Depression & Generalised Anxiety Disorder Treatment Summary (Primary and acute care) v1.6
Step 1
•Screening for depression
•During the last month have you been feeling down, depressed or hopeless?
•During the last month have you often been bothered by having little interest or
pleasure in doing things?
•If yes, during the last month, have you often been bothered by: Feelings of
worthlessness? Poor concentration? Thoughts of death
•Screening for Anxiety
•During the past four weeks, have you been bothered by feeling worried, tense, or
anxious most of the time?
•Are you frequently tense, irritable, and having trouble sleeping?
Step 2
Step 3
•Treatment of mild depression/generalised anxiety disorder
•Offer watchful waiting/active monitoring, guided self-help (e.g. internet based
CBT), group CBT or referral to community psychology services (IAPT) (mandatory
in all children) .
•Short periods of exercise may be helpful.
•Offer antidepressants if there is a history of major depression, symptoms persist
after other interventions or symptoms are protracted (more than 2 years).
•Pharmacologic treatment of depression (Treatment threshold: PHQ-9 ≥12/27)
•Consider psychology (IAPT) or an antidepressant or both.
•1st line: citalopram or fluoxetine 20mg OD . Start 10 mg OD in elderly and *children.
•2nd line antidepressant: If no response after 6 weeks, switch to an alternative SSRI
(sertraline 100mg OD) or mirtazapine 30mg OD.3rd line: If still no response within 6
weeks, switch to venlafaxine immediate release (75mg BD or greater) or consider
augmentation strategy. Also consider referring to mental health services. Augmenting in
adults sooner may bring about remission in more patients. For GPs with special interest
in mental health, consider adding a second antidepressant (e.g. venlafaxine+mirtazapine
or sertraline+(mirtazapine or venlafaxine). For specialists, consider adding the following to
an antidepressant: lithium (>0.4mmol/L), an antipsychotic i.e. risperidone (1-2mg/day),
olanzapine (2.5-5mg/day ) or quetiapine (150-300mg/day) or liothyronine. Prescribing in
children should be initiated by a specialist.
•Pharmacologic treatment of generalised anxiety disorder
•1st line: sertraline 200 mg/day (unlicensed) or paroxetine 20 mg/day
•2nd line : If no response consider switching to an alternative SSRI or venlafaxine
75mg/day
•3rd line: Pregabalin 200 to 450 mg/day in 2 divided doses
Considerations when choosing an antidepressant
Seizures: avoid TCAs, use SSRIs
Renal, liver impairment, children or elderly: start low & increase slowly,
consider mirtazapine or a SSRI with a shorter half-life.
Increased risk of bleeding: mirtazapine 1st line. Consider adding a PPI when
using other antidepressants.
CVD: mirtazapine 1st line. CVE: sertraline 1st line.
All SSRIs (escitalopram and citalopram especially) increase the QTc interval.
Where possible avoid other QTc prolonging drugs or monitor ECG.
All antidepressants may increase the risk of suicidal ideation in children and
young adults, monitor closely. Fluoxetine should be used 1st line.
Hyponatraemia: trazodone (lower risk) & agomelatine (non-formulary),
elderly/those with a low BMI are prone. Monitor sodium.
BPSD: Use an antidepressant when there are significant depressive features.
*Referral
Practitioners without
a special interest in
mental health are
advised to refer all
patients with severe,
chronic, resistant
depression, patients
at high risk of
suicide or any
children and
adolescents with
depression to
mental health
services.
Advice & Support
Psychiatric Medicines Information (020 3513 4566) OR your local Mental Health Team.
For professionals: www.bnf.org.uk www.medicines.org.uk www.nhsevidence.nhs.uk
For patients & carers: www.medicationandchoice.org/swlstg-tr (medicines & comparison charts)
www.nhschoices.nhs.uk www.swlstg-tr.nhs.uk/advice-support/
1
Homeless Persons Units: www.homelesslondon.org
Employment: www.adviceguide.org.uk
Depression and anxiety disorder treatment
Introduction
This guidance is intended to give clinicians in South West London information concerning the treatment of
depression and anxiety in line with local prescribing policy and national treatment and technology
appraisals and guidance.
Screening questions (See summary)
Screening questions are useful tools to assess whether a patient should be further investigated for
depression and anxiety. Those with long term physical health conditions should be targeted as these are
associated with higher levels of depression than the general population.
Diagnosis
1. Assessment of depression:
 Severity of depression is likely to be greater when more symptoms are present with functional and
social impairment, and a longer duration of symptoms.
 Assess for these symptoms to make a diagnosis of depression using the ICD 10:
2. Anhedonia – loss of interest in pleasurable
 CORE SYMPTOMS:
activities
1. Persistent pervasive low mood
3. Decreased energy
d) Negative image about self and the future
 ADDITIONAL SYMPTOMS:
e) Ideas/acts of self-harm or suicide
a) Reduced attention and concentration
f) Disturbed sleep
b) Reduced self-esteem and self confidence
g) Disturbed appetite
c) Ideas of guilt and unworthiness
 MILD EPISODE: At least 2 core symptoms and 2 other additional symptoms
 MODERATE EPISODE: At least 2 core symptoms and 3 other additional symptoms
 Both mild and moderate episodes can be present with/without somatic symptoms.
 SEVERE EPISODE: All 3 core symptoms and 4 or more additional symptoms with severe intensity.
2. Assessment of Anxiety disorder:
 The symptoms must be present for most days for at least several weeks at a time and usually for
several months.
 Generalised and free floating anxiety.
 Persistent symptoms of apprehension, motor tension and autonomic over activity.
 Frequent need for reassurance and recurrent somatic symptoms may be prominent.
 However, if the person does not fulfil these criteria (sub-threshold symptoms), they should not be
dismissed as they may still have potential for considerable morbidity.
Assess the risk of suicide
 Ask all suspected patients with depressive symptoms about suicidal ideation and current intent at
assessment, follow-up and on initiation and dose changes of antidepressants. Suggested questions
are below. In depression the more actions a patient has taken to attempt suicide and the fewer
barriers there are to stop them undertaking the act, the higher risk of suicide (in personality disorder
the clinical picture may be more complicated). Those depressed with a diagnosis of bipolar disorder
are known to have a higher risk of suicide than those with depression alone.
o Do you ever think about suicide?
o Have you made any plans for ending your life?
o Do you have the means for doing this available to you?
o What has kept you from acting on these thoughts?
Risk factors for suicide1
Social characteristics
Male gender
Young age (< 30 years)
Advanced age
Single or living alone (poor social
support & no responsibility for children)
2
History
Prior suicide attempt(s)
Family history of suicide
History of substance abuse
Recently started on
antidepressants
Clinical/diagnostic features
Hopelessness
Psychosis
Anxiety, agitation, panic attacks
Concurrent physical illness
Severe depression
Rating scales objectively rate the severity of symptoms of depression and anxiety and help to empower
patients. Suggested scales are:
 Depression self-administered Scale (PHQ-9): ≥12 (max 27) threshold for treatment, download free:
www.depression-primarycare.org
 Anxiety Scale (Covi): ≥9 clinically relevant anxiety
Consider co-morbidities, social and cultural factors







Consider coexisting psychological and psychiatric disorders, such as bipolar disorder, dementia,
eating disorders, obsessive compulsive disorder, post-traumatic stress disorder and alcohol abuse.
Grief reaction may present as depression. The first line of management should be bereavement
counselling rather than medicines.
Dementia may present as depression as they share symptomatology (disorientation, memory loss,
and distractibility).
o Approximately a third of people with dementia develop depressive symptoms. Pseudodementia
describes cognitive impairment due to depression in the elderly.
o A primary diagnosis of depression is suggested by:
o Preservation of a reasonable memory.
o Personal or family history of depression.
o A successful trial of treatment for depression which alleviates symptoms of dementia.
Parkinson’s Disease is associated with mild dementia in approximately a third of people, and tends
to become more severe in the end stages. Approximately half of people with Parkinson’s disease
develop depression during their illness.
Consider underlying medical conditions with known associations with depression:
o Chronic diseases (e.g. chronic pain, diabetes and cardiac disease).
o Cerebrovascular disease (stroke, subarachnoid haemorrhage).
o Endocrine disorders (hypothyroidism, Cushing’s syndrome, adrenal insufficiency,
hyperparathyroidism, hypopituitarism).
o Cancer (e.g. pancreatic)
o Autoimmune conditions.
Consider the effect of substances of abuse and psychiatric side effects of medical drugs:
o Carbon monoxide poisoning.
o Substance misuse (e.g. alcohol, anabolic steroids, cannabis, cocaine & opiates).
o Centrally-acting antihypertensives (such as methyldopa), lipid-soluble beta-blockers (e.g.
propranolol), central nervous system depressants, opioid analgesics, retinoids (e.g.
isotretinoin), interferons & steroid withdrawal.
Consider socio-cultural differences in presentation: eg: Asian women presenting with somatic
symptoms rather than mood symptoms.
Treatment
Mild depression or sub threshold symptoms
 Antidepressants are not recommended and are considered ineffective unless the symptoms inhibit
treatment of a physical health condition, there is a history of major depression, symptoms persist after
other interventions or symptoms are protracted (more than 2 years).2&3
 Watchful waiting, guided self-help4 (e.g. internet based CBT), group CBT or referral to community
psychology services (IAPT) may be useful.5 Evidence for exercise is conflicting, short periods of
exercise may be enough to have an effect.6
 Those with anxiety disorders alone should be offered psychological therapies before initiation of
antidepressants.
IAPT services (hyperlinks below)
All accept self-referral from patients with borough based GPs and referrals from GPs for the treatment
of anxiety and depression. Wandsworth 0203 513 6264 Sutton & Merton 0800 032 4207 Richmond
020 8548 5550 Kingston 0203 513 3000
Moderately severe depression or anxiety
 Non-pharmacological interventions via referral to local psychological therapist or IAPT should be
considered along with antidepressant medicines.
3






1st line antidepressant treatment for working age adults are citalopram or fluoxetine, 20mg each
morning. These doses treat acute depression and prevent return of symptoms.
Treatment may take up to 2 weeks to begin to have a therapeutic effect and should be continued for 6
months after abatement of symptoms in 1st episode depression. Long term treatment may be
considered in chronic or relapsing depression. NICE recommends continuation for at least 2 years
where there is a risk of relapse.
Short-term (2 weeks) hypnotics may be prescribed for insomnia: zopiclone 3.75-7.5mg ON PRN or
promethazine 25-50mg ON PRN.
After six weeks of no response to 1st line antidepressant, consider switching to a 2nd SSRI (sertraline
100mg OD) or mirtazapine 30mg OD.
Those with anxiety alone or generalised anxiety disorder requiring treatment should have a 1st line
antidepressant (SSRI). Paroxetine 20mg or sertraline 200mg (unlicensed) should be prescribed 1st
line. If no response consider switching to an alternative SSRI or venlafaxine 75mg/day. Patients who
have not responded to a first and second antidepressant or do not tolerate antidepressants may have
a trial of pregabalin (prescribed twice daily, titrated to 200 mg to 450 mg/ day).
Depression as a ‘behavioural and psychological symptom of dementia should be treated taking in to
consideration co-morbidities in line with recommendations for treating elderly patients. Agitation in
BPSD with a background of depressive symptoms may improve when treated with SSRIs (citalopram
or sertraline).7 See the “Medicines for behavioural and psychological symptoms in dementia (BPSD)
guidance” for further information.
Considerations when initiating an anti-depressant
 Antidepressants increase the risk of seizures, there is a paucity of evidence to choose one
antidepressant over another; avoid tricyclic antidepressants.
 All antidepressants increase the risk of hyponatraemia (excluding agomelatine); trazodone may be
lower risk. Elderly/those with low BMI are more prone and require sodium level monitoring.
 Antidepressants may accumulate in renal & liver failure. Start low and increase the dose slowly.
Antidepressants that affect serotonin increase the risk of bleeding (especially when combined with
anticoagulants or NSAIDS). Mirtazapine is the 1st line option where there is an increased risk of
bleeding. Mirtazapine may still slightly increase the INR when given with warfarin. Other
antidepressants may increase the risk of bleeding; consider adding a PPI when prescribing other
antidepressants in patients with a high risk of bleeding (e.g. peptic ulcer in elderly or other
comorbidities).
 Avoid TCAs in those with a known history of overdose. Mirtazapine is the drug of choice in
cardiovascular disease, avoid TCAs which increase the risk of MI in the first 3 months of treatment.8
Cardiac side-effects are also less common with moclobemide.
 Citalopram and escitalopram (non-formulary in South West London except by recommendation from
Tier 4 OCD services) are known to cause QTc elongation. They should not be prescribed in
combination with other QTc prolonging medicines and in high doses unless in line with South West
London recommendations.
o All SSRIs have reports to the MHRA that they cause QTc prolongation. Mirtazapine (as yet)
does not. Venlafaxine is known to cause QTc prolongation in overdose at the same rate as
SSRIs.
o Having cardiovascular disease does not contraindicate the use of QTc prolonging
antidepressants, close monitoring is advised. They should be avoided in those at high risk of
torsades e.g. untreated electrolyte abnormalities or malignant arrhythmias.
 Pregnancy & Lactation: See National guidelines
 Agomelatine, bupropion, duloxetine, escitalopram and reboxetine are non-formulary in South West
London for the treatment of depression and anxiety.
 If alcohol or use of illicit substances are considered to be a primary factor in contributing to depression
or anxiety consider referring to local Drug and Alcohol Teams before initiating treatment. The majority
of symptoms of depression and anxiety resolve when there is abstention from drugs and alcohol.
Severe, chronic or resistant depression
Practitioners without a special interest in mental health are advised to refer all patients with severe,
chronic, resistant depression or are at high risk of suicide to mental health services.
Treatment of chronic or resistant depression may involve augmenting an antidepressant with a second
antidepressant or other agents such as: lithium, an antipsychotic (risperidone, olanzapine or quetiapine) or
4
liothyronine (not advised as augmenting agent by NICE). Evidence suggests that of the formulary
antidepressants sertraline may be the most effective and augmenting sooner may bring about remission in
more patients.
Further information, advice & support on medicines (See summary)
Mental health services contacts
Kingston
Wandsworth
Merton OP CMHT
Merton assessment (18-75)
Sutton OP CMHT
Sutton assessment (18-75)
Kingston Hospital OP Liaison
St George’s Hospital Liaison
Merton CAMHs Sutton & Merton CMH & ID
Sutton CAMHs
Kingston Hospital Liaison
St Helier Hospital Liaison
Children & young people (under 18 years)
Depression
Children & young people should only be offered antidepressants in conjunction with psychological
therapies (as this may be a more effective treatment than antidepressant alone) initiated in secondary
care.9&10
Fluoxetine is the antidepressant of choice in those aged 8 and above.11 Start at 10mg each day
(20mg/5mL liquid) increasing to 20mg each day after a week if necessary. Doses of 40-60mg each day
are rarely needed. Those with lower body weight or intellectual disabilities may require lower doses.
Poor or no response to fluoxetine & psychological therapies may warrant switching antidepressants after
exclusion of other contributing factors. Sertraline (start at 25mg each day and gradually increase to the
adult dose over 2-4weeks) and citalopram (start at 10mg each day and gradually increase to 20mg each
day over 2-4weeks) are second line agents.
Venlafaxine may be prescribed as a third line agent, but is associated with more side-effects then
SSRIs.12
All antidepressants with the exception of fluoxetine have regulatory warnings over the risk of suicide,
aggression and paucity of evidence of therapeutic benefit in children and young people with
depression.13,14,15,16&17 Children and young people should be monitored for the appearance of suicidal
behaviour, self-harm or hostility on initiation and dose changes of antidepressants.
Evidence supports the use of sertraline in those 6 years and above. TCAs are not effective in pre-pubertal
children.18
Anxiety & generalised anxiety disorder in children and adolescents
Management largely follow the treatments for adults. Medicines used to treat anxiety in children and
adolescents should only be tried after failure of non-pharmacological interventions.
Switching & stopping antidepressants
All antidepressants have a risk of discontinuation effects. These may range from anxiety symptoms to flulike symptoms and ‘electric shock’ effects. Discontinuation effects are not harmful but can be very
uncomfortable. Antidepressants should be tapered down thereby reducing the risk of discontinuation
effects.
Switching antidepressants may involve cross tapering or stopping one antidepressant before starting
another. Advice should be sought before attempting to switch: See the Maudsley Prescribing Guidelines
(free via NHSevidence) or contact Specialist Medicines Information 020 3513 6829 for advice.
5
Submission to SWL Medicines Decision Making Groups
Date of Meeting:
Person presenting at meeting:
Agenda No:
Attachment:
Title of Document:
Depression & anxiety disorder
treatment guidance
Purpose of Report:
For discussion and comment &
Approval
for primary care or acute care health providers
Report Author:
Submitting Team/Organisation:
Carl Holvey
Mental Health Interface Prescribing Forum
Contact details:
Carl.holvey@nhs.net 020 3513 4566
Executive Summary: (precise purpose of document)
To aid clinicians working in primary care and acute care organisations to prescribe for
depression and generalised anxiety disorder.
This documented is to be shared across healthcare organisations in South West London to
ensure there is consistency and a shared understanding of the treatment of depression.
Key sections for particular note (paragraph/page), areas of concern etc:
Recommendation(s) for the committee:
Approve and communicate the publication across the organisation.
Committees which have previously discussed/approved/declined the report and/or
Leads who have been consulted and key outcomes
See below
Financial Implications:
Nil
Other Implications if applicable:
(including patient and public involvement/Legal/Governance/Risk/Diversity/ Staffing)
This guide has been seen by patient and care representatives as part of South West London and St George’s
NHS Trust.
How will this document be disseminated and to whom?
The Mental Health Interface prescribing forum proposes joint education meetings in
depression and physical health of those with severe and enduring mental illness between
primary and secondary care to aid dissemination of this guide.
6
Working in Partnership
Depression & anxiety disorder treatment guidance
for primary care or acute care health providers
7
Version
1.6 TWC21a
Ratified by
SWLStG Drug & Therapeutics Committee
(& other CCG/participating body organisations)
Date ratified
12/2/2014
Contributors
Sedina Agama, Chief Pharmacist, Merton CCG
Gursharon Bains, Primary Care Pharmacist, Kingston CCG
Carl Holvey, Principal Clinical and Deputy Chief Mental Health Pharmacist, Kingston CCG &
South West London & St George’s NHS Trust
Hetal Naik, Pharmacist, Merton CCG
Shaistah Qureshi, Senior Pharmacist Richmond CCG
Dr Nova Hart, Consultant Psychologist
Fiona White, Nurse Practitioner, Merton CCG
Dr Chris Keers, Sutton CCG
Dr Andrew Otley, Merton CCG
Dr Anthony Hughes, Kingston CCG
Dr Shubra Rao, SWLStG, Adult & ID Psychiatrist
Dr Alice Lomax, SWLStG, Psychiatrist
Dr Jim Bolton, SWLStG, Liaison Psychiatrist
Dr Maurice Zwi, SWLStG, Child & Adolescent Psychiatrist
Dr Sim Roy-Chowdhury, East London NHS FT, Consultant Clinical Psychologist and
Psychotherapist
Responsible committee
Drugs and Therapeutics Committee
Mental Health Interface Prescribing Forum
Date of implementation
-
Date of last review
-
Date of next review
12/2/16
Target audience
Clinicians treating depression & anxiety in primary care or
Acute Care
Equality impact assessment & Governance
This policy is written by South West London and St George’s NHS Trust for CCGs and acute care. They
are responsible for the monitoring and implementation of this policy. Review will occur at the South West
London Mental Health Interface Prescribing forum.
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Acting on recommendations
and Lead(s)
Change in practice
and lessons to be
shared
The CCGs
receive
prescribing
review
information on
prescribing
antidepressants
as part of the
London wide
QIPP initiative
Each CCGs
will have
their own
lead.
See
London
procure
partnershi
p website.
QIPP data is
send
quarterly by
the London
Procurement
Partnership
to CCGs
and NHS
Provider
Trusts.
Each CCG
and
organisation
are
responsible for
reviewing and
reporting to
their
prescribing
lead group.
The Mental Health Interface
Prescribing forum will suggest
possible actions required for
CCGs or acute provider
organisations to aid
compliance with this policy.
The medicines ratification
body in each organisation is
responsible for ensuring
action s identified and
carried out from review of
compliance of this policy.
Each CCG and organisation
are responsible for acting on
their own results from
compliance with this policy.
ASSOCIATED DOCUMENTS
South West London Mental health formulary
SWLStG Shared care of psychotropics & discharge of patients
Psychotropic Physical monitoring of Mental health medicines for GPs summary
All shared mental health prescribing policies for South West London are available:
http://www.swlstg-tr.nhs.uk/for-health-professionals/
Equality Impact Assessment Tool
Yes/No
1.
Does the policy/guidance affect one group less or
more favourably than another on the basis of:
 Race
No
 Ethnic origins (including gypsies and travellers)
No
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian, gay and bisexual
people
No
 Age
No
 Disability - learning disabilities, physical disability,
sensory impairment and mental health problems
No
2.
Is there any evidence that some groups are affected
differently?
No
3.
If you have identified potential discrimination, are any
No
8
Comments
Yes/No
Comments
exceptions valid, legal and/or justifiable?
4.
Is the impact of the policy/guidance likely to be
negative?
No
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to
policy/guidance without the impact?
7.
Can we reduce the impact by taking different action?
achieving
the
N/A
N/A
References
1
National Institute for Clinical Excellence. Depression: The treatment and management of depression in adults. Clinical Guideline
90. Amended October 2009. www.nice.org.uk.
2 Barbui C, Cipriani A, Patel V et al. (2011) Efficacy of antidepressants and benzodiazepines in minor depression: systematic
review and meta-analysis. British Journal of Psychiatry 198: 11–16 Full text: www.bjp.rcpsych.org/content/198/1/11.full.pdf+html
3 Gartlehner G, Hansen RA, Morgan LC et al. (2011) Comparative benefits and harms of second-generation antidepressants for
treating major depressive disorder: an updated meta-analysis. Annals of Internal Medicine 155: 772–85 Full text:
www.annals.org/content/155/11/772.full.pdf+html
4 Cuijpers P, Donker T, Johansson R et al. (2011) Self-guided psychological treatment for depressive symptoms: a meta-analysis.
PLoS ONE 6: e21274 Full text: www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0021274
5 van t’Hof, Cuijpers P, Waheed W et al. (2011) Psychological treatments for depression and anxiety disorders in low- and middleincome countries: a meta-analysis. African Journal of Psychiatry 14: 200–7 Full text:
www.ajop.co.za/Journals/july2011/Psychological treatments.pdf
6 Krogh J, Nordentoft M, Sterne JAC et al. (2011) The effect of exercise in clinically depressed adults: systematic review and
meta-analysis of randomized controlled trials. Journal of Clinical Psychiatry 72: 529–38. www.article.psychiatrist.com/dao_1login.asp?ID=10007122&RSID=35271304530341
7 Pollock BG et al. Comparison of Citalopram, Perphenazine, and Placebo for the Acute Treatment of Psychosis and Behavioural
Disturbances in Hospitalized, Demented Patients. Am J Psych 2002; 159(3):460-465.
8 Ray, W.A. et al: Cyclic Antidepressants and the Risk of Sudden Cardiac Death; Clin. Pharm. Ther. 2004; 75(3): 234-41. Tata et
al 2005. General population based study of the impact of tricyclic and selective serotonin reuptake inhibitor antidepressants on
the risk of acute myocardial infarction Heart 2005;91:465-471
http://heart.bmj.com/cgi/content/full/91/4/465
9 NICE Clinical Guideline 28, September 2005. Depression in children and young people. Identification and management in
primary, community and secondary care. www.nice.org.uk.
10 Reference guide to consent for examination or treatment (2001). Accessed on www.dh.gov.uk 1st June 2010.
11 Duff G. Safety of venlafaxine in children and adolescents under 18 years in the treatment of depressive illness. 19th September
2003.
12 March et al. Fluoxetine, cognitive-behavioural therapy, and their combination for adolescents with depression: Treatment for
Adolescents with Depression Study (TADS) Team. JAMA 2004; 292: 807-820.
13 Goodyer et al. A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by
selective serotonin reuptake inhibitors. The ADAPT trial. Health Technology Assessment 2008; Vol. 12: No. 14
14 Dubicka B, Elvins R, Roberts C et al. Combined treatment with cognitive–behavioural therapy in adolescent depression: metaanalysis. Br J Psychiatry 2010; 197:433–40.
15 Bridge JA, Iyengar S, Salary CB et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric
antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 2007; 297:1683–96.
16 Hughes CW, Emslie GJ, Crismon ML et al. Texas Children’s Medication Algorithm Project: update from Texas Consensus
Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. J Am Acad Child Adolesc Psychiatry 2007;
46:667–86.
17 MHRA Citalopram and escitalopram: QT interval prolongation—new maximum daily dose restrictions (including in elderly
patients), contraindications, and warnings. Drug Safety Update Vol 5 Issue 5, Dec 2011: A1.
18 Cochrane Database of Systematic Reviews: Plain Language Summaries. Tricyclic drugs for depressed children and
adolescents. First published: June 18, 2013; Review content assessed as up-to-date: April 12, 2013.
References in relation to Equality Impact Assessments (section 4.5)

Health and Social Care Act 2001

The Human Rights Act 1998

The Equal Pay Act (as amended) 1970

Promoting Equality and Human Rights in the NHS - A Guide for Non-Executive Directors of NHS Boards (2005) Department
of Health

NHS Act 2006

The Equality Act 2010

NHSLA template on policy for policies June 2007
9