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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.

Stepped psychological and medication treatment

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Routine stepped care is too slow

Imminent suicide, psychotic depression, catatonia, severe self-neglect, inability to eat or drink or danger to dependants requires urgent specialist and physical intervention rather than sequential low-intensity trials.

Action: Create immediate safety and medical support, obtain same-day specialist assessment and consider admission, combined treatment or ECT according to clinical need and preference. Assess capacity and use the least restrictive lawful setting while ordinary treatment choices continue in parallel.

Synopsis

Match evidence-based psychological, social and medication options to depressive severity, function, preference and prior response, begin with the least intrusive effective choice and escalate through planned review rather than passive waiting.

  • Treat immediate risk, housing, pain, substance use, physical illness and safeguarding needs alongside depression rather than waiting for mood remission.
  • For less severe depression, discuss active monitoring, guided self-help, structured group physical activity, group behavioural activation or CBT and mindfulness-based options according to NICE and preference.
  • Do not routinely make antidepressants the initial offer for less severe depression unless the person understands options and prefers medication.
  • For more severe depression, discuss individual CBT, behavioural activation, antidepressant treatment and combination individual CBT plus an antidepressant as evidence-based choices.
  • SSRIs are generally well tolerated and often considered before other antidepressant classes, but prior response, adverse effects, overdose toxicity, interactions and preference determine selection.
  • Explain onset, common harms, withdrawal, adherence and duration; antidepressant benefit is commonly expected within about four weeks when treatment is effective.
  • Review usually within two weeks, or within one week for people aged 18 to 25 or when suicide risk is a particular concern, with further review based on need.
  • If response is absent or limited, assess delivery and barriers, then collaboratively increase psychological intensity, switch modality or antidepressant, or combine treatments.
  • Continue effective antidepressant treatment for at least six months after remission unless a reason to stop exists, then review relapse risk and taper gradually when ending.

    • Key red flags

    A person with less severe symptom count may still need urgent care when suicide risk, psychosis, safeguarding or physical compromise is present.

    Antidepressants are not routinely offered as the initial treatment for less severe depression unless that is the person's informed preference.

    Psychological treatment must be delivered at an adequate therapeutic dose by trained practitioners; a waiting-list entry is not an intervention.

    Early agitation, akathisia, emergent suicidal thoughts, mania or severe adverse effects after medication initiation requires prompt review rather than automatic continuation.

    Non-response should trigger review of diagnosis, adherence, dose, duration, social barriers, substances and comorbidity before the person is labelled resistant.

    Investigation priorities

    01
    Severity, function and preference assessmentFirst step

    Choose an initial option aligned with clinical need, previous response, goals and treatment burden.

    Management branches

    Less severe careStart with acceptable low intrusion

    Symptoms and impairment fall within less severe depression without an overriding urgent need.

    1. Explain active monitoring and guideline-listed psychological, behavioural and social options and identify the person's priorities and access barriers.
    2. Offer the least intrusive acceptable intervention, while prescribing an antidepressant when informed preference supports it rather than as routine default.
    3. Set an active review of symptoms, function and safety and escalate when deterioration or inadequate response changes the balance.

    Key medicines

    SertralineFor adult major depression, start 50 mg orally once daily; if needed, increase in 50 mg steps no more often than weekly to a maximum 200 mg daily.Check interactions, bleeding risk, hyponatraemia, activation, sexual effects and serotonin toxicity; use particular caution in bipolarity, hepatic impairment, pregnancy and concurrent serotonergic medicines.
    MirtazapineUse 15 to 30 mg orally at night initially, then adjust by response and tolerability within the licensed 15 to 45 mg daily range.Discuss somnolence, increased appetite, weight gain, dizziness and rare blood dyscrasia; sedation can impair driving, and switching or combination requires interaction and serotonin-risk review.
    Open full textbook →Answer 2 questions
    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    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.

    • NICE NG222 depression in adults recommendationsLess and more severe treatment tables, medication, review and continuation.
    • Sertraline UK summary of product characteristicsLicensed adult depression dose, titration, contraindications and adverse effects.
    • Mirtazapine UK summary of product characteristicsLicensed adult dose range, administration, cautions and adverse effects.
    • NICE NG215 medicines withdrawal recommendationsShared staged withdrawal and monitoring of withdrawal symptoms.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom