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Switching strategies for antidepressants

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Topics: Mental health and illnessSwitching

The choice of antidepressant switching strategy depends on the person and antidepressant. We describe the current strategies and their application.

Contents
  1. Switching strategies
  2. Strategy options
    1. Cross-taper
    2. Direct switch
    3. Taper, stop and switch
    4. Taper, washout and switch
    5. Stop, washout and switch
  3. Individual switches

Switching strategies

Choosing an appropriate strategy will depend on the type of antidepressants being switched, as well as the person’s symptoms which will guide the speed of the switch. The following articles will help you manage this.

Strategy options

Below we’ve listed the switching strategies available.

Cross-taper

Gradually reduce and stop the first antidepressant whilst simultaneously starting the second at a low dose and gradually increasing. Cross-tapering can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability.

Example

The Maudsley Prescribing Guidelines in Psychiatry provides  an example of a cross-tapering regimen shown in the table below.

Pre-switch dose
Week 1
Week 2
Week 3
Week 4
Withdrawing citalopram
 40mg daily 20mg daily 10mg daily 5mg daily 2.5mg daily
Introducing mirtazapine
 Nil 15mg daily 30mg daily 30mg daily 45mg daily (if required)

Direct switch

Direct switches may be possible when antidepressants have similar pharmacology or mode of action. The second antidepressant should alleviate discontinuation symptoms of the first.

Stop the first antidepressant and start the second at the usual therapeutic dose the next day.

Taper, stop and switch

Gradually reduce and then stop the first antidepressant; start the second immediately after stopping the first, usually on the next day.

Taper, washout and switch

Gradually reduce the dose of the first antidepressant and stop; wait for a period (the “washout”) before starting the second.

Stop, washout and switch

Stop the first antidepressant; wait for a period (the “washout”), before starting the second.

Individual switches

We have advice on how to switch between individual antidepressants of different types. Browse our collection below.

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