Antidepressants (SSRIs, SNRIs, tricyclics, MAOIs)

1. Introduction

Version followed: current US FDA prescribing information for one representative product per class (sertraline/Zoloft, label revised 8/2023, for SSRIs; venlafaxine extended-release/Effexor XR, revised 8/2022, for SNRIs; amitriptyline tablets, revised 05/2025, for tricyclics; phenelzine/Nardil, label revised February 2009, for MAOIs), the FDA's paediatric suicidality safety page, the NICE guideline NG222 Depression in adults (June 2022, amended to December 2025) for the UK care pathway, and Health Canada's 2021 safety review on persistent sexual dysfunction. Labels differ between products and countries; the client's own product leaflet or Medication Guide is the authoritative document for that client. [source: FDA labels and pages listed in Sources; NICE NG222 update information]

What this is. Antidepressants are prescription medicines. They are prescribed and managed by a doctor or other authorised prescriber (for example a GP, psychiatrist or other prescribing clinician), not by a psychotherapist. This guide is therefore written for the psychotherapist working alongside the prescriber. It covers (1) what official labelling and guidelines say about how these medicines are delivered and monitored, at a descriptive level only, and (2) the psychotherapist's own interventions: referral, collaborative care, psychoeducation, support for informed consent, conversations about adherence and ambivalence, passing on side effects and warning signs, crisis planning and integrating psychotherapy. It contains no doses, schedules, switching, combining or stopping instructions. Any question about starting, changing or stopping a medicine goes to the prescriber. [synthesis]

The four classes named here. Selective serotonin reuptake inhibitors (SSRIs, e.g. sertraline), serotonin–norepinephrine reuptake inhibitors (SNRIs, e.g. venlafaxine), tricyclic antidepressants (TCAs, e.g. amitriptyline) and monoamine oxidase inhibitors (MAOIs, e.g. phenelzine). Health Canada's review lists citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone and vortioxetine as SSRIs (as Health Canada groups them) and desvenlafaxine, duloxetine, levomilnacipran and venlafaxine as SNRIs. [source: Health Canada SSR 2021] Formulations named in the labels used here include tablets, film-coated tablets, extended-release capsules and an oral solution. [source: Zoloft, Effexor XR, amitriptyline labels]

Regulatory status. In the US all four are FDA-approved prescription drugs with a class boxed warning on suicidal thoughts and behaviours in children, adolescents and young adults, plus a required Medication Guide. [source: FDA suicidality page; labels] Paediatric approval is limited: the FDA page lists fluoxetine (Prozac) for paediatric major depression, and fluoxetine, sertraline, fluvoxamine and clomipramine for paediatric OCD; amitriptyline, venlafaxine ER and phenelzine labels say they are not approved for paediatric use. [source: FDA suicidality page; amitriptyline, Effexor XR, Nardil labels] In the UK, NICE NG222 places SSRIs and SNRIs first-line among antidepressants because of tolerability, a TCA where someone has responded to one before and has no contraindications, and recommends CBT plus an antidepressant as an effective option for more severe depression. [source: NICE NG222 rationale] UK MHRA product information is not drawn on in this guide. [uncertain]

Core idea of how change happens (for the therapist's purposes). The labels describe the drugs' pharmacology; this guide does not explain mechanism of action. What matters for the psychotherapist is that the medicine is one component of care chosen by the client with the prescriber, that the early weeks and any change in treatment are periods of heightened risk and need closer observation, and that psychotherapy can run alongside it. [source: FDA suicidality page; NICE NG222 rationale; synthesis]

2. Framework

There is no psychotherapist "protocol" for antidepressants. The phases below follow the course of medication treatment as the labels and NICE describe it, with the psychotherapist's task in each. Prescribing appointments run on the prescriber's schedule; psychotherapy sessions keep their own format and frequency. [synthesis]

Phase A: Considering medication. Goal: the client can make an informed choice with the prescriber. NICE says people want realistic information about benefits and harms, how long the drug takes to work, how long treatment lasts, what withdrawal involves and how they will be monitored, and that for less severe depression the choice between options is personal. Therapist task: recognise when a medical review is warranted, refer, help the client prepare questions. Move on when the client and prescriber have made a decision (including a decision not to use medication). [source: NICE NG222 rationale; synthesis]

Phase B: Starting and early treatment. Goal: safety and early side-effect detection. The labels and FDA require close monitoring of all treated patients for clinical worsening, suicidality and unusual changes in behaviour, especially during the first few months of treatment and at dose changes, with families and caregivers observing daily and staying in contact with the prescriber. NICE amended NG222 in April 2023 to clarify an earlier first review for people aged 18 to 25 or where there is a particular concern about suicide risk, and in December 2025 to stress regular reviews. Therapist task: increase attention to risk, activation, side effects and adherence; pass on concerns promptly. [source: FDA suicidality page; amitriptyline label; NICE NG222 update information]

Phase C: Continuation and maintenance. Goal: recovery, relapse prevention, integrated therapy. NICE says people at higher risk of relapse should be considered for continued treatment, with follow-up so treatment does not continue indefinitely without review. Therapist task: integrate the psychological work, track mood and functioning, support ongoing reviews. [source: NICE NG222 rationale]

Phase D: Stopping, when the client and prescriber decide on it. Goal: the client feels supported and symptoms are recognised. The labels warn against abrupt stopping and describe discontinuation symptoms; NICE notes people want clinicians to acknowledge their fears about withdrawal. Therapist task: emotional support, helping the client notice and report symptoms, never advising on the process itself. [source: Zoloft, Effexor XR, Nardil labels; NICE NG222 rationale]

Phase E: After treatment ends. Goal: maintain gains; recognise relapse, protracted withdrawal or persistent side effects and route them to the prescriber. [source: Effexor XR label; Health Canada SSR 2021; synthesis]

Criteria for movement between phases are medical decisions made by the client and prescriber. The therapist's own "movement criteria" are triggers for contact with the prescriber (see 4.B2) and for an urgent or emergency response (see 4.B7, 4.B8). [synthesis]

3. Guiding principles

Scope of practice. The psychotherapist does not prescribe, recommend a specific drug, or advise on dose, timing, switching, combining or stopping. Meaning: every medication question ends with "take this to your prescriber", and you help the client do that. [synthesis]
Route to the prescriber, early. Meaning: when in doubt, contact (with consent) rather than wait; the labels place responsibility for monitoring on the prescriber and require families and patients to communicate with them. [source: FDA suicidality page; synthesis]
Respect for client choice. NICE describes treatment choice as personal and stresses meaningful discussion. Meaning: you stay neutral on whether the client takes medication, and you protect their right to decide with the prescriber. [source: NICE NG222 rationale]
Accurate, sourced psychoeducation. Meaning: you describe what the label or patient leaflet says, point the client to their Medication Guide, and do not offer personal opinions about particular drugs. [source: FDA suicidality page (Medication Guide requirement); synthesis]
Heightened vigilance at start and change. Meaning: in the first months and around any change, ask about mood, agitation, sleep, impulsivity and suicidal thoughts every session. [source: FDA suicidality page; Nardil label]
Take side effects seriously, including sexual ones. Labels ask prescribers to enquire about sexual function before and during treatment. Meaning: ask about side effects plainly, normalise reporting, and pass them on. [source: Zoloft, Effexor XR labels]
Combination is legitimate. NICE recommends CBT plus an antidepressant as an option for more severe depression and for symptoms that have not responded to an antidepressant alone. Meaning: medication is not a sign that therapy has failed, and therapy is not a reason to stop medication. [source: NICE NG222 rationale]
Acknowledge fears about withdrawal. Meaning: listen to and validate fears about stopping without either dismissing or amplifying them; route the practical questions to the prescriber. [source: NICE NG222 rationale]
Consent-based collaboration. Meaning: get explicit consent before sharing information with the prescriber, except where your duty in an emergency overrides it under your professional code and local law. [synthesis]
Safety first. Meaning: current risk assessment and safety planning are part of every course of treatment that involves an antidepressant, with attention to medicine storage because some classes are dangerous in overdose. [source: amitriptyline label; synthesis]
Document. Meaning: record what the client reported, what you advised (always: discuss with the prescriber), and any contact you made. [synthesis]

4. Intervention inventory

Part A describes how the treatment is delivered and monitored, as the official labelling and NICE describe it, so that you can understand what the client is going through and what to listen for. It is descriptive only and is not a guide to prescribing. Part B gives the psychotherapist's own interventions. [synthesis]

Part A. The treatment as labelling and guidelines describe it

A1. Who prescribes and how treatment is reviewed

Purpose: know who holds clinical responsibility and what reviews the client should expect.
What sources say: the prescriber weighs the risk of suicidality against clinical need, monitors all patients closely and counsels patients, families and caregivers on benefits and risks; families should observe daily and communicate with the prescriber. Prescriptions should be written for the smallest quantity consistent with good management, to reduce overdose risk. [source: FDA suicidality page; amitriptyline label] NICE says people value knowing how they will be monitored and being able to track their own symptoms; its December 2025 amendment stresses regular reviews and gives timing for the first review (not reproduced here). [source: NICE NG222 rationale; update information]
Watch for: a client who does not know who their prescriber is or when the next review is; help them find out. [synthesis]

A2. Boxed warning: suicidal thoughts and behaviours in young people

Purpose: the class-wide boxed warning is the single most important safety message for a therapist.
What sources say: antidepressants increased the risk of suicidal thinking and behaviour compared with placebo in short-term trials in children, adolescents and young adults. The amitriptyline label states the risk relative to placebo was higher under 18 and at ages 18 to 24, not increased at 25 to 64, and reduced at 65 and over, and that depression itself carries a suicide risk. [source: amitriptyline label] In the pooled paediatric analysis behind the original warning (nine drugs, 24 short-term trials, over 4,400 patients) the average risk of suicidality was 4% on drug versus 2% on placebo, and no suicides occurred. [source: FDA suicidality page] Signs families and patients are asked to watch for and report include anxiety, agitation, panic, insomnia, irritability, hostility, impulsivity, hypomania, mania, worsening depression and suicidal thoughts, especially early in treatment and when the dose goes up or down. [source: Nardil label patient counselling; FDA suicidality page]
Watch for: in a client under 25, or any client early in treatment or after a change, new restlessness, sudden energy, agitation, sleeplessness or a sudden lift in mood alongside unchanged hopelessness. [synthesis]

A3. Screening for bipolar disorder before treatment

What sources say: labels ask prescribers to screen for a personal or family history of bipolar disorder before starting, because an antidepressant may trigger a mixed or manic episode; a depressive episode may be the first presentation of bipolar disorder. [source: Zoloft, Effexor XR, amitriptyline labels]
Therapist relevance: you may hold history the prescriber lacks (past hypomanic periods, family history). With consent, pass it on. Report signs of hypomania or mania during treatment. [synthesis]

A4. Serotonin syndrome

What sources say: serotonin syndrome can occur with an SSRI, SNRI or TCA alone and more often with other serotonergic medicines; the Zoloft label lists examples including triptans, opioids, tramadol and St John's wort, and MAOIs including linezolid and intravenous methylene blue. Symptoms the Zoloft label describes: mental status changes (agitation, hallucinations, delirium, coma), autonomic instability (fast heart rate, unstable blood pressure, high temperature), neuromuscular signs (tremor, rigidity, overactive reflexes), seizures and gastrointestinal symptoms. The labels say treatment should be discontinued and supportive care given if it occurs, a decision for the medical team. The amitriptyline label calls it potentially life-threatening. [source: Zoloft, Amitriptyline, Effexor XR labels]
Watch for: a client who reports these symptoms, especially after a new medicine, supplement or recreational drug. This is a same-day medical matter (see B7). [synthesis]

A5. Discontinuation (withdrawal) symptoms

What sources say: symptoms reported after stopping, especially abruptly, include nausea, sweating, dysphoric mood, irritability, dizziness, "electric shock" sensations, anxiety, insomnia and seizures (Zoloft label); the Effexor XR label adds agitation, confusion, fatigue, flu-like symptoms, headache, nightmares, sensory disturbances, tremor, vertigo and vomiting, and reports serious, protracted reactions after marketing, including suicidal thoughts and aggression. The labels say not to stop abruptly and that any reduction is planned with the prescriber. [source: Zoloft, Effexor XR labels] The Nardil label describes an uncommon withdrawal syndrome after abrupt stopping, typically starting within days, ranging from agitation and vivid nightmares to psychosis and convulsions. [source: Nardil label] NICE notes some antidepressants are associated with more withdrawal symptoms than others, that drug-specific data on incidence and severity are lacking, and that people want clinicians to acknowledge their fears. [source: NICE NG222 rationale]
Therapist relevance: withdrawal symptoms can be mistaken for relapse, and vice versa. You do not decide which it is; you help the client describe what is happening (onset, physical versus mood symptoms) to the prescriber. [synthesis] The Royal College of Psychiatrists' 2020 position, as summarised by its immediate past president, is that withdrawal symptoms are often mild and short-lived but for some people more severe and much longer-lasting, and that ongoing monitoring is needed to tell withdrawal from emerging relapse; the College's free patient resource on stopping antidepressants is endorsed by the Royal College of General Practitioners and the Royal Pharmaceutical Society. [source: Burn, The BMJ Opinion, 25 September 2020] NICE's recommendation text on stopping is not summarised here. [uncertain]

A6. MAOI-specific requirements (phenelzine as example)

Diet (tyramine): the label contraindicates food high in tyramine. It lists aged cheeses, pickled herring, liver, yeast extract (including brewer's yeast in large amounts), dry sausage (including Genoa and hard salami, pepperoni and Lebanon bologna), broad (fava) bean pods, yogurt, beer and wine, high-protein food that has undergone protein breakdown, and excessive caffeine and chocolate. The Warnings section adds sauerkraut, meat extracts, alcohol-free or reduced-alcohol beer and wine, and spoiled or improperly stored protein foods. It allows cottage cheese and cream cheese. Lists vary between MAOI products. [source: Nardil label]
Medicines: contraindicated with sympathomimetics (including amphetamines, cocaine, methylphenidate, dopamine, epinephrine, norepinephrine and L-dopa), dextromethorphan, CNS depressants including alcohol, meperidine, other MAOIs, bupropion, buspirone and serotonergic drugs (SSRIs, venlafaxine); avoid over-the-counter cold, cough, decongestant, hay fever, sinus, asthma inhaler, appetite-suppressant and "pep" products and L-tryptophan, during treatment and for a period after stopping as the label specifies. The label sets required intervals between an MAOI and other antidepressants; these are for the prescriber and are not reproduced here. Patients should tell every doctor and dentist they take it; elective surgery under general anaesthesia and local anaesthetics with vasoconstrictors are contraindicated. [source: Nardil label]
Hypertensive crisis signs to report at once: headache at the back of the head that may spread forward, palpitations, neck stiffness or soreness, nausea, vomiting, sweating (sometimes with fever or cold clammy skin), dilated pupils, sensitivity to light, fast or slow heartbeat, and constricting chest pain; intracranial bleeding has been reported. [source: Nardil label]
Other: postural hypotension (dizziness on standing). [source: Nardil label]

A7. Tricyclic-specific warnings (amitriptyline as example)

What sources say: contraindicated with MAOIs and cisapride and in the acute recovery phase after a heart attack; arrhythmias, fast heart rate and prolonged conduction reported; close monitoring in cardiovascular disease; atropine-like (anticholinergic) effects, so caution in urinary retention and risk of an angle-closure glaucoma attack; caution with a seizure history; enhanced effects of alcohol and other CNS depressants; impaired ability to drive or do hazardous tasks; older people more sensitive to anticholinergic effects, with greater fall and low-sodium risk. [source: amitriptyline label]
Overdose: the label states "Deaths may occur from overdosage with this class of drugs"; critical signs include heart rhythm disturbance, severe low blood pressure, convulsions and CNS depression including coma, plus confusion, agitation, hallucinations, dilated pupils, rigidity and temperature disturbance. Overdose needs emergency hospital care. [source: amitriptyline label]
Therapist relevance: this is central to safety planning for a client with suicidal thoughts (see B8). [synthesis]

A8. SNRI-specific warnings (venlafaxine ER as example)

What sources say: dose-related rises in blood pressure and sustained hypertension; blood pressure should be monitored before and regularly during treatment; rare interstitial lung disease and eosinophilic pneumonia (progressive breathlessness, cough or chest discomfort need prompt evaluation); false-positive urine immunoassay screens for PCP and amphetamine, including for several days after stopping. [source: Effexor XR label]

A9. Warnings shared across SSRIs and SNRIs

Bleeding: increased risk with aspirin, NSAIDs, warfarin and other anticoagulants or antiplatelets, from bruising to life-threatening haemorrhage. [source: Zoloft, Effexor XR labels]
Low sodium (hyponatraemia): more likely in older people, those on diuretics or volume-depleted; signs include headache, confusion, weakness and unsteadiness that can lead to falls; severe cases can cause seizures, coma or death. [source: Zoloft label]
Angle-closure glaucoma: avoid in untreated anatomically narrow angles. [source: Zoloft, Effexor XR labels]
QT prolongation (sertraline postmarketing reports) and seizures (use with caution). [source: Zoloft label]
Sexual dysfunction: in men, delayed or absent ejaculation, reduced libido and erectile dysfunction; in women, reduced libido and delayed or absent orgasm; prescribers should ask about sexual function before and during treatment. [source: Zoloft, Effexor XR labels] Health Canada (January 2021) could neither confirm nor rule out a causal link between stopping SSRIs/SNRIs and persistent sexual dysfunction; some reported symptoms lasted weeks to years; it recommended labels be updated so professionals inform patients of the possibility. [source: Health Canada SSR 2021] In the EU, the EMA's Pharmacovigilance Risk Assessment Committee concluded in May 2019 that SSRI and SNRI product information should include persistent sexual dysfunction after withdrawal. [source: Medsafe MARC paper, 12 September 2019] In the UK, product information and patient leaflets have mentioned since 2019 that long-lasting sexual dysfunction has been reported to continue despite stopping; the MHRA says "PSSD" is not a recognised regulatory term, but symptoms can be reported as suspected side effects through the Yellow Card scheme. [source: MHRA FOI 23/059 response, April 2023]
Pregnancy: the Zoloft label mentions possible withdrawal-type symptoms or persistent pulmonary hypertension in the newborn, and a pregnancy exposure registry. Pregnancy decisions belong with the prescriber and maternity team. [source: Zoloft label]
Other: the Zoloft label notes false-positive urine benzodiazepine screens; the oral solution contains alcohol and is contraindicated with disulfiram; allergic reactions should be reported. [source: Zoloft label]

A10. UK care pathway (NICE NG222)

What sources say: treatment choice involves meaningful discussion and a trusting relationship; for less severe depression NICE offers a table of options and the choice is personal; for more severe depression CBT combined with an antidepressant is effective and cost-effective; combination is also recommended where symptoms have not responded to an antidepressant alone; SSRIs and SNRIs first-line among antidepressants; combinations of antidepressants with each other or with other agents need specialist advice; for psychotic depression combination treatment is reviewed regularly. [source: NICE NG222 rationale] NICE's guidance on medicines associated with dependence or withdrawal symptoms (NG215) and on shared decision-making (NG197) are referenced by the NHS Specialist Pharmacy Service for deprescribing conversations. [source: SPS deprescribing page; the content of NG215 and NG197 is not summarised here: uncertain]
Cross-reference: ketamine-assisted psychotherapy and psychedelic-assisted therapy are covered in Domain VII; esketamine nasal spray is a separate entry. [synthesis]

Part B. The psychotherapist's interventions

All Part B procedures are general good practice drawn together for this guide [synthesis], anchored where stated to the labelling and NICE. None comes from a named founder or manual.

B1. Medication-aware assessment

Purpose: know what the client takes and how it is going, without straying into prescribing. Use at intake and whenever medication changes.
Steps: (1) Ask which medicines, supplements and recreational substances the client uses, and who prescribes. (2) Ask when the antidepressant was started or last changed (this tells you if they are in a higher-vigilance period). (3) Ask about side effects, including sleep, agitation and sexual function, and whether the prescriber knows. (4) Ask how the client feels about the medicine and how they actually take it. (5) Note history relevant to label warnings that the prescriber may not know: past hypomanic or manic periods, family history of bipolar disorder, previous overdoses, heavy alcohol use. (6) Record, and ask consent to share where relevant. [synthesis; bipolar screening and alcohol cautions per Zoloft and amitriptyline labels]
Example language (illustrative): "I'm not the person who prescribes or adjusts medication, but it helps me to know what you're taking and how it's been for you, so I can work alongside your doctor."
Watch for: reluctance to disclose (shame, fear of judgement); a client in the first months or just after a change, who needs closer risk monitoring.

B2. Recognising when to suggest a medical review

Purpose: act as an early-warning link to the prescriber.
Steps: suggest the client contacts the prescriber soon (and offer to help) when there is: new or worse suicidal thinking; new agitation, restlessness, insomnia, irritability, impulsivity or hostility; signs of hypomania or mania; side effects the client finds hard to bear, including sexual ones; symptoms after missed doses or stopping; signs of low sodium in an older client (confusion, unsteadiness, falls); unusual bruising or bleeding; a new medicine or supplement started elsewhere; pregnancy or planned pregnancy; lack of improvement over time; the client wanting to stop or change. [source: warning lists in Zoloft, Effexor XR, amitriptyline, Nardil labels; triggers assembled as synthesis]
Example language (illustrative): "What you're describing is the kind of thing your prescriber would want to hear about. Would you be willing to call them this week? We could work out together what to say."
Watch for: the client following through; if not, explore barriers next session.

B3. Referral and collaborative care

Purpose: connect psychotherapy and prescribing so care is coordinated.
Steps: (1) Agree with the client what will be shared and why; record consent. (2) Contact the prescriber in writing or by phone with: your role and frequency of sessions, the client's presenting concerns, observations relevant to medication (mood trend, side effects the client reported, risk), and the client's questions. (3) Offer, never request, specific medication actions. (4) Agree how you will reach each other if risk rises. (5) Where no prescriber exists and the client wants a medical opinion, help them book with their GP or primary care clinician, or refer under your service's pathway. [synthesis; collaborative stance consistent with NICE emphasis on discussion and review, NG222 rationale]
Example language (illustrative, to prescriber): "With [client]'s consent I'm letting you know she has described new restlessness and poor sleep since her review two weeks ago, and is worried about it. I have not advised any change to her medication; she plans to contact you."
Watch for: information flowing both ways; avoid becoming the client's go-between for every medical question.

B4. Psychoeducation from official sources

Purpose: help the client understand their treatment accurately, reducing fear and misinformation.
Steps: (1) Ask what the client already knows and believes. (2) Show them where the Medication Guide or patient leaflet is and what it covers. (3) Describe in plain terms the key items for their class: the young-person suicidality warning if relevant; early side effects and that improvement can take time; serotonin syndrome signs; not stopping abruptly and why; for MAOIs, the diet and medicine restrictions and hypertensive crisis signs; for TCAs, overdose danger and dizziness/falls; for SNRIs, blood pressure monitoring. (4) Make clear you are describing the leaflet, not giving medical advice, and send detailed questions to the prescriber or pharmacist. [source: FDA Medication Guide requirement; labels A2–A9; NICE NG222 rationale on information people want]
Example language (illustrative): "Your leaflet says that in the first weeks some people feel more restless or agitated. If that happens to you, it's worth telling your doctor straight away, and telling me too."
Watch for: the client leaving more anxious than they came; balance safety information with the fact that many people take these medicines without serious problems [synthesis].

B5. Supporting informed consent and shared decision-making

Purpose: help the client take part fully in decisions made with the prescriber. NICE describes people wanting realistic information on benefits, harms, time to work, treatment length, withdrawal and monitoring. [source: NICE NG222 rationale]
Steps: (1) Explore the client's values, hopes and fears about medication and about therapy. (2) Help them write a question list for the prescriber (e.g. expected benefits, common side effects, when they will be reviewed, what to do if they feel worse, what stopping would involve later, interactions with other medicines they take). (3) Rehearse raising concerns if they find doctors hard to talk to. (4) Afterwards, review what they understood and what remains unclear. (5) Respect the decision, including a decision to decline medication. [synthesis]
Example language (illustrative): "It sounds like you'd like to know how long you might be on it and what coming off would be like. Shall we put those at the top of your list for your appointment?"
Watch for: pressure from family, employer or you; the decision should be the client's.

B6. Adherence and ambivalence conversations

Purpose: explore mixed feelings without steering the client towards taking or not taking the medicine.
Steps: (1) Ask neutrally how the client actually takes it ("Many people miss doses or take it differently from the label; how is it for you?"). (2) Reflect both sides of the ambivalence (benefits noticed, costs, meaning of taking a medicine, stigma). (3) Explore what the client wants to do and what information they need. (4) Whatever the direction, bring it to the prescriber: "That sounds like something to decide with your doctor." (5) If the client has already stopped or changed on their own, do not advise restarting or stopping; encourage prompt contact with the prescriber and monitor for discontinuation symptoms and mood change. [synthesis; no-abrupt-stopping message per Zoloft, Effexor XR, amitriptyline labels; NICE expects choice and information to improve adherence, NG222 rationale]
Example language (illustrative): "Part of you wants to stop because of the side effects, and part of you is scared the low mood will come back. Both make sense. Your prescriber is the person who can go through the options with you. What would you want them to know?"
Watch for: your own views about medication leaking into the conversation; a rupture if the client hears judgement (see Section 5).

B7. Monitoring and passing on side effects and warning signs

Purpose: make sure what the client tells you reaches the prescriber at the right speed.
Steps: (1) In higher-vigilance periods, ask briefly each session about mood, sleep, agitation, suicidal thoughts and side effects. (2) Suggest the client keeps a simple daily log of mood and any physical symptoms to take to reviews; NICE notes people value tracking their own symptoms. (3) Triage: routine (tell the prescriber at or before the next review); soon (contact the prescriber within days: troublesome side effects, sexual side effects, signs of low sodium); urgent or emergency (same-day medical help or emergency services: suspected serotonin syndrome; MAOI hypertensive crisis signs such as severe headache, chest pain, stiff neck; signs of overdose; signs of a severe allergic reaction; mania with risk; imminent suicide risk). (4) Record what you passed on and to whom. [source: warning signs per Zoloft, Effexor XR, amitriptyline, Nardil labels; NICE NG222 rationale on symptom tracking; triage levels are synthesis]
Example language (illustrative): "The muscle twitching, sweating and confusion you're describing since starting the new painkiller need checking today. Let's call your doctor's urgent line now, or if you can't reach them, emergency services."
Watch for: under-reporting of sexual side effects; older clients' confusion being dismissed as mood.

B8. Suicide risk monitoring and crisis/safety planning

Purpose: keep the client safe, especially early in treatment, after changes, and in clients under 25.
Steps: (1) Assess suicidal thinking directly and regularly, following your service's current risk-assessment practice. (2) Build or update a collaborative safety plan: warning signs, coping strategies, people and places for support, professional and crisis contacts, and the prescriber's contact. (3) Lethal-means counselling for medicines: discuss safe storage, not stockpiling, returning unused medicines to a pharmacy, and whether someone else could hold medicines during a crisis; with consent, tell the prescriber about current suicide risk so they can consider supply quantities (the FDA asks for the smallest quantity consistent with good management, and the amitriptyline label warns deaths can occur from overdose of this class). (4) For young clients, involve parents or carers as appropriate; the labels ask families to observe daily and contact the prescriber. (5) Agree what you will do if risk rises between sessions. [source: FDA suicidality page; amitriptyline label; steps are synthesis]
Example language (illustrative): "Since your medicines could be dangerous if you took too many when you're feeling this bad, could we think together about where they're kept and who could look after them for now?"
Watch for: a sudden calm after agitation; giving away possessions; increased access to medicines.

B9. Integrating psychotherapy before, during and after medication

Purpose: make the two treatments work together.
Steps: (1) Before: help the client clarify goals for each treatment. (2) During: continue your own evidence-based therapy as usual (NICE names CBT plus an antidepressant for more severe depression); track changes in energy, sleep and mood to time activity-based or cognitive work; notice if the client credits all change to the pill or to therapy, and explore their own part in the change. (3) Around stopping: strengthen relapse-prevention skills and plan for early warning signs. (4) After: consolidate gains and plan how to seek help early. [source: NICE NG222 rationale on combination; steps are synthesis]
Example language (illustrative): "You've got a bit more energy now. That gives us a chance to try some of the things that felt impossible a month ago."
Watch for: emotional blunting reducing access to feelings in therapy; raise it with the client as something to mention to the prescriber, not as a reason to stop.

B10. Supporting the stopping phase

Purpose: emotional and practical support while the client and prescriber manage stopping.
Steps: (1) Check the plan is agreed with the prescriber; you do not set or alter it. (2) Acknowledge fears about withdrawal (NICE notes people want this). (3) Help the client notice and record symptoms and when they began, so the prescriber can judge whether they are discontinuation symptoms or a return of depression. (4) Increase session frequency or check-ins if possible during this period. (5) Revisit the safety plan; the Effexor XR label reports protracted reactions including suicidal thoughts and aggression. (6) If symptoms are severe or prolonged, encourage contact with the prescriber. [source: NICE NG222 rationale; Effexor XR label; steps are synthesis]
Example language (illustrative): "It's worth writing down the dizziness and the 'zaps' and when they started, alongside your mood each day. That will help your doctor work out what's going on."
Watch for: the client being told symptoms are 'just relapse' or 'just withdrawal' without assessment; support them to ask for a review.

B11. Particular groups

Young people and their families: the boxed warning applies; most antidepressants lack paediatric approval for depression (see Section 1); agree with family and young person how concerns will be passed on. [source: FDA suicidality page]
Older adults: higher risk of low sodium, falls and anticholinergic effects (TCAs); treat new confusion as a medical question. [source: Zoloft, amitriptyline labels]
People with possible bipolar disorder: pass on relevant history; report hypomanic signs. [source: labels A3]
Pregnancy and breastfeeding: refer questions to the prescriber and maternity team; do not reassure or alarm. [source: Zoloft, Nardil labels; synthesis]
People on MAOIs: support practical planning around eating out, travel and buying medicines; remind them to tell every clinician. [source: Nardil label; synthesis]
Example language (illustrative): "Because you're on an MAOI, it's worth telling the dentist and the pharmacist too. Shall we add that to your list for appointments?" [synthesis]
Watch for: a group-specific risk going unreported because the client assumes another clinician already knows; check who has been told. [synthesis]

B12. Support after treatment ends

Purpose: maintain recovery and catch problems early.
Steps: review relapse-prevention plan; agree who to contact and how if mood drops; ask about lingering effects, including sexual function (Health Canada describes reports lasting weeks to years) and pass them on; offer booster sessions if your service allows. [source: Health Canada SSR 2021; synthesis]
Example language (illustrative): "Sometimes people notice changes for a while after stopping. If anything like that comes up, including in your sex life, it's OK to raise it here and with your doctor."
Watch for: return of earlier symptoms, or lingering effects the client is embarrassed to mention; pass them on to the prescriber with consent. It is working when the client knows whom to contact and uses the plan. [synthesis]

5. Handling problems

The labels and NICE do not address the psychotherapist's difficulties directly; all responses below are [synthesis] unless a source is tagged.

"Should I take it?" / "What would you do?" Do not give a recommendation. Explore the client's values and questions, offer balanced information from the leaflet, and help them take the decision to the prescriber. NICE frames the choice as personal. (illustrative) "I can't tell you whether to take it, but I can help you work out what matters to you and what you want to ask your doctor." [source: NICE NG222 rationale; synthesis]
Client says they are about to stop, or has stopped, without the prescriber. Do not tell them to restart or to carry on stopping. Say plainly that the leaflet advises against stopping suddenly without talking to the prescriber, encourage prompt contact, monitor for discontinuation symptoms and mood change, and update the safety plan. [source: Zoloft, Effexor XR, amitriptyline labels; synthesis]
Client reports side effects but won't tell the prescriber (shame, fear of being taken off it, poor relationship). Explore the barrier; rehearse the conversation; offer to write a note with consent; for sexual side effects, normalise them by noting labels ask prescribers to ask about them. [source: Zoloft label; synthesis]
Prescriber hard to reach or dismissive. Help the client use the practice's urgent route, a pharmacist, or a second opinion; document your attempts; for emergencies use emergency services directly.
Signs of activation, agitation or emerging hypomania in session. Assess risk now; with consent contact the prescriber the same day; if risk is high, follow your crisis pathway. Do not interpret it as only psychological. [source: FDA suicidality page; labels A3]
Suspected serotonin syndrome, MAOI hypertensive crisis or overdose during or between sessions. Treat as a medical emergency: emergency services or urgent medical care; stay with the client if in person; do not wait for the next review. [source: Zoloft, Nardil, amitriptyline labels]
Client distressed by withdrawal symptoms that have been called relapse (or the reverse). Validate the experience without taking a side on the cause; help them record timing and symptoms; support a request for review. NICE notes drug-specific withdrawal data are limited. [source: NICE NG222 rationale; synthesis]
Persistent sexual dysfunction after stopping. Take it seriously and without dismissal; Health Canada documents such reports lasting weeks to years without confirming cause. Encourage medical review and reporting to the regulator (Health Canada names Canada Vigilance; in the UK, patients and clinicians can report suspected side effects to the MHRA Yellow Card scheme [source: MHRA FOI 23/059 response]); address the psychological and relational impact. [source: Health Canada SSR 2021]
Family or partner pressure (to take or to stop). Support the client's own decision; with consent, offer the family psychoeducation from the leaflet; with young people, balance autonomy and the labels' emphasis on family observation. [source: FDA suicidality page; synthesis]
Rupture over medication (the client feels judged for taking it, or for not taking it). Name the rupture, own any part of your communication that sounded like a view, restate your neutral role, and return to what the client wants.
Therapist's own bias (for or against medication). Monitor it in supervision; stick to sourced information; never present your view as fact.
Client attributes all improvement to medication (or all to therapy). Explore what they have done differently; this strengthens self-efficacy for relapse prevention and makes stopping, when it happens with the prescriber, less frightening.
Stuck therapy with emotional blunting. Explore its impact on the work and encourage the client to raise it with the prescriber; adapt methods (more behavioural, body-based or concrete work) while it lasts.
MAOI client under social pressure around food, drink or cold remedies. Problem-solve practical scripts and planning ahead; remind them to show their medicine card or list to pharmacists and dentists. [source: Nardil label; synthesis]
High-risk client on a tricyclic. Prioritise means safety and, with consent, inform the prescriber of the risk; the label states overdose can be fatal. [source: amitriptyline label]
Client asks you about doses, missed doses, switching or combining. Do not answer; direct them to the prescriber or a pharmacist, today if it is urgent.

Sources

Web pages and documents:

Not summarised in this guide [uncertain]: the text of the Royal College of Psychiatrists patient resource Stopping antidepressants; the NICE NG222 recommendations chapter (including the stopping-antidepressants section and the review timings in recommendation 1.4.11); NICE NG215 and NG197; MHRA Drug Safety Updates; the full EMA PRAC assessment; the NHS Scotland patient leaflet on stopping antidepressants. Check these directly before relying on UK-specific details.

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