Stepped Care

Stepped Care ApproachStepped Care Approach

Stepped Care Approach

A stepped approach for the treatment of depression within primary care
Step One Early IdentificationStep One Early Identification

Step One Early Identification

Action: Screening and Assessment
Step Two Mild DistressStep Two Mild Distress

Step Two Mild Distress

Action: Active Monitoring
Step Three Moderate To Severe DistressStep Three Moderate To Severe Distress

Step Three Moderate To Severe Distress

Action: More Intensive Intervention and Close Monitoring
Step Four Recurrent, Atypical & High RiskStep Four Recurrent, Atypical & High Risk

Step Four Recurrent, Atypical & High Risk

Action: Risk Management, Complex Psychological Intervention

Antidepressant Medication

The following table compares different classes of anti-depressant medication. It is intended for use by health professionals to aid in decision-making and guidance on prescribing, but contains information that may be useful to patients. For patients, please consult your GP or health professional if you have any further questions regarding your medication.

Antidepressant Comparison October 2012

Generic Name Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
Amitriptyline
Nortriptyline
Clomipramine
Dothiepin
Doxepin
Imipramine
Maprotiline (tetracyclic)
Mianserin
Venlafaxine Mirtazepine Moclobemide

SSRI
Selective Serotonin
Reuptake Inhibitor

Tricyclic
Non-Selective Cyclic Antidepressant

SNRI
Selective Serotonin
Noradrenaline
Reuptake Inhibitor

NaSSA
Noradrenergic /
Specific Serotonergic Antidepressant

RIMA
Reversible Inhibitor of MAO-A

Sedation

Low (generally) individuals may have marked sedation

Low - High Varies with agent

Low-Mod*

High

Low

Toxicity /
Overdose risk

Low

High

Mod-High

Low

Low#

Withdrawal

Risk decreases with longer half life
Stop gradually (not fluoxetine)

Risk
Stop gradually

Risk
Stop gradually

Possible
Stop gradually

No

Interactions²

Yes
Lithium
Serotonergic drugs
(eg triptans, SNRI, tricyclics, tramadol, opiates)
NSAIDS/ antiplatelets or anticoagulants
Seizure risk drugs
QT prolonging drugs

Yes
Serotonergic drugs
(eg triptans, SSRIS, SNRIs, tramadol, opiates)
CNS depressants
Seizure lowering drugs
QT Prolonging drugs

Yes
Serotonergic drugs
(eg triptans, SSRIS, tricyclics, tramadol, opiates)
Anticholinergics
Antipsychotics
NSAIDS/ antiplatelet or anticoagulants
Seizure risk drugs

Yes
Serotonergic drugs
(eg SSRIs, Tricyclics, SNRI, triptans, tramadol)
CNS depressants
Non-reversible MAOIs
5-HT3 Antiemetics
Stimulants

Yes
Yes
Serotonergic drugs
Antidepressants
Lithium
Narcotics
Stimulants
Sympathomimetics

Sexual Dysfunction

High

High

High

*# Low-Moderate
risk inc with age

Low

Weight

Varies
(some intital loss but many gain over time - monitor)

Risk of weight gain varies with agent
Low - high

Low risk of gain

High risk of gain

Low risk of gain

Anticholinergic effects

Low

Moderate-High
Varies with agent

Low

Minimal-Mod

Low-Mod

Orthostatic Hypotension

Low

Low-High
Varies with agent

3Moderate

Low

Mod

Place in Therapy

First Line

Second Line

Third Line
Spec Auth

Third Line
Spec Auth

First or Second Line

Monitoring

Clinical monitoring, especially when first starting an antidepressant (or altering the dose) is essential.

Drug Monitoring

Electrolytes1 at baseline, after 4 weeks & if symptomatic.
Risk increases in older people, women, low weight & in combo with agents than can lower Na+

Nortriptyline Serum level if used to augment SSRI, in higher doses, or toxicity suspected

No

No

No


* Dose Dependent

# unless combined with another antidepressant

² NOT a full list. Abbreviated to most serious/ common

3 May cause hypertension in higher doses


Notes:

  1. All antidepressants may provoke hyponatraemia. SSRIs (up to 32% incidence) and Venlafaxine have the highest risk of this effect - up to 4 times higher according to some studies.
    While the problem often presents in the first 2 weeks it may occur at any time throughout treatment
  2. All antidepressants may provoke seizures. The degree to which this occurs depends on the epileptogenic characteristics of each agent, the patient's seizure threshold and dose.

References available upon request.

Disclaimer: The information and advice contained in this document is based upon evidence from available resources at our disposal at the time of publication, and reflects best practice. However, this information is not a substitute for clinical judgement and individualised medical advice. Compass Health accepts no responsibility or liability for consequences arising from use of this information.

Antidepressant Switching

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