• Patients taking SSRI’s and MAOI’s must be informed of the fact that these drugs can take up to 3 weeks in order to exert an effect, and that they must not expect full effects to be seen until 6-8 weeks post treatment.

• TCA’s exert a therapeutic effect of a period of around 2-3 weeks.

• If patients have been on antidepressant therapy for a period of 1 month without any improvements in their condition, they must consult their prescriber. In this case the medication regimen may be altered, or an alternative agent may be prescribed.

• Patients taking SSRI's should be warned that they may feel drowsy and therefore avoid driving if this is the case  

• ​Patients should also be informed that antidepressants normally exert effects (alleviating depressive and anxiety symptoms), approximately 1 month after treatment is initiated. Therefore it is vital for patients to understand that anxiety and depressive symptoms (including suicidal ideation) may be intensified in the first few weeks of treatment. For this very reason depressive patients should know where to find appropriate support.

• For patients taking TCA’s or related antidepressants, ensure that patient has had an ECG prior to treatment and on an annual basis.

• For patients taking duloxetine or venlafaxine ensure that patients’ blood pressure is regularly measured.

• For patients taking mianserin, a full blood count must be taken monthly during the first 3 months of treatment and then regularly.

• Prior to treatment check that patients have had liver function tests at intervals of 6, 12, and 24 weeks of treatment, then conduct tests on an annual basis.

• Patients must be encouraged to continue treatment 6-9 months after recovering. Elderly patients should continue treatment 12 months after recovery.

• Treatment should be continued for 2 years in patients who have a history of recurrent depression.

 

 

Lifestyle:

• In terms of lifestyle patients must be reminded to avoid tyramine as this can induce hypertension

• Tyramine is found in the following food:  yoghurt, cheese, liver, Marmite, Oxo, Bovril, brewer's yeast, soya bean extract and large amounts of chocolate. Also found in alcoholic drinks, including beer, lager or wine (especially red wine). It is best to avoid all alcoholic drinks and some non-alcoholic beers. The patient should be advised to only eat fresh foods and avoid food that is ‘stale’ especially meat, fish, poultry or offal while taking an MAOI and for two weeks after you stop. This is because these foods may contain tyramine. 

• Patients should be advised to reduce alcohol intake achieving safe limits:

      Women: 14 units/ week

      Men: 21 units/ week

• Patients should be counselled on good sleep hygiene.

• Encourage patients to cease smoking and educate them about the benefits associated with smoking cessation. If the patient wishes to stop smoking, then refer them to appropriate smoking cessation services.

• Advise patients to engage in regular exercise and lose weight (in patients with a BMI greater than 25kg/m²). Explain that exercise is beneficial in alleviating depressive symptoms, and reducing the risks of developing chronic illnesses such as cardiovascular disease, diabetes etc.

• Inform the patient that therapy is gradually decreased over one month (fluoxetine is an exception)

• Emphasise the importance of adhering to the medication regimen prescribed, and discourage patient from stopping treatment unless advised. Warn patients of withdrawal symptoms e.g. feeling cold, headache, nausea, sleep disturbances including insomnia and nightmares.

• Explain to patients that depression is an illness. Alleviate any misconceptions they may have regarding antidepressants, specifically that they do not cause tolerance, addictions or cravings.  

• Patients suffering from a pulsating headache must be referred without delay. ​Smoking The prevalence of smoking in patients
  with mental health conditions is roughly twice
  that of the general population – although around
  50 per cent want to stop smoking. Pharmacists
  therefore have a valuable role in helping these
  patients access stop smoking services, or
  supporting patients during quit attempts