Selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressant in less severe depression due to their tolerability. However, the draft guideline emphasises that antidepressants should not be routinely offered as a first-line treatment in less severe depression unless that is the person’s preference. St John’s wort should also not be used for less severe depression.4
For more severe depression, NICE says there is good evidence for the effectiveness and cost effectiveness of different antidepressants (SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and mirtazapine). The draft guideline proposes SSRIs and SNRIs should be recommended as first line, but past positive experience of a TCA may support it being used again.
Mono amine oxidase inhibitors (MAOIs) are included as a second-line medication option for people with chronic depressive symptoms.
NICE also discusses the potential use of combining medicines, providing the patient is willing to accept the possibility of an increased side-effect burden. If another antidepressant is to be added it should have a complementary mechanism of action, but the practitioner needs to be aware of potentially dangerous combinations, such as a SSRI, SNRI or TCA with a MAOI.
It may also be appropriate to combine (potentially off-label) an antidepressant with an atypical antipsychotic (such as aripiprazole, olanzapine, quetiapine or risperidone) or lithium.