists have a pivotal role in dispelling misconceptions and offering accurate information to support the treatment choices available, especially in stigmatised conditions such as depression​[10,11]​.

One of the most common misconceptions is that antidepressants always take two to four weeks to show effects. However, this is not true: patients tend to have the highest rates of improvement in the first two weeks. It is important to note that different response patterns exist, and treatment needs to be tailored to the individual. As a rule, if no improvement is observed within three to four weeks, it is unlikely the current dosage is going to be effective and a dose adjustment may be required​[9,12]​.

Other misconceptions include:

• Antidepressants are stimulants — they are not, and they will not change a patient’s personality;
• Antidepressants are addictive — they are not.

Importance of taking antidepressants consistently

Non-adherence to treatment costs the NHS more than £930m per year​[13]​. Addressing this requires tailored strategies beyond basic education and extended consultations​[14]​. Strategies include:

• Shared decision making;
• Considering patient/carer views about treatment;
• What the patient/carer wants to get out of treatment;
• Considering patient/carer expectations;
• Alleviating any concerns the patient/carer has about their treatment;
• Addressing any misinformation the patient/carer has heard or read about.

Strategies for clear and effective communication in pharmacy practice

Most (40–80%) of the medical information provided by healthcare professionals to patients is forgotten immediately, especially in patients with depression​[15]​. Some strategies that pharmacists can adapt to keep their communication clear and simple include:

• Using plain language;
• Repeating key information;
• Avoiding information overload;
• Checking for understanding;
• Offering patient education materials.

Pharmacists have a crucial role in reinforcing verbal instructions through written communication; for instance, using the manufacturer’s patient information leaflet and other leaflets, such as those available on the Choice and Medication website. Written information about antidepressants is available for specific areas of treatment, such as antidepressant use in pregnancy and lactation via UKTIS, Lactmed and BUMPS.

Patients with depression are far less likely to adhere to treatment than those without (16% versus 40%)​[16]​. There are significant risks when patients do not take their antidepressant treatment as prescribed, including:

• Relapse or recurrence of symptoms;
• Chronic depression;
• Poor psychosocial outcomes and functioning;
• Heightened suicidal tendencies​[14]​.

Consequently, shared decision making becomes paramount in personalising care and strengthening the therapeutic relationship between healthcare professionals, patients and carers. To ensure the safe and effective implementation of treatment plans, close monitoring and timely assessment of outcomes are essential.

Missed doses of antidepressants

Missing doses of an antidepressant can make treatment less effective and withdrawal symptoms may be experienced, especially with antidepressants with a short half-life, such as paroxetine and venlafaxine​[17]​. With antidepressants that have a longer half-life, such as fluoxetine, withdrawal symptoms may be delayed, possibly by up to six weeks​[18]​. While most symptoms are generally mild and resolve on their own, there can be individual variation, and some patients may experience more severe effects.

The term ‘withdrawal symptoms’, although generally accepted, implies physical dependence. Therefore, the language used to describe these symptoms needs to be used with care. ‘Discontinuation symptoms’ is an alternative term that is less associated with physical dependence​[12]​.

Discontinuation symptoms fall into three main categories:

• Physical (e.g. nausea, headache, diarrhoea);
• Sleep (e.g. insomnia, increased dreaming, nightmares);
• Emotional (e.g. anxiety, mood changes, agitation)​[19]​.

Further information on stopping antidepressants can be found in the learning article ‘Case-based learning: safe withdrawal and tapering of antidepressants‘ and from the Royal College of Psychiatrists[19].

Discontinuing an antidepressant suddenly can lead to severe withdrawal-prompted symptoms. NICE recommends a staged, patient-led withdrawal of antidepressants, using hyperbolic tapering to ensure that withdrawal symptoms are tolerable before the next reduction​[20]​. For more on the effects of severe discontinuation symptoms listen to the PJ Pod episode: ‘Antidepressant withdrawal: why has it been ignored for so long?‘

Encouraging adherence to antidepressant medications and discussing discontinuation with patients are important aspects of a pharmacist’s role in supporting mental health. Table 1 lists some tips for pharmacists on communicating effectively with patients.

Remember, effective communication involves active listening, empathy and tailoring information to the individual patient’s needs. Pharmacists play a crucial role in supporting patients through their mental health journey, during both medication adherence and discontinuation phases.

Antidepressants are not a cure all

Antidepressants, even when clinically indicated, are unlikely to be an effective sole treatment. The patient should be counselled not to expect an antidepressant to resolve all their symptoms.

NICE recommends a combination of psychological and psychosocial interventions alongside pharmaceutical interventions. However, in 2022, the Royal College of Psychiatrists reported that 23% of patients waiting for psychological and psychosocial referrals waited for at least 12 weeks, 12% of patients waited more than 6 months, and 6% waited for more than a year; therefore, NICE also recommends that the healthcare professional:

• Stays in touch with the patient at regular intervals;
• Makes sure the patient is aware of how to access help, especially if their condition worsens;
• Ensures the patient is informed of who to contact about their progress on the waiting list;
• Provides self-help materials and addresses social support issues​[5,21]​.

If an antidepressant is started, the patient needs to be aware of common side effects and coping strategies, as detailed in Table 2​[22–24]​.