Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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Possible severe psychotropic toxicity
Hyperthermia, marked rigidity or clonus, autonomic instability or altered consciousness after a psychotropic change may indicate a life-threatening medicine reaction.
Action: Arrange emergency assessment, use ABCDE and stop suspected causative medicines while obtaining urgent senior and specialist input. Investigate alternative causes such as infection and metabolic disturbance; do not manage severe agitation by automatically adding further psychotropics.
Synopsis
Select and review common psychiatric medicines using the diagnosis, patient priorities and adverse-effect profile, while recognising high-risk monitoring, interruption and reproductive-safety issues.
Establish the indication and screen for bipolar symptoms, suicide risk, substance use and relevant physical illness before antidepressant prescribing.
Select treatment with the person using expected benefit, previous response, adverse effects, interactions and overdose risk.
For adult depression, the cited sertraline SmPC starts treatment at 50 mg orally once daily; increase only when indicated, by 50 mg at intervals of at least one week, maximum 200 mg daily.
Key red flags
Vomiting or diarrhoea with coarse tremor, ataxia or confusion in a person taking lithium requires withholding lithium and urgent lithium level, renal/electrolyte assessment and specialist advice.
Investigation priorities
01
Mental-state and risk assessmentFirst step
Establish treatment need and the safety of the proposed setting.
Management branches
Worked caseStart an antidepressant with early review
A 24-year-old has a depressive episode with substantial functional impairment and chooses medication after discussing treatment options. There is no history suggesting mania, no current suicidal intent, no interacting medicine and no relevant hepatic disease; reliable follow-up is available.
Confirm the diagnosis and risk assessment, discuss previous treatment and agree a functional goal such as returning to regular work attendance. Explain that psychological support remains available and that medication selection can be revisited if the adverse-effect profile is unacceptable.
If sertraline is selected, prescribe 50 mg orally once daily for depression, using the product-specific regimen in the prescribing section. Discuss common adverse effects and what to do if symptoms worsen; avoid promising immediate relief or automatic dose escalation.
Key medicines
Sertraline for an adult depressive episodeStart 50 mg orally once daily; if needed and tolerated, increase by 50 mg at intervals of at least 1 week, maximum 200 mg daily. Review early and continue an effective regimen for at least 6 months after remission before reassessing longer-term need.Check bipolar features, suicide risk, serotonergic interactions and MAOI contraindications. Use a lower or less frequent dose in hepatic impairment and avoid severe hepatic impairment; consider bleeding, hyponatraemia and sexual adverse effects. Reduce gradually when stopping.
Mirtazapine for an adult major depressive episodeThe cited UK SmPC allows 15 or 30 mg orally daily initially; a selected cautious start is 15 mg at night. Effective doses are usually 15–45 mg daily; assess response over 2–4 weeks. NICE supports continuing effective depression treatment for at least 6 months after remission, with review.Sedation and weight gain may limit acceptability. Review renal or hepatic impairment, other sedatives, bipolar features and suicide risk. Avoid relevant MAOI combinations; fever or sore throat warrants prompt assessment for possible blood dyscrasia. Plan gradual withdrawal and continuation review after recovery.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.