Selective serotonin re-uptake inhibitors (SSRIs) are inappropriate to use in patients aged 65 years and older with current or recent significant hyponatraemia i.e. serum Na+ < 130 mmol/l (risk of exacerbating or precipitating hyponatraemia).

   Tricyclic antidepressants (TCAs) are inappropriate to use in patients aged 65 years and older:

  • if they have dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism, or prior history of urinary retention (risk of worsening these conditions)
  • for initiation as first-line antidepressant treatment (higher risk of adverse drug reactions with TCAs than with SSRIs or SNRIs).
  • if concomitant use of two or more drugs with antimuscarinic/anticholinergic properties (e.g. bladder antispasmodics, intestinal antispasmodics, tricyclic antidepressants, first generation antihistamines) (risk of increased antimuscarinic/anticholinergic toxicity)

All patients should be told about the side effects of antidepressants, particularly the possibility of an increase in suicidality, restlessness or agitation

All patients should be informed about the withdrawal (discontinuation) effects of antidepressants

For people with learning difficulties initiate treatment with low doses and titrate cautiously with frequent monitoring for side effects

Additional resources

British Association for Psychopharmacology Evidence-based guidelines for treating depressive disorders with antidepressants

NICE Summary of all guidance on depression

NICE CG90 The treatment and management of depression in adults

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