Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Choose an antidepressant from individual benefits, harms, overdose safety, interactions, comorbidity and preference, prescribe a usable regimen and monitor early suicidality, activation, withdrawal and physical adverse effects at guideline-aligned intervals.
Medication begins with a shared treatment question. Confirm that an antidepressant matches severity and informed preference. Review previous benefit, adverse effects and withdrawal; family response may inform but does not determine choice. Screen bipolar history and current psychosis. Assess overdose access, alcohol and substances, pregnancy or breastfeeding, epilepsy, bleeding, liver and renal function, cardiac disease, glaucoma, urinary symptoms and falls according to the drug. Reconcile prescribed, over-the-counter, herbal and recreational substances.
Discuss priorities explicitly. SSRIs commonly offer an acceptable balance, but sexual dysfunction, gastrointestinal effects, sleep disturbance, hyponatraemia and bleeding may matter greatly. Mirtazapine can cause sedation and weight gain, potentially helpful or unacceptable depending on the person. Venlafaxine requires blood-pressure and withdrawal consideration. Tricyclics have anticholinergic, cardiac and overdose toxicity. Monoamine oxidase inhibitors and complex combinations require specialist use. St John's wort has variable preparations and important interactions and is not a simple safe alternative.
The person's comorbidity, interactions, adverse-effect priorities and overdose risk favour a selective serotonin reuptake inhibitor after informed discussion.
New restlessness, reduced sleep need, increased speech, confidence, activity or risk-taking after initiation requires urgent review and bipolar assessment.
Subjective inner restlessness with observable inability to stay still differs from ordinary anxiety and can sharply worsen distress.
Headache, confusion, seizure, weakness or falls after treatment, especially with older age or diuretic use, warrants urgent sodium assessment.
Dizziness, electric-shock sensations, flu-like symptoms, anxiety or vivid dreams soon after reduction suggests withdrawal and needs slower individual tapering.
Avoid with MAOIs and review serotonergic combinations; monitor activation, bleeding, sodium, sexual dysfunction and hepatic factors, and consider pregnancy and breastfeeding guidance individually.
Dose-dependent QT prolongation requires review of cardiac disease, bradycardia, electrolytes and QT-prolonging medicines; avoid with known QT prolongation and follow current MHRA contraindications.
Warn about drowsiness, weight gain, appetite increase and driving impairment; investigate fever or sore throat for rare blood dyscrasia and review hepatic or renal impairment.
Sertraline and citalopram are both SSRIs but differ in interactions, cardiac restrictions and individual previous response, so selection remains medicine specific.
Patients may describe unbearable anxiety without naming motor restlessness; ask what the body feels compelled to do and observe movement.
Short prescriptions or supervised dispensing can reduce overdose opportunity while preserving access to effective medication and dignity.
Transient nausea or sleep change may settle, but severe activation, mania, suicidality or serotonin toxicity requires immediate reassessment.
Rapid onset after dose reduction and prominent sensory or disequilibrium symptoms support withdrawal, although both processes can coexist.
Selecting an antidepressant without screening previous mania, overdose risk and interactions.
Prescribing citalopram above current age or hepatic limits or ignoring QT combinations.
Calling akathisia anxiety and increasing the medicine without assessment.
Waiting several weeks to review a young adult with suicide concerns after initiation.
Assuming no benefit after a few days means a therapeutic trial has failed.
Supplying large quantities despite an active overdose scenario without a safety plan.
Stopping abruptly or using alternate-day dosing for short half-life medicines without a taper plan.
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A 72-year-old with depression is being considered for citalopram. What is the current maximum daily dose because of dose-dependent QT prolongation risk?
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 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Early monitoring is a clinical intervention. Review response and adverse effects within two weeks of starting, with one-week review for people aged 18 to 25 or when suicide risk is a particular concern. Ask specifically about new suicidal thoughts, agitation, akathisia, reduced sleep need and impulsivity. Assess sleep, appetite, sexual effects, adherence and function. Involve a chosen supporter when the person agrees and provide an urgent contact route. Do not increase automatically because improvement is not complete during the first days.
Continue long enough to judge benefit and prevent early relapse. If there is no response by about four weeks at a therapeutic dose with adherence, reassess diagnosis and treatment. After remission, continue at least six months unless contraindicated and review recurrent-risk factors. When stopping, reduce in stages, often with smaller proportional reductions at lower doses. Distinguish withdrawal, which may begin soon after reduction and include sensory or disequilibrium symptoms, from depressive relapse, which generally follows the person's prior syndrome.