Key takeaways

  • Speak to the doctor straight away about suicidal thoughts or an urge to self-harm after starting. Get emergency help if you cannot keep yourself safe. The NHS identifies people aged 24 or under, or with previous such thoughts, as potentially most at risk. NHS
  • Expect early review appointments. NHS guidance describes a doctor review every 1 to 2 weeks when treatment starts, checking benefit and side effects. NHS
  • Benefit usually starts after 1 to 2 weeks and can take up to 8 weeks to develop fully. Side effects can arrive sooner. Discuss difficulties rather than giving up on treatment yourself. NHS
  • Treatment usually continues for at least 6 months after you feel better. Agree the duration with your prescriber. NHS
  • Plan stopping with the doctor. A gradual reduction over weeks or months helps manage withdrawal; do not stop suddenly. NHS
  • Include painkillers and supplements in the medicine list. NHS interaction advice names NSAIDs, other antidepressants and St John’s wort, as well as alcohol and some recreational drugs. NHS

Every antidepressant in this catalogue carries the young-person suicide-risk boxed warning. It calls for close monitoring of all treated patients for worsening symptoms and suicidal thoughts or behaviour. It does not say antidepressants cause suicide or should be avoided; the age group and early treatment period explain why review appointments matter.

What does the boxed warning actually say?

That the risk was seen in under-25s, that it was not seen in older adults, and that everyone should be monitored early in treatment.

The fuller wording, from the fluoxetine label, is worth reading in full rather than in summary:

Antidepressants increased the risk compared to placebo of suicidal thinking and behaviour in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders. Anyone considering their use in a child, adolescent or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality in adults beyond age 24, and there was a reduction in risk in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality or unusual changes in behaviour. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

  1. The study signal was in under-25s. The short-term results did not show an increase beyond 24, and showed a reduction at 65 and older.
  2. Depression itself carries suicide risk. Going untreated is not automatically the safer choice.
  3. Arrange the early monitoring. The NHS describes reviews every 1 to 2 weeks after starting, to discuss benefit and side effects. NHS
  4. Tell a family member or carer what to watch for. The label asks for close observation and contact with the prescriber; it applies to patients of all ages.

Agree the review plan before starting. The NHS also identifies a history of suicidal thoughts as a risk factor, and says to contact the doctor straight away if thoughts of suicide or self-harm emerge. If you are in immediate danger or cannot keep yourself safe, seek emergency help. NHS

What happens in the first few weeks?

Side effects usually arrive before the benefit does, which is the single commonest reason people stop too early.

NHS guidance puts the first effect at 1 to 2 weeks and the full effect at up to 8 weeks. Nausea, headache, disturbed sleep, restlessness or increased anxiety can appear in the first days and often settle. Some side effects continue during treatment, so review is still needed if they are troublesome. NHS

That sequence, feeling somewhat worse before feeling better, is difficult and it is where most treatment fails. Knowing it is coming makes it survivable, and it is the reason prescribers ask to see people early rather than at the end of a long first prescription.

Symptoms that should prompt contact rather than waiting:

  • new or worsening thoughts of self-harm or suicide
  • marked agitation, restlessness or an inability to sit still
  • a sudden or unusual change in behaviour, particularly in a young person
  • worsening of mood rather than the expected slow improvement

None of those means the medicine was the wrong choice. They mean the prescriber needs to know now rather than at the next scheduled appointment.

Why can I not just stop when I feel better?

Because stopping abruptly causes withdrawal symptoms, and because stopping too early is when relapse happens.

Antidepressant withdrawal, sometimes called discontinuation symptoms, can include dizziness, electric-shock sensations, nausea, sleep disturbance, irritability and flu-like symptoms. They vary a great deal between medicines and between people, and they are more likely with medicines that leave the body quickly.

Two clarifications that matter:

  • Withdrawal symptoms are not addiction. Antidepressants are not addictive in the sense of craving or dose escalation. The body adapts to their presence and needs time to adapt to their absence.
  • Feeling well is the treatment working, not evidence it is no longer needed. Continuing for a period after recovery is standard practice to reduce relapse risk. It is not necessarily lifelong; duration depends on your history and number of episodes and is agreed with the prescriber.

Ask the prescriber for a stopping plan. The NHS describes gradual reduction over weeks or months and usual continuation for at least 6 months after symptoms improve. Withdrawal often begins within days and lasts a few weeks, but can be delayed for weeks or months and last months or longer. Report that experience; the doctor may slow the reduction or return to a higher amount before trying again. NHS

Order repeats before running out. A supply gap is an unplanned abrupt stop.

Are they all the same?

Their side effects, interactions and withdrawal patterns differ, so the first choice may need changing.

The catalogue covers several groups:

  • SSRIs such as sertraline, fluoxetine, escitalopram, citalopram and paroxetine.
  • SNRIs such as venlafaxine and duloxetine, which also has a role in neuropathic pain.
  • Mirtazapine, which affects sleep and appetite differently from the SSRIs.
  • Tricyclics such as amitriptyline, also widely used at lower doses for neuropathic pain rather than depression.
  • Bupropion, which has a different mechanism again.

They differ in side effect profile, in interactions, in how quickly they leave the body and therefore in withdrawal behaviour, and in what else they help with. Someone with insomnia and poor appetite may suit a different medicine from someone with fatigue and low motivation.

Needing to switch is common and is not failure. It is one of the reasons the early review appointments exist.

What should I tell my prescriber?

Everything you take, and anything that has happened before.

Worth raising before starting:

  • any previous experience of antidepressants, including what happened
  • other medicines, including ones from another country, over-the-counter products, and supplements such as St John’s wort
  • pregnancy, or plans for it, and breastfeeding
  • any history of bipolar disorder or manic episodes, which changes the approach
  • epilepsy or seizures
  • other conditions being treated, since some antidepressants are chosen partly for their effect on pain or sleep

The NHS interaction list includes NSAID painkillers, other antidepressants, St John’s wort, cannabis and ketamine. It also warns that alcohol can worsen symptoms or cause sleepiness and dizziness. Supplements belong on the list even if you do not think of them as medicines. NHS

Do and don’t

Do:

  • Agree the early appointments before starting. NHS guidance describes reviews every 1 to 2 weeks. NHS
  • Tell someone close to you what to watch for, as the label advises.
  • Expect side effects before benefit, and report worsening rather than enduring it.
  • Order repeats early so you never run out.
  • Discuss tapering when you want to stop, and report withdrawal that starts late or lasts longer than expected. NHS guidance recognises that it can last months or longer. NHS
  • Say if you have switched brands or presentation.

Don’t:

  • Don’t stop suddenly, and don’t let the supply lapse.
  • Don’t assume a slow start means the medicine has failed.
  • Don’t treat withdrawal symptoms as evidence of addiction.
  • Don’t take someone else’s antidepressant.
  • Don’t add supplements, including St John’s wort, without telling your prescriber.

Where can I match an existing prescription?

Use the active ingredient and strength when continuing treatment started abroad.

The antidepressants and mental health categories list what is stocked here, and the ingredients index maps active ingredients to the brands containing them, which is the reliable way to continue a prescription started in another country.

MedicForce option: our listings show active ingredient and strength, which is what you need to match when continuing existing treatment.

  • Antidepressants, NHS patient-facing guidance on how antidepressants work, side effects and stopping.

The boxed warning text quoted above is from the approved product information for fluoxetine and sertraline. The same warning appears on the labels of the other antidepressants in this catalogue.