Suggested Medication Considerations before Referral  from Primary to  Secondary CMHT Care for Depression


Full treatment guidelines for primary care can be found at www.nice.org.uk/CG90 

Before referring, unless significant suicide risk or pregnant :


1.    Please check TFTs, FBC, UEC, LFT’s, glucose and CRP if clinically indicated. Consider IAPT services.


2.    Prescribe an SSRI and increase to the maximum dose. We suggest using Sertraline however all the SSRIs are acceptable. Sertraline can now be prescribed at higher equivalent doses than Citalopram; Fluoxetine is very long acting and difficult to change or combine; Paroxetine causes agitation and is more difficult to stop than other SSRIs.


3.    Please then consider prescribing the maximum daily dose of 375mg Venlafaxine (unless there is a personal or family history of bipolar disorder) using the chart below.



Commonly prescribed antidepressants can be changed using the following regime:





Week 1


Week 2


Week 3


Week 4


From Sertraline

to Venlafaxine

Sertraline 100mg*

Venlafaxine m/r 37.5mg

Sertraline 50mg

Venlafaxine m/r 37.5mg

Sertraline  25mg

Venlafaxine m/r 75mg

Stop Sertraline

Venlafaxine m/r 112.5mg






From Citalopram to Venlafaxine

Citalopram 20mg

Venlafaxine m/r 37.5mg

Citalopram 10mg

Venlafaxine m/r 37.5mg

Citalopram 5mg


Venlafaxine m/r 75mg

Stop Citalopram


Venlafaxine m/r







From Fluoxetine to Venlafaxine

Fluoxetine 20mg

Fluoxetine 10mg

Fluoxetine 5mg

Stop Fluoxetine

Start Venlafaxine 37.5mg


Venlafaxine can then be increased by 37.5mg a week or 75mg every two weeks.


Evidence: STAR –D trial - 2786 chronically depressed patients who received Citalopram 40mg a day, remission which was defined as a 50% reduction in symptoms score was only seen in 30%.  Of those who did not recover and were switched to Venlafaxine, 25% then recovered.


*If Rx over 100mg a day of Sertraline, reduce by 50mg a week and start changeover when dose is down to 100mg a day.


COST NOTE: m/r capsules >> m/r tablets >> plain tablets

but m/r thought better tolerated