Depression
Red Flags — act before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| Active suicidal ideation with plan and intent | Imminent risk of completed suicide. Access to means (medication, weapons) multiplies lethality. Must establish plan, intent, and means before patient leaves surgery. | Same-day psychiatric review |
| Recent suicide attempt or serious self-harm | The single strongest predictor of future completed suicide is a prior attempt. Even if the patient appears stable, same-day psychiatric liaison assessment is required. | 999 / A&E now |
| Psychotic features (hallucinations, nihilistic delusions) | Psychotic depression carries very high suicide risk and does not respond to antidepressant monotherapy. Requires urgent psychiatric assessment and likely hospital admission. | Same-day CMHT / crisis team |
| Postpartum psychosis (within days of delivery) | Rapidly evolving psychiatric emergency. Confusion, rapidly changing mood, grandiosity, hallucinations within days of birth. High infanticide and maternal suicide risk. | 999 — psychiatric admission |
| Severe self-neglect — not eating, not drinking, not leaving home | Indicates profoundly severe depression with medical deterioration risk, dehydration, and vulnerability to exploitation. Requires same-day urgent risk assessment and possible admission. | Same-day urgent review |
| Prescribed medication posing overdose risk — patient stockpiling | Patients with suicidal ideation who have access to lethal quantities of medication (TCAs, paracetamol, opioids) require immediate means restriction — prescribe only small quantities and review access. | Same-day — restrict supply |
| Sudden onset severe headache or focal neurology with mood change | Organic brain pathology (intracranial tumour, subdural haematoma, encephalitis, CVA) must be excluded before a psychiatric label is applied — particularly in atypical or first presentations. | A&E same-day |
Safeguarding Considerations — Consider in Every Consultation
🏠 Domestic Abuse / Intimate Partner Violence
- Depression is a direct consequence of ongoing domestic abuse — failure to identify the root cause condemns the patient to ineffective treatment that cannot succeed
- Use validated HARK questions (Humiliation, Afraid, Rape, Kick) in a safe, private moment during the consultation
- Controlling or coercive behaviour by a partner may prevent attendance, honest disclosure, or engagement with treatment
- Make a safeguarding referral if risk to the patient or their dependants is identified — patient consent is not required when risk is serious and imminent
👴 Older Adults / Carer-related Concern
- Depression in older adults is frequently and dangerously attributed to 'normal ageing' — this delays diagnosis and treatment
- Unexplained weight loss, social withdrawal, and financial disarray may signal carer neglect or financial abuse by a trusted person
- Cognitive decline combined with depression increases vulnerability to exploitation and reduces capacity to seek help
- Document capacity formally if the patient appears unable to make decisions about their own welfare — refer to Adult Social Care under Mental Capacity Act 2005
🧒 Children in the Household
- A parent with severe depression may be unable to provide safe care, adequate supervision, or emotional warmth — this is a child protection concern, not merely a clinical note
- Children's emotional and developmental wellbeing is directly impaired by parental depression — early intervention prevents long-term harm
- Ask directly: "Who is looking after the children at the moment? Is there another adult at home to help?"
- Refer to children's social care if children's basic needs are at risk — use the Think Family framework; you do not need certainty to refer
💊 Self-Harm / Medication Misuse Risk
- Always assess means access: prescribed medications (especially TCAs, opioids, antiepileptics), OTC analgesics (paracetamol), and access to weapons
- Prescribe only small quantities of antidepressants at first initiation — 2-week supply — until safety is established at 1–2 week review
- Where risk is significant, involve a family member or trusted adult in medication storage — with patient's consent where possible
- Document your risk assessment clearly, including protective factors identified, and create a written safety plan with the patient before they leave
💸 Financial Stress & Poverty
Financial insecurity chronically activates the stress-threat system, elevating cortisol and suppressing serotonergic tone via HPA axis dysregulation. Debt and housing insecurity are among the strongest predictors of treatment-resistant depression seen in primary care.
"Are you worried about money at the moment — things like bills, debt, or your housing situation?"If present: social prescribing referral, Citizens Advice, signpost to PIP or ESA assessment. Without addressing financial stressors, antidepressants alone are very unlikely to achieve or maintain remission.
💔 Relationship Conflict & Social Isolation
Marital discord, loneliness, and absence of social support are independent risk factors for depression onset and relapse. Social isolation eliminates the interpersonal protective factors that buffer suicidal risk most powerfully.
"How are things at home with your partner or family? Do you have people around you that you can talk to and lean on?"If isolated: IPT (interpersonal therapy) referral via NHS Talking Therapies, social prescribing, befriending services. If the relationship itself is harmful: screen for domestic abuse — see safeguarding section above.
💼 Work-Related Stress & Burnout
Work stress, workplace bullying, unmanageable workloads, and lack of professional autonomy are established direct causes of depression. Returning to an unchanged, stressful working environment is the most consistent driver of relapse after antidepressant treatment.
"What's your work situation like at the moment — is that adding to how you're feeling, or is it the other way around?"If work is causative: occupational health referral, fit note with specific functional adaptations (phased return, altered duties), ACAS advice for bullying situations. Fit note must name the work-limiting reason specifically.
🕯️ Bereavement & Loss
Grief is normal and should not be pathologised. However, complicated grief that is prolonged beyond 6 months with significant functional impairment, or that is accompanied by active suicidal ideation, meets criteria for a depressive episode and warrants treatment.
"Have you lost anyone important to you recently — or experienced other significant losses, like a relationship ending or losing your job?"Normal grief: Cruse bereavement support, watchful waiting, normalising. Complicated grief meeting ICD-11 criteria: consider antidepressant and referral for grief-focused CBT via NHS Talking Therapies Step 3.
🍷 Alcohol & Substance Use as Coping
Many patients self-medicate depression with alcohol, creating a self-reinforcing cycle. Alcohol worsens next-day mood via acetaldehyde accumulation and disrupts REM sleep architecture. The cycle is: depression → drinking → worse depression → more drinking.
"A lot of people use alcohol or other things to help them cope when they're feeling down — has that been part of your picture at all recently?"Non-judgemental framing substantially improves honest disclosure. If confirmed: address alcohol use as a treatment priority. Refer to NHS Talking Therapies dual-diagnosis pathway or alcohol services. Antidepressants are markedly less effective without concurrent alcohol reduction.
🏥 Chronic Physical Illness & Pain
Depression is 2–3× more prevalent in patients with chronic conditions (diabetes, COPD, heart failure, cancer, chronic pain). The mechanism involves chronic neuroinflammation via pro-inflammatory cytokines, sustained HPA axis dysregulation, and progressive loss of functioning and autonomy.
"You're also managing [chronic condition] — has dealing with that been getting on top of you? How does the physical side affect how you're feeling emotionally?"For comorbid chronic pain and depression: duloxetine (SNRI) has dual licensed indication and targets both conditions simultaneously. For cancer-related depression: involve palliative care team; lower threshold for psychiatric referral in life-limiting illness.
- Opening with PHQ-9 before an open question — signals task completion over patient-centred care, immediate Relating to Others deduction
- Failing to ask about suicidal ideation — non-negotiable omission in any depression case; patient safety failure
- Not screening for bipolar features before discussing antidepressants — serious prescribing safety omission
- Using clinical jargon without checking understanding — "serotonin reuptake inhibitor", "major depressive episode"
- Offering medication before exploring ICE — misses hidden concerns about antidepressants that will cause non-adherence
- Not asking about psychosocial triggers — plan will be biologically correct but contextually incomplete
999 or Same-Day Hospital
Call 999 / Acute Psychiatric / A&E now- Active suicidal ideation with plan and meansIntent + access to means (medication, weapons) → 999 or immediate mental health crisis team activation
- Recent serious suicide attemptOverdose or self-injury requiring medical treatment → 999, A&E, psychiatric liaison same day
- Postpartum psychosisWithin days of delivery: confusion, hallucinations, rapidly changing mood → 999; psychiatric mother-and-baby unit admission
- Severe psychotic depression with dangerous behaviourActing on command hallucinations, extreme agitation, inability to care for self → 999 admission
- Organic cause with acute confusion and neurological signsNew onset focal neurology, headache, altered consciousness → A&E immediately; exclude intracranial pathology first
Same-Day GP / Urgent CMHT
Same day to 2 weeks- Passive suicidal ideation without planPHQ-9 Q9 ≥1: "I'd be better off dead" without active intent → same-day GP review + written safety plan before leaving
- PHQ-9 ≥20 (severe) with poor social supportSevere depression + living alone or no protective factors → urgent CMHT referral same week
- Suspected bipolar disorderDepressive episode + possible hypomanic history → urgent CMHT before any antidepressant is prescribed
- Severe self-neglectNot eating, not drinking, not managing basic hygiene → same-day risk assessment; consider admission
- EPDS ≥13 postnatalPerinatal depression: same-day or next-day assessment; involve midwife, health visitor, specialist perinatal mental health team
- SSRI activation / increased SI in first 2 weeksWorsening agitation or suicidal ideation on initiating antidepressant → same-day urgent review (MHRA / NICE NG222)
Manage in Primary Care
GP practice pathway- Mild depression (PHQ-9 5–9)Watchful waiting, guided self-help, NHS Talking Therapies Step 2 referral, exercise prescription, follow-up in 2–4 weeks
- Moderate depression (PHQ-9 10–14)NHS Talking Therapies Step 3 referral (CBT/IPT) + consider SSRI; mandatory 1–2 week review after starting medication
- Recurrent depression — stable, no current riskLong-term maintenance monitoring, medication review, annual PHQ-9, duration of treatment discussion
- Subthreshold depression (PHQ-9 <5)Active monitoring, lifestyle advice, psychosocial intervention, watchful waiting, review in 4–8 weeks
- Adjustment disorderSupportive counselling, NHS Talking Therapies low-intensity, watchful waiting, psychosocial support — antidepressants not routinely indicated
- Triaging a patient with active suicidal ideation as 'routine' without a personalised safety plan — patient safety failure
- Prescribing antidepressants to a patient with possible bipolar disorder without flagging this clearly and referring before prescribing
- Failing to escalate postpartum psychosis — treating it as ordinary postnatal depression is a clinical emergency failure
- Sending a severely depressed patient away with only lifestyle advice and no follow-up or crisis resource
- Dismissing passive suicidal ideation as "not serious" without exploration, safety plan, or documented risk assessment
- Not using or referencing PHQ-9 in any depression consultation — missed mandatory Tasks domain item
- Treating PHQ-9 as the diagnosis rather than one component of full clinical assessment
- Forgetting to document baseline BP and weight before initiating antidepressants — prescribing safety failure
- Missing the opportunity to screen for organic cause when the patient has significant unexplained weight loss
- Ordering investigations without explaining the rationale to the patient — loses Relating to Others marks
- Failing to check TFTs in a patient with clinical features suggestive of organic cause — missed treatable diagnosis
- Not checking U&Es as a baseline before SSRI initiation in an elderly patient — SIADH hyponatraemia risk not addressed
- Ordering a full shotgun panel without clinical indication — over-investigation without explanation
"What you're experiencing is depression — and I want to explain what that actually means, because the word carries a lot of baggage. Depression isn't a sign of weakness or a choice. It's a medical condition where the brain's chemical signalling system — particularly serotonin and noradrenaline — gets out of balance. Think of it a bit like how the thyroid can go underactive: the biology shifts, and the whole system runs below its normal level. The parts of the brain that regulate your mood, your sleep, your appetite, your energy, and your ability to concentrate are all affected — which is why you feel it so broadly. The good news is that it's very treatable, and most people with the right support get back to feeling like themselves."
"I think I'm just stressed — I don't think I'm actually depressed."
"That makes complete sense, and stress is definitely part of the picture. But what happens is that prolonged stress actually changes the brain chemistry over time — it's not a sudden switch, it creeps up. What you're describing — the poor sleep, the loss of enjoyment, the difficulty concentrating — these are the brain's response to sustained pressure, and they're telling us the system needs some support to get back to where it was."
"I don't want to be on antidepressants — they're addictive and will change my personality."
"That's one of the most common worries I hear, and it's worth unpicking. Antidepressants aren't addictive in the way people imagine — they don't give a high, and they don't create cravings. The reason we taper them slowly at the end is to let the brain adjust gently, not because of addiction. And they don't change who you are — most people say they feel more like themselves because the depression lifts and lets the real them come through."
Mild Depression (PHQ-9 5–9)
Two or more core symptoms for ≥2 weeks with mild functional impairment. Watchful waiting, guided self-help, NHS Talking Therapies Step 2, exercise prescription. Antidepressants not first-line for mild depression — NICE NG222 explicitly recommends psychological and social interventions first.
Moderate Depression (PHQ-9 10–14)
Persistent low mood and/or anhedonia with moderate functional impairment in at least two domains. SSRI combined with NHS Talking Therapies Step 3 (CBT or IPT). NICE NG222: combined treatment superior to either alone for moderate depression.
Adjustment Disorder
Low mood or anxiety in response to an identifiable stressor, within 3 months, resolving within 6 months of stressor ending. Antidepressants not routinely indicated. Supportive counselling, social support, and watchful waiting are the evidence-based first line.
Recurrent Depressive Disorder
Two or more discrete depressive episodes separated by a period of recovery. Increased recurrence risk with each subsequent episode. NICE NG222: after third episode, discuss long-term maintenance antidepressant therapy as a serious option.
Bipolar Disorder (Type I or II)
Depressive episode with history of manic or hypomanic episodes. Do NOT prescribe antidepressant monotherapy — risk of precipitating a manic switch that can be severe, dangerous, and irreversible. Urgent CMHT referral for mood stabiliser initiation (lithium or quetiapine). Bipolar II is the most commonly missed diagnosis in primary care depression.
Treatment-Resistant Depression (TRD)
Defined as failure of two adequate antidepressant trials at therapeutic dose for adequate duration (4–6 weeks each). Refer to CMHT for augmentation strategies (quetiapine, lithium, mirtazapine combination) or specialist psychological therapies. Do not initiate lithium or augmentation antipsychotics in primary care without specialist initiation.
Emotionally Unstable Personality Disorder (EUPD)
Chronic emotional dysregulation, impulsivity, unstable relationships, and chronic feelings of emptiness — may closely mimic or coexist with depression. Antidepressants have limited evidence as monotherapy in EUPD. Refer to CMHT for structured psychotherapy (dialectical behaviour therapy — DBT) as the treatment of choice.
Severe Depression with Psychotic Features
PHQ-9 ≥20 with psychotic features (nihilistic or guilty delusions, auditory hallucinations). Antidepressant monotherapy is insufficient and potentially dangerous. Requires urgent CMHT referral; likely needs antipsychotic + antidepressant combination or electroconvulsive therapy (ECT).
Imminent Suicidal Crisis
Active suicidal ideation with plan, intent, and access to means. Psychiatric emergency — do not leave patient unaccompanied. Immediate crisis team contact or 999. Means restriction is mandatory: prescribe only 2-week supply of any medication. Written safety plan before patient leaves the surgery. Named contact person involved where possible.
Postpartum Psychosis
Onset within days of delivery. Confusion, hallucinations, disorganised behaviour, rapidly fluctuating mood, grandiosity. Psychiatric emergency — 999 immediately. Mother-and-baby psychiatric unit admission required. High infanticide and maternal suicide risk. Involves obstetrics, midwifery, health visiting, and social care simultaneously.
Organic Brain Pathology Presenting as Depression
Brain tumour, subdural haematoma, encephalitis, or stroke presenting with mood change and neurological signs. Do not apply a psychiatric label without excluding organic pathology when presentation is atypical or focal signs are present. Same-day A&E. The psychiatric label delays the diagnosis that will save the patient's life.
- Using clinical jargon without plain-language explanation ("major depressive episode", "serotonin reuptake inhibitor")
- Not addressing the patient's specific beliefs about antidepressants before offering them — those beliefs will cause non-adherence
- Missing the bipolar DDx — this is a clinical and prescribing safety failure, not just a knowledge gap
- Diagnosing adjustment disorder as depression and prescribing an SSRI that is not indicated
- Not linking PHQ-9 score to a specific treatment decision in the consultation — the number must mean something clinically
- Prescribing antidepressant to a patient with possible bipolar before specialist has reviewed — patient safety failure
- Referring to CMHT without specifying urgency — "routine" is not adequate for severe or at-risk patients
- Treating referral as a complete handover — no safety plan, no interim GP follow-up, no crisis contact provided
- Prescribing tricyclics in a patient with severe depression and suicidal ideation — extremely high overdose lethality
- Not involving health visitor and midwife in any perinatal depression case — standard shared care pathway
Validate — name their expectation
Before offering any plan, name what the patient came for. Whether it is antidepressants, a sick note, counselling, or simply to be heard — validate the expectation explicitly without immediately agreeing or refusing. This single act is the most powerful predictor of subsequent adherence.
"It sounds like you've come today partly hoping for some medication to help you through this — is that right? I want to make sure we talk through that properly before we decide together."Explain — share your clinical reasoning
Explain your thinking out loud. If you are starting with therapy rather than medication, explain why — not as a refusal, but as clinical reasoning the patient can follow and engage with. Patients accept a recommendation far better when they understand the logic behind it.
"The reason I want to start with the talking therapy option is that for the level of depression you're describing, the evidence shows therapy works just as well as tablets — and it gives you skills that last long after the treatment ends. That feels like a better starting point for you."Negotiate — offer something concrete today
Never end the consultation without something concrete. Even if deferring medication, offer something immediately: an NHS Talking Therapies referral, a sick note, a follow-up appointment, a crisis number, or a written safety plan. The patient must leave with more than they came with.
"What I can do today is get you referred to the psychological therapy service — they're usually in touch within 2 weeks — and give you a sick note if that would help. And if things get worse before then, I want you to call us same-day. Shall we agree that plan now?"Aerobic exercise increases BDNF (brain-derived neurotrophic factor), stimulating neurogenesis in the hippocampus — the region most reduced in volume in depression. It also increases serotonin and noradrenaline synthesis and reduces cortisol output from the HPA axis.
Social prescribing referral to parkrun, NHS walking groups, or GP exercise on prescription schemes. Start with 20-minute walks if motivation is low. Group activity is superior to solo exercise for depression (additional social engagement mechanism). Name a specific first step: "Can you walk to the end of the road and back tomorrow morning?"
Depression and poor sleep are bidirectionally causal. Sleep deprivation reduces prefrontal cortex activity (impulse control, mood regulation) and amplifies amygdala reactivity — directly worsening depressive symptoms and significantly increasing suicidal ideation the following day.
Fixed wake time (even on weekends) is the single most evidence-based sleep hygiene intervention. Cognitive shuffling or CBT-I (cognitive behavioural therapy for insomnia) available via NHS Talking Therapies. Avoid alcohol as a sleep aid — it suppresses REM sleep and dramatically worsens morning mood. For chronic insomnia: refer to NHS Talking Therapies CBT-I pathway.
Social connection activates the opioid, oxytocin, and dopamine reward systems — the same systems most suppressed in depression. Social withdrawal is a powerful maintaining factor, not just a consequence. Isolation significantly increases suicidal ideation through loss of protective interpersonal buffering.
Social prescribing: refer to community link workers, befriending services, Men in Sheds, arts on prescription. Plan one specific activity per week — even low-threshold (coffee with a neighbour, attending a local group). Behavioural activation (scheduling valued activities) is the core mechanism underlying CBT for depression.
Alcohol is a GABA-A agonist: acute intoxication mimics antidepressant relief but chronic use depletes serotonin precursors (tryptophan), disrupts REM sleep architecture, and causes sustained HPA axis dysregulation. Next-day acetaldehyde accumulation directly and measurably worsens PHQ-9 score.
AUDIT-C score at every depression consultation. Brief intervention (5–10 minutes) reduces hazardous drinking by 20% in primary care. Refer to local alcohol services or NHS Talking Therapies dual-diagnosis pathway if AUDIT ≥8. Do not give antidepressant prescription without explicitly discussing alcohol use — prescribing into active alcohol dependence is ineffective.
The gut-brain axis (gut microbiome → vagus nerve → HPA axis → serotonin production) is directly implicated in depression. Omega-3 fatty acids (EPA/DHA) reduce neuroinflammation. Tryptophan (serotonin precursor) is depleted by ultra-processed food diets. Folate deficiency (found in leafy greens, legumes) directly impairs serotonin and dopamine synthesis.
Mediterranean diet: oily fish 2×/week, leafy greens, legumes, wholegrains, olive oil. Budget-friendly options: tinned sardines, lentils, frozen spinach. Avoid meal-skipping — blood glucose instability worsens mood acutely. Replace folic acid if deficient. Regular mealtimes stabilise HPA axis circadian rhythm.
NICE-approved digital CBT programmes deliver cognitive restructuring and behavioural activation via structured modules. NHS Talking Therapies Step 2 guided self-help achieves PHQ-9 reduction equivalent to low-intensity therapist sessions while the patient is waiting for high-intensity therapy. The mechanism is identical to face-to-face CBT — the format is different.
Prescribe via NHS Talking Therapies referral or NHS Apps Library: SilverCloud and Beating the Blues are NICE-recommended for depression. For elderly or digitally excluded patients: bibliotherapy — Feeling Good by David Burns (explicitly recommended by NICE as a low-intensity intervention). Prescribe it like a medication: "Start chapter 2 this week, come back in 2 weeks and tell me how you found it."
Sertraline 50mg once daily: NICE NG222 recommended first-line antidepressant for most adults.
- Standard choice (most patients) → Sertraline 50mg od; titrate to 100–200mg if partial response at 4 weeks
- Cardiac disease / post-MI → Sertraline (best cardiac evidence — SADHART trial; safest post-MI)
- Breastfeeding / pregnancy → Sertraline (lowest transfer to breast milk of all SSRIs)
- Comorbid anxiety (high baseline agitation) → Start at 25mg for first week, then increase to 50mg to reduce activation risk
- Severe insomnia + significant weight loss → Consider mirtazapine 15mg nocte as alternative first-line (sedating + appetite-stimulating)
If sertraline is ineffective after 4–6 weeks at therapeutic dose, switch to an alternative SSRI or augment with high-intensity psychological therapy.
- SSRI GI intolerance → Citalopram 20mg od or escitalopram 10mg od (better GI profile; check ECG if QTc risk)
- Adherence concern or irregular taker → Fluoxetine 20mg od (long half-life tolerates missed doses)
- No antidepressant response at 6 wks at therapeutic dose → Switch class (Step 3) rather than another SSRI
- Partial SSRI response → Add high-intensity CBT (NHS Talking Therapies Step 3) — combined treatment superior to either alone
After failure of two adequate SSRI trials, switch to a pharmacologically distinct class.
- Venlafaxine 75mg od (SNRI) → Effective for depression and generalised anxiety; titrate to 150–225mg; check BP (raises at higher doses)
- Duloxetine 60mg od (SNRI) → Dual licensed indication for depression and chronic pain/diabetic neuropathy
- Mirtazapine 15–30mg nocte (NaSSA) → Sedating and appetite-stimulating; no sexual side effects; useful for severe insomnia and weight loss
- Mirtazapine + SSRI combination → 'California Rocket Fuel' (Stahl): superior to either alone in moderate-severe TRD under CMHT guidance
- Quetiapine augmentation (25–50mg nocte, CMHT-initiated) → effective in TRD; metabolic monitoring mandatory
- Lithium augmentation → Specialist initiation only; baseline TFTs, renal function, ECG, calcium; narrow therapeutic window (0.4–1.0 mmol/L)
- Aripiprazole or olanzapine augmentation → Specialist-initiated; annual metabolic monitoring including fasting glucose, lipids, BMI, BP
- ECT (electroconvulsive therapy) → For severe psychotic depression, catatonia, or life-threatening TRD; inpatient, specialist-consented
- Suspected bipolar disorder → Do NOT prescribe antidepressant monotherapy; refer to CMHT first without exception
- Mild depression (PHQ-9 5–9) → Antidepressants not first-line (NICE NG222); NHS Talking Therapies, exercise, self-help first
- Adjustment disorder → Not routinely indicated; watchful waiting and psychological support preferred
- Active alcohol dependence → Address alcohol dependence first; antidepressants substantially less effective without sobriety
- First trimester pregnancy → Avoid paroxetine (cardiac septal defects); prefer sertraline after full risk-benefit discussion
- Tricyclic antidepressants → Avoid for depression with suicidal ideation in primary care — extremely lethal in overdose; specialist advice only
- MAOIs (phenelzine, tranylcypromine) → Never prescribe in primary care; multiple potentially lethal food-drug interactions; specialist-only
Select patient characteristics — see relevant drug cards below for tailored recommendations
"These tablets usually take 4 to 6 weeks to work fully — please don't stop them if you don't feel better straight away. You might feel a bit more anxious or jittery in the first week — this is normal and settles. If you ever feel your thoughts about harming yourself get worse in the first couple of weeks, please contact us that same day."
SCA pearl: NG222 requires an early review — within 1 week if the patient is aged 18–25 inclusive or at increased risk of suicide, otherwise within 2 weeks — and state it explicitly in the consultation. Getting that boundary right (18–25 inclusive, plus any increased-risk patient of any age) is the examinable detail. Always warn about activation and suicidal ideation risk in the first fortnight. Not mentioning the 4–6 week onset loses a Tasks domain mark. Pre-warning about sexual dysfunction prevents the commonest cause of covert non-adherence.
"Take this in the morning as it can affect your sleep if taken at night. It takes 4 to 6 weeks to work. If you ever need to stop it, we'll need about 5 weeks for it to fully leave your system — so always check with me before starting anything new, including herbal remedies."
SCA pearl: Fluoxetine has a uniquely long half-life — 5-week MAOI washout (not 2 weeks like other SSRIs). This is the commonest drug interaction trap in SCA depression prescribing questions. Also: avoid in breastfeeding and first-trimester pregnancy — both contraindications are absolute preferences for sertraline. The CYP2D6 inhibition effect on tamoxifen is clinically significant — always check when prescribing for women on tamoxifen.
"This medication can occasionally affect the heart's electrical rhythm — which is why I checked your heart beforehand. Please don't take any new medications, including herbal remedies, without checking with me first. If you notice palpitations, dizziness, or feel faint after starting, contact us the same day."
SCA pearl: Citalopram and escitalopram are the only SSRIs with an MHRA-mandated QTc warning. In any SCA case where the patient is on domperidone, antipsychotics, or a macrolide antibiotic — flag the QTc drug interaction explicitly before prescribing citalopram and switch to sertraline. This is a patient safety point that scores directly in the Tasks domain.
"This works on two brain chemicals instead of one, which makes it effective for some people where other tablets haven't worked. One critical thing: when you're eventually ready to stop, we need to reduce it very slowly — much more slowly than other antidepressants. Stopping too quickly causes dizziness, a kind of electric shock feeling in the head, and flu-like symptoms. Never stop it suddenly — always come and talk to me first."
SCA pearl: Venlafaxine discontinuation syndrome is a major SCA examination topic. 'Brain zaps' (electric shock sensations in the head), severe dizziness, and flu-like symptoms within days of dose reduction = discontinuation, not relapse. Counsel about this explicitly at initiation. Also: check BP before prescribing and at 1 month — hypertension at higher doses is a clinically significant and often missed adverse effect.
"Take this one at night — it's quite sedating, which actually helps with sleep, and that's one of the reasons we're choosing it for you. You may notice your appetite increases, especially for sweet things — being aware of this upfront helps you manage it. If you ever get a fever or a really sore throat while on this tablet, please contact us promptly as we'd want to check your blood count."
SCA pearl: Mirtazapine is counterintuitively less sedating at higher doses — the H1 blocking sedation is proportionally less as noradrenergic effects dominate. Starting at 30mg for insomnia is a common error; 15mg is the more sedating dose. The one antidepressant without sexual side effects — mention this proactively if the patient has experienced SSRI-induced sexual dysfunction or raises this concern.
"This is a different type of medication from your antidepressant — it works alongside it to boost the effect in a different way. Because it can affect your weight, blood sugar, and cholesterol, we do a blood test every year to keep a close eye on those. It can make you drowsy, especially at first — please don't drive until you know how it affects you, and if you feel it's affecting your driving significantly, we need to tell the DVLA about that."
SCA pearl: Annual metabolic monitoring is a NICE-mandated requirement for all patients on antipsychotics — including quetiapine augmentation. This is a mandatory Tasks domain item in any SCA case involving quetiapine. Also: quetiapine augmentation should be initiated by CMHT, not independently by the GP. Your role in primary care is the annual metabolic monitoring and shared care prescribing once CMHT has initiated and stabilised the dose.
Driving & DVLA Obligations
Depression itself can impair driving: reduced concentration, psychomotor slowing, and impaired reaction time are objective cognitive deficits. DVLA guidance states Group 1 (car) licence holders should not drive if depression is severe enough to significantly affect concentration and attention — this is a clinical and legal obligation to discuss.
Antidepressants: SSRIs at therapeutic doses do not generally impair driving once established. Mirtazapine and quetiapine cause clinically significant sedation — advise the patient not to drive until the sedative effect is established and they are confident it does not impair them. Group 2 (HGV/bus/PSV) licence holders must notify DVLA of any psychiatric condition affecting driving — mandatory, not advisory.
DVLA notification: if the patient refuses to notify DVLA and continues to drive when you believe they are unsafe, you have a GMC-backed public interest duty to inform the DVLA yourself — document this discussion and the patient's response fully in the clinical notes.
"While you're feeling this low, your concentration and reactions aren't at their best — I'd encourage you to think carefully about driving until things improve. If you hold a commercial licence, this is something we have a legal obligation to notify the DVLA about."Work, Fit Notes & Occupational Health
Depression is the leading single cause of workplace absence in the UK. Inability to concentrate, make decisions safely, or manage workplace relationships constitutes incapacity for work. Under the Equality Act 2010, depression lasting or likely to last more than 12 months (or recurrent) may constitute a disability — requiring reasonable adjustments by the employer.
Fit note (Med3): issue when depression prevents safe or effective work. Describe the specific functional limitation rather than the diagnosis alone: "unable to maintain concentration required for role" or "risk of deterioration without reduced workload." Specific language protects the patient and is more useful to employers and occupational health.
Return to work: phased return to work is substantially more effective than abrupt return. Occupational Health referral enables workplace adjustments under the Equality Act reasonable adjustments duty. Access to Work (DWP scheme) can fund workplace mental health support.
"I'll give you a sick note today — this is a legitimate medical reason to be away from work. When you're ready to think about going back, we can plan a phased return so it doesn't set back your recovery."Sexual Dysfunction & Intimate Relationships
SSRI-induced sexual dysfunction affects 30–40% of patients: delayed ejaculation, anorgasmia, and reduced libido are the most commonly reported effects. This is the single most common reason for covert non-adherence to antidepressants — patients stop their tablets without telling their GP because they are embarrassed or assume it is inevitable and permanent.
Proactively pre-empt this: "Some people find these tablets affect their sex life — it's one of the side effects I want to mention upfront so you know what to watch for and know it's worth telling me about." Options if it occurs: dose reduction, timing change (morning vs evening), switching to mirtazapine (no sexual side effects via different mechanism), or adjunct PDE-5 inhibitor for SSRI-induced erectile dysfunction.
Relationship impact: depression strains relationships through emotional withdrawal, irritability, reduced emotional availability, and loss of physical intimacy. Partner or carer support is one of the strongest protective factors — with patient consent, offering a joint appointment can substantially improve outcomes and reduce carer burnout.
"One thing I want to mention upfront about these tablets: some people find they affect their sex drive or make it harder to reach orgasm. It's quite common. If that happens, please tell me — it's absolutely worth talking about and there are things we can do."Stigma, Disclosure & Insurance
Stigma remains a major and damaging barrier to help-seeking and treatment adherence in depression. Fear of being labelled 'mentally ill' or 'weak', concerns about employment implications, and worry about insurance are consistently cited as reasons people either do not seek help or stop treatment early without telling anyone.
Insurance disclosure: life insurance and critical illness cover policies vary widely. Patients are generally required to disclose significant mental health conditions on application forms. However, successfully treated, resolved depression has substantially less impact on premiums than untreated, chronic, or recurrent depression from an underwriter's risk perspective — treatment protects future insurability.
Occupational disclosure: employees are not required to proactively disclose mental health conditions to employers unless specifically asked on an occupational health form. Under the Equality Act 2010, employers are legally prohibited from asking health questions before a conditional job offer. The patient has a right to confidentiality.
"You're not required to tell your employer about your diagnosis. What you can share, if you choose, is that you have a health condition affecting your work — that gives you legal protection under the Equality Act without disclosing the specifics."Pregnancy, Fertility & Contraception
Depression during pregnancy and the postnatal period is common and substantially undertreated due to concerns about medication. Untreated depression in pregnancy carries significant evidence-based risks to both mother and infant: low birth weight, preterm delivery, impaired mother-infant bonding, and increased risk of postpartum psychosis in the postnatal period.
Medication in pregnancy: sertraline is the preferred SSRI throughout pregnancy and during breastfeeding — the evidence base is strongest and infant exposure lowest. Paroxetine is avoided in the first trimester (cardiac septal defects). SSRIs in late third trimester can cause neonatal adaptation syndrome (transient jitteriness, poor feeding, mild respiratory symptoms) which is self-limiting. Full risk-benefit discussion is required for every individual case.
Future pregnancy planning: if the patient is considering pregnancy, proactive pre-conception planning produces substantially better outcomes than reactive management once pregnant. Involve the specialist perinatal mental health team early. Discuss contraception adequacy while on antidepressants — drug interactions are uncommon but relevant for enzyme-inducing antidepressants.
"If you're thinking about getting pregnant in the future, I'd really like us to plan that together before you stop your contraception — the safest approach for you and the baby is to have that conversation proactively, not after the fact."Financial Support, Benefits & Social Prescribing
Depression disproportionately affects people in financial hardship, and the resulting inability to work creates a reinforcing cycle of poverty and worsening mental health. Many patients are entirely unaware of their entitlements. Employment and Support Allowance (ESA) supports those unable to work due to illness. Personal Independence Payment (PIP) is available if depression substantially limits daily activities for more than 12 months.
Social prescribing: the practice social prescriber or link worker is one of the most powerful under-used resources in primary care depression. They can coordinate financial assessment, benefits navigation, debt counselling, food bank referral, community group connections, and befriending services. These upstream interventions address the root causes that antidepressants cannot touch.
Access to Work (DWP): can fund workplace mental health coaching, occupational therapy assessment, and practical adaptations for patients returning to work with depression. Refer via employer or self-referral at gov.uk/access-to-work. This resource is dramatically under-utilised in primary care.
"I'd like to connect you with our social prescriber — they can help you navigate what financial support you might be entitled to, because I know that money stress is one of the things making everything harder right now."1 week if aged 18–25 or at increased suicide risk · otherwise 2 weeks — Mandatory (NICE NG222)
Assess for worsening suicidal ideation or activation/agitation. NG222 sets the one-week review for people aged 18 to 25 inclusive and for anyone at increased risk of suicide at any age; everyone else is reviewed at 2 weeks, then every 2–4 weeks for 3 months. Check early side-effect tolerability (GI upset, insomnia, agitation). Reinforce the 4–6 week message — do not stop. Prescribe next 2-week supply only until safety is confirmed. Review alcohol and substance use if relevant.
4–6 Weeks — Treatment Response Assessment
Repeat PHQ-9 formally. Define response: ≥50% reduction = responding well; <50% = consider dose increase before switching. Check for emerging side effects (sexual dysfunction, weight change, sleep quality). Confirm NHS Talking Therapies therapy has been started or is scheduled. If moderate-severe and therapy not yet commenced — expedite NHS Talking Therapies referral. Review fit note and return-to-work planning if applicable.
3 Months — Full Response and Therapy Progress Review
Repeat PHQ-9 — target <5 (remission). If no response despite adequate antidepressant trial at therapeutic dose: switch antidepressant class or add high-intensity CBT or IPT. Confirm NHS Talking Therapies engagement and progress. Review fit note and discuss return-to-work timeline. If CMHT referral is pending, follow up on waiting time and maintain GP support in the interim.
6 Months — Consolidation and Relapse Prevention
If in remission (PHQ-9 <5): the minimum treatment duration has been reached — but do not stop the antidepressant at 6 months. NICE NG222: continue for a minimum of 6 months after the point of remission before considering tapering. Begin relapse prevention discussion: identify the patient's personal early warning signs, lifestyle factors, and psychosocial triggers. Consider Mindfulness-Based CBT (MBCT) for patients with ≥3 previous depressive episodes — evidence base is equivalent to maintenance antidepressant.
12 Months — Tapering Decision and Long-Term Plan
Review whether to taper or continue long-term maintenance therapy. Three or more previous depressive episodes: discuss indefinite maintenance antidepressant explicitly — the evidence base supports this as strongly as it supports any other relapse prevention intervention. Tapering protocol: reduce dose by 25% every 4–6 weeks, monitoring carefully. The key clinical skill: distinguishing discontinuation syndrome (onset within days of dose reduction, resolves quickly with dose reinstatement) from relapse (gradual return of depressive symptoms 2–6 weeks after stopping).
Memory rule — monitoring antidepressant treatment in depression
After starting any antidepressant: Suicide risk reassessment at 1–2 weeks · Mood response (PHQ-9) at 4–6 weeks · Assess side effects (sexual dysfunction, weight, BP) at 6–8 weeks · Remission target = PHQ-9 <5 · Treatment duration minimum 6 months post-remission. Special monitoring: Na⁺ in elderly at 2 weeks (SIADH) · BP on venlafaxine at 1 month · Metabolic panel on quetiapine at 3 and 12 months · BMI on mirtazapine at 3 and 6 months.
⚠ Three scenario-specific phrases — use these verbatim or very close
Why safety-netting matters beyond good clinical care
- Handing over the prescription without confirming the patient has understood the 4–6 week onset and the importance of not stopping early
- No safety-netting for suicidal ideation — mandatory in every depression consultation regardless of PHQ-9 score or apparent stability
- Failing to give a specific named follow-up time — "come back if you're worried" is not a safety net; a named appointment is
- Not closing by checking whether the patient's original concern (from ICE) was addressed — the consultation must circle back to where it started
- Prescribing antidepressant without confirming absence of bipolar features — even in the last 30 seconds of the consultation
- Not providing a 24-hour crisis resource (Samaritans 116 123, 111) before ending — patients with depression deteriorate at night and on weekends
- Systematic data gathering: PHQ-9 administered and scored; severity correctly classified; bipolar screen explicitly performed; suicidal ideation directly assessed and fully explored
- Appropriate diagnosis reached: depression severity correctly matched; relevant DDx considered (bipolar, organic, adjustment disorder); diagnosis explained in plain biological language using an accessible analogy
- Severity-appropriate management: NICE NG222 pathway followed — watchful waiting for mild; SSRI + NHS Talking Therapies for moderate-severe; CMHT referral if indicated by bipolar features or severity
- Safety: suicidal ideation assessed formally; means restriction discussed if indicated; written safety plan created; specific 1–2 week review booked and confirmed with patient
- Prescribing safety: sertraline first-line unless contraindicated; dose, onset, and discontinuation counselling given; sodium and monitoring plan discussed; no antidepressant in bipolar without CMHT review
- Patient-led consultation: open question used as the genuine opener; patient's narrative fully explored before moving to structured questioning or PHQ-9
- ICE fully explored: all three components (Ideas, Concerns, Expectations) elicited, acknowledged, and explicitly referenced when presenting the management plan to the patient
- Empathy and non-stigmatising language: depression framed as a medical biological condition throughout; patient not made to feel weak, flawed, or judged; compassion evident
- Shared decision-making: treatment options (medication vs therapy vs combined vs watchful waiting) presented with evidence; patient's preference genuinely sought and respected in the final plan
- Understanding checked: diagnosis and key messages (onset, discontinuation, safety-netting) explained and patient asked to confirm understanding; checking done naturally not formulaically
- Proactive psychosocial discussion: driving, work fit note, sexual side effects, and 24-hour crisis resources raised proactively without waiting for the patient to raise them
Who you are
Marcus, 41, secondary school history teacher. Off sick 10 days with "exhaustion." Married, two children (7 and 11). No past mental health history. No regular medications. Alcohol increasing — currently 20–25 units/week (up from ~12); uses it to switch off. Almost cancelled this appointment.
Hidden agenda
Father was on fluoxetine ("Prozac") for 20 years and "was like a zombie — he wasn't himself at all." Marcus is terrified of becoming emotionally numb. He wants a sick note to buy time, not tablets. He is ashamed of not coping, especially given his job involves supporting struggling teenagers.
Symptoms if asked directly
- Low mood most days for 6 weeks ("flat, not sad")
- Can't enjoy anything he used to — football, cooking
- Waking at 3–4am and can't get back to sleep
- Concentration "shot" — can't plan lessons
- Appetite poor — down about 4kg
- No psychotic features; no prior episodes
Hidden disclosures (only if asked directly)
- Passive SI: "Sometimes I think everyone would be better off without me" — discloses only if asked calmly and directly; visibly relieved to be asked
- Paracetamol stockpile: 8–10 packets at home; not a plan, just "accumulated" — discloses only if GP asks specifically about means access
- Alcohol units: Initially "a bit more than usual" — gives 20–25 only if pushed for a number, non-judgementally
Resolution: Accept the management plan only when: (1) the father's Prozac story is addressed directly and accurately ("modern SSRIs are different to what your father took"); AND (2) suicidal ideation has been asked and explored; AND (3) specific 1–2 week follow-up named and confirmed; AND (4) means restriction (paracetamol) discussed if stockpile was disclosed.
- Active SI with plan, intent, and means access
- Recent serious suicide attempt
- Postpartum psychosis (days post-delivery)
- Organic neurology with mood change
- Severe psychotic depression — dangerous behaviour
- Passive SI (no plan) — safety plan + same-day review
- PHQ-9 ≥20 with poor social support
- Suspected bipolar disorder — CMHT before any Rx
- EPDS ≥13 postnatal — perinatal MH team
- Severe self-neglect (not eating/drinking)
- Mild (PHQ-9 5–9): NHS Talking Therapies Step 2, exercise, watchful waiting
- Moderate (PHQ-9 10–14): Sertraline 50mg + NHS Talking Therapies Step 3
- Subthreshold (<5): psychosocial, lifestyle, review
- Adjustment disorder: watchful waiting, counselling
| Drug / Situation | Test | Timing | Action threshold |
|---|---|---|---|
| All SSRIs (elderly / diuretics) | Serum Na⁺ | Baseline + 2 wks post-start | Na⁺ <130: withhold SSRI, investigate SIADH, medical review. Recheck after dose change. |
| Citalopram / Escitalopram | 12-lead ECG | Baseline if any QTc risk | QTc >450ms (M) / >470ms (F): switch to sertraline. QTc >500ms: stop + cardiologist. |
| Venlafaxine ≥150mg | Blood pressure | Baseline · 1 month · 3-monthly | Diastolic >90 sustained: reduce dose or switch. Check BP at every prescription review. |
| Mirtazapine | BMI + weight | Baseline · 3 months · 6 months | >7% weight gain: dietary review; consider switch. FBC if fever/sore throat (agranulocytosis). |
| Quetiapine augmentation | Fasting glucose + lipids + BMI | Baseline · 3 months · annually (NICE) | HbA1c ≥48: diabetes management. Annual metabolic panel is NICE-mandated for all antipsychotics. |
| All antidepressants — 18–25 inclusive or ↑suicide risk | Suicidal ideation (clinical) | 1 week (2 weeks for others) | Any worsening SI or agitation: same-day urgent GP review. NG222 review timing; MHRA warning applies to the activation risk. |
| All SSRIs / SNRIs | PHQ-9 | Baseline · 4–6 wks · 3 months | <50% reduction at 6 wks: dose increase first. Still inadequate at 3 months: switch class. |
→ "Tell me in your own words what's been going on" — always first. PHQ-9 is a tool, not an opener.
→ Ask calmly and directly. PHQ-9 Q9 does not replace verbal exploration. Not asking is a patient safety failure.
→ "Have you ever had a period of feeling unusually high?" — mandatory before any antidepressant is discussed.
→ Elicit ICE first. The "Prozac zombie" or addiction fear must be corrected before prescribing — otherwise the patient will stop covertly.
→ Name it explicitly: "Takes 4–6 weeks — do not stop at 2 weeks thinking it hasn't worked."
→ Name symptoms + 24-hr resource: "If SI worsens — Samaritans 116 123, or call us same day, or A&E."
→ "I'll book you in to see me in 1–2 weeks" — NICE NG222 mandatory requirement. State it explicitly.
→ Check interactions (domperidone, antipsychotics, macrolides). Use sertraline if any QTc-prolonging co-prescription present.
→ NICE NG222: watchful waiting, guided self-help, NHS Talking Therapies Step 2, exercise first. SSRI is NOT first-line for mild depression.