Establish the need, what to switch to, and the strategy

Before you are able to monitor an antidepressant switch for the treatment of depression, you’ll need to establish the need for the switch, the medicine to switch to, and the strategy you’re following.

• Establishing if a person needs to switch their antidepressant
• Considerations when choosing an alternative antidepressant
• Planning and agreeing an antidepressant switching strategy

Monitoring schedules

Generally, people should be reviewed within 2 weeks after starting the new antidepressant for the treatment of depression. People with suicide risk or aged 18 to 25 should be reviewed 1 week after starting the new antidepressant, and then again as often as needed (but no later than 4 weeks after initiation).

Advising people

Ensure the person knows the monitoring they can expect after the switch, by whom, and when. Advise people at their review appointment on aspects such as the:

• time required for treatment to be effective—it may take 1 to 2 weeks before the benefits of the treatment are felt. If no benefit is seen after 4 to 6 weeks the medicine will need to be reviewed.
• possibility of side-effects and that discontinuation symptoms may also be associated with the switch
• risks of serotonin syndrome and what to look out for
• risk of relapse, and that medication may be needed for 6 months or longer (if relapse risk is higher) even after remission of symptoms
• non-addictive nature of antidepressants
• management of missed or extra doses and the risks associated with stopping an antidepressant
• availability of self-help groups, and how and from whom to seek urgent support

Discontinuation symptoms

People may experience discontinuation symptoms from abruptly stopping their antidepressant treatment. Gradual withdrawal may minimise risk and the person’s symptoms should guide the speed of the switch.

Symptoms

Discontinuation symptoms may include:

• restlessness
• trouble sleeping
• unsteadiness
• sweating
• stomach problems
• feeling as if there’s an electric shock in your head
• feeling irritable, anxious or confused

Serotonin syndrome

Health Education England provides a good overview of serotonin syndrome, an uncommon but potentially serious side effect of most antidepressants. Concomitant or sequential use of antidepressants can increase the risk of serotonin syndrome as most antidepressants increase serotonin levels in the brain.

Symptoms

Can be mild to life-threatening and include:

• autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, sweating, shivering and diarrhoea)
• neuromuscular hyperactivity (tremor, rigidity, myoclonus, clonus and hyperreflexia)
• altered mental state (agitation, confusion, mania and coma)

Individual switches

We have advice on how to switch between individual antidepressants of different types. Browse our collection below.

• MAOI to other antidepressants: switching in adults
• Moclobemide to other antidepressants: switching in adults
• Trazodone to other antidepressants: switching in adults
• Vortioxetine to other antidepressants: switching in adults
• SNRIs to other antidepressants: switching in adults
• Agomelatine to other antidepressants: switching in adults
• Mirtazapine to other antidepressants: switching in adults
• Tricyclics to other antidepressants: switching in adults
• SSRIs to other antidepressants: switching in adults

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