Current Mental Health Medication Recommendations

Clinical status: This is an educational prescribing overview, not a substitute for the BNF, product SmPC, local formulary, specialist advice, or individual assessment. Dose limits and licensing can vary by formulation, indication, age, comorbidity and interacting medicines. Off-label use is identified where especially relevant.

1. Core prescribing principles

Shared decision-making: Choice of medicine should be driven by diagnosis, symptom profile, previous response, physical health, interaction burden, overdose risk, reproductive considerations, side-effect preferences and the person's own priorities.

· Check the current BNF/SmPC and local formulary before prescribing. Brand-specific modified-release products are not always interchangeable.

· Document baseline physical observations and relevant investigations before medicines that affect cardiovascular, metabolic, endocrine, renal, hepatic or haematological systems.

· Review early after initiation or dose change when clinical risk is higher. For antidepressants, NICE advises the first review usually within 2 weeks, or within 1 week for people aged 18–25 or where suicide risk is a particular concern.

· Avoid abrupt discontinuation of antidepressants, benzodiazepines, pregabalin, guanfacine/clonidine and other medicines associated with withdrawal or rebound phenomena.

· Assess pregnancy potential and reproductive risk where relevant; valproate now has particularly stringent UK regulatory requirements.

· Use the lowest effective dose and avoid routine psychotropic polypharmacy unless there is a clear rationale, evidence base and monitoring plan.

2. Depression

Current position. For less severe depression, NICE does not recommend routinely offering an antidepressant first-line unless this is the person's informed preference. For more severe depression, medication is one of several first-line options and may be combined with psychological treatment. SSRIs remain the usual first-choice antidepressants for most people because of tolerability and relative safety.

Selective serotonin reuptake inhibitors (SSRIs)

Medicine	Typical adult dose*	Common adverse effects	Key considerations
Sertraline	Usually 50–200 mg once daily	Nausea, diarrhoea, headache, insomnia or somnolence, sexual dysfunction	Common first-choice SSRI; substantial evidence across depression and anxiety disorders. Withdrawal can occur if stopped abruptly.
Fluoxetine	Usually 20–60 mg once daily	Nausea, activation/insomnia, headache, GI disturbance, sexual dysfunction	Long half-life generally reduces withdrawal risk, but clinically important CYP interactions can occur.
Citalopram	Usually 20–40 mg once daily; lower maxima in older adults/hepatic impairment	Nausea, sweating, fatigue, sexual dysfunction	Dose-related QT prolongation; consider cardiac risk, interacting QT-prolonging drugs and MHRA dose restrictions.
Escitalopram	Usually 10–20 mg once daily	Nausea, insomnia/somnolence, dizziness, sexual dysfunction	Generally well tolerated; QT cautions still apply, with lower maximum doses in some groups.
Paroxetine	Usually 20–50 mg once daily depending on indication	Sedation, weight gain, sexual dysfunction, anticholinergic symptoms	Short half-life and comparatively prominent withdrawal. More interaction burden than some SSRIs; reproductive planning requires individualized review.
Fluvoxamine	Usually 50–300 mg/day depending on indication	Nausea, sedation, GI upset	More often used for OCD than depression in UK practice; significant CYP-mediated interaction potential.

SNRIs and other commonly used antidepressants

Medicine	Typical adult dose*	Common adverse effects	Key considerations
Venlafaxine MR	Commonly 75–225 mg/day; higher specialist doses may be used	Nausea, sweating, insomnia, sexual dysfunction, BP increase	Monitor BP, especially at higher doses. Marked withdrawal can occur; taper carefully.
Duloxetine	Usually 60 mg/day; may increase to 120 mg/day	Nausea, dry mouth, dizziness, constipation, fatigue	Also used for GAD and some pain conditions. Monitor BP; avoid or use caution with significant hepatic disease/heavy alcohol use.
Mirtazapine	15–45 mg at night	Sedation, increased appetite, weight gain, dry mouth	Useful where insomnia or low appetite is prominent; often lower sexual side-effect burden than SSRIs.
Vortioxetine	5–20 mg once daily	Nausea, dizziness, abnormal dreams, GI symptoms	NICE option after no or limited response to at least 2 antidepressants in the current episode.
Trazodone	Dose varies by indication and formulation	Sedation, dizziness, postural hypotension; rare priapism	May be used where sedation is helpful; combination strategies should consider additive serotonergic and sedative effects.

Tricyclic antidepressants (TCAs) and MAOIs

· TCAs remain effective but are usually later-line because of anticholinergic effects, cardiovascular toxicity and danger in overdose. Lofepramine has a relatively better overdose safety profile than many TCAs.

· Amitriptyline is widely used at lower doses for neuropathic pain, but antidepressant doses carry greater anticholinergic and cardiotoxic burden.

· Clomipramine has an important role in OCD after SSRI strategies fail; overdose toxicity and ECG/cardiac risk require attention.

· Irreversible MAOIs such as phenelzine remain specialist options for selected treatment-resistant depression. Switching to or from an MAOI requires careful washout and interaction management.

Further-line and augmentation strategies

· Before declaring non-response, review diagnosis, adherence, dose, duration, substance use, physical illness and psychosocial factors.

· NICE options after limited response include dose optimization, switching within or between antidepressant classes, adding psychological treatment, or specialist combination treatment.

· Specialist augmentation may include lithium or a second-generation antipsychotic such as aripiprazole, quetiapine, olanzapine or risperidone; lamotrigine or liothyronine may be considered in selected specialist contexts.

· Combination antidepressant treatment increases side-effect and interaction burden and should be planned carefully.

· ECT remains an evidence-based option for severe depression when a rapid response is needed or other treatments have failed, depending on clinical circumstances and consent/capacity.

Withdrawal: NICE advises staged dose reduction over time. The taper should be individualized to the medicine, duration of treatment, dose, previous withdrawal experience and emerging symptoms. Very short half-life agents such as paroxetine and venlafaxine may require especially careful reduction.

3. Anxiety disorders

Generalised anxiety disorder (GAD)

· If drug treatment is chosen, an SSRI is generally offered first. NICE specifically identifies sertraline as a cost-effective first option, although this indication may be off-label depending on product.

· If sertraline is ineffective, consider another SSRI or an SNRI, taking account of withdrawal profile, interactions, overdose toxicity and patient preference.

· If SSRIs/SNRIs are not tolerated, pregabalin can be considered. In the UK it is a Class C, Schedule 3 controlled drug; assess misuse/dependence risk and pregnancy considerations.

· Benzodiazepines should not be used routinely for GAD other than short-term during crises.

Panic disorder

· SSRIs are standard pharmacological options; SNRIs and some TCAs also have evidence depending on licensing and individual factors.

· Start low and titrate because transient activation can initially worsen anxiety or panic symptoms.

· Benzodiazepines are not a preferred long-term strategy because of dependence, tolerance and poorer long-term risk-benefit.

· Propranolol may reduce peripheral adrenergic symptoms in selected situations but does not treat the core panic disorder process.

· Individual CBT is usually a key first-line treatment. If medication is preferred, NICE recommends an SSRI such as escitalopram or sertraline.

· If response is inadequate or adverse effects are problematic, another SSRI or venlafaxine can be considered.

· Phenelzine or moclobemide may be specialist later-line options in selected resistant cases.

4. Obsessive-compulsive disorder (OCD)

· SSRIs and CBT with exposure and response prevention (ERP) are core evidence-based treatments. Medication trials often need to be longer than for depression before judging response.

· Depending on the SSRI and tolerability, doses toward the upper licensed range are often required. Avoid exceeding licensed maxima without specialist justification and careful risk assessment.

· If an SSRI is ineffective, review adherence and adequacy of trial, consider another SSRI, and integrate ERP-focused CBT where possible.

· Clomipramine is an established later-line pharmacological option, particularly after SSRI non-response or intolerance; overdose and cardiac toxicity are important.

· Antipsychotic augmentation is a specialist strategy for severe treatment-resistant OCD. The evidence is strongest for selected agents and should not be presented as routine treatment.

2025 NICE surveillance: NICE reviewed CG31 and did not update the guideline. Pharmacological augmentation and relapse-prevention strategies were specifically identified as areas that may warrant future review.

5. Post-traumatic stress disorder (PTSD)

· Trauma-focused psychological treatment remains central. Medication is not a universal first-line substitute for trauma-focused therapy.

· For adults who prefer medication, or when psychotherapy is not suitable/available or symptoms remain clinically significant, an SSRI such as sertraline or an SNRI such as venlafaxine may be considered according to NICE guidance and licensing.

· Sedating antidepressants may sometimes be chosen when sleep disturbance is prominent, but the evidence base is less robust than for first-choice options.

· Prazosin is used off-label by some specialists for trauma-related nightmares, but evidence is mixed and hypotension/syncope risk must be considered.

· Avoid routine benzodiazepines for core PTSD treatment because they do not treat the disorder and carry dependence and cognitive risks.

6. Psychosis and schizophrenia

Key update. The source document stated that atypical antipsychotics are usually preferred first-line. NICE instead recommends choosing the antipsychotic jointly with the patient, based on likely benefits and adverse effects. First- and second-generation drugs can both be appropriate.

Medicine	Prominent adverse-effect profile	Clinical notes
Aripiprazole	Akathisia, insomnia, nausea; relatively lower metabolic/prolactin burden	Partial dopamine agonist. Useful when weight gain, sedation or prolactin are major concerns, though akathisia can be limiting.
Risperidone	Prolactin elevation, EPS at higher dose, weight/metabolic effects	Effective oral and LAI options. Monitor prolactin-related symptoms and movement effects.
Olanzapine	High weight gain/metabolic risk, sedation	Highly effective for many patients but metabolic burden is substantial; monitor weight, glucose/HbA1c and lipids.
Quetiapine	Sedation, postural hypotension, metabolic effects	Also has roles in bipolar disorder and depression augmentation; dose depends markedly on indication.
Amisulpride	Prolactin elevation, EPS, QT risk	Dose-dependent effects; ECG and renal considerations can be important.
Paliperidone	Prolactin elevation, EPS, metabolic effects	Multiple long-acting formulations can support adherence; renal function affects dosing.
Haloperidol	EPS, akathisia, dystonia, QT risk	Still useful in selected acute and maintenance settings; lower metabolic burden but higher movement-disorder burden.
Clozapine	Neutropenia/agranulocytosis, myocarditis, severe constipation/ileus, seizures, hypersalivation, metabolic effects	Offer after inadequate response to 2 adequate antipsychotic trials, at least one a non-clozapine second-generation drug. Mandatory blood monitoring; urgently assess chest symptoms, fever and bowel obstruction/constipation concerns.

Baseline and ongoing monitoring

· Before starting: weight, waist circumference, pulse, blood pressure, fasting glucose or HbA1c, lipids, prolactin, movement-disorder assessment, nutritional status, diet and physical activity.

· Offer an ECG before treatment where required by the SmPC, where cardiovascular risk/history is present, or for inpatients.

· Treat each antipsychotic as an explicit therapeutic trial: define target symptoms, expected benefit, acceptable adverse effects, dose and duration, then document response.

· Long-acting injectable antipsychotics should be considered when the person prefers them or when avoiding covert non-adherence is a clinical priority.

· Routine antipsychotic polypharmacy should be avoided except for short periods during switching or selected specialist augmentation, especially after optimized clozapine.

7. Bipolar disorder

Acute mania or hypomania

· If the person is not already taking an antipsychotic or mood stabilizer, NICE recommends offering haloperidol, olanzapine, quetiapine or risperidone, taking account of preference, prior response and adverse effects.

· If the first antipsychotic is ineffective or poorly tolerated, consider another recommended antipsychotic.

· If antipsychotic treatment is insufficient, lithium can be added when suitable and acceptable. Valproate is a later option only with full MHRA restrictions and reproductive-risk precautions.

· If mania/hypomania develops while taking an antidepressant, consider stopping the antidepressant, whether used alone or with a mood stabilizer.

Bipolar depression

· NICE options include quetiapine or fluoxetine combined with olanzapine in specific circumstances; olanzapine alone or lamotrigine may be alternatives depending on current treatment and preference.

· If already taking lithium, check the plasma level and optimize it if appropriate before adding treatment.

· Lamotrigine has a role in bipolar depression and maintenance but not acute mania; titrate slowly because of serious rash risk.

· Avoid antidepressant monotherapy in bipolar disorder because of the risk of mood switching and destabilization.

Long-term treatment

· Lithium remains NICE's first-line long-term pharmacological treatment for bipolar disorder when suitable.

· If lithium is ineffective, not tolerated or unsuitable, an antipsychotic such as aripiprazole, olanzapine, quetiapine or risperidone may be considered.

· Lithium requires regular plasma levels, renal function, thyroid function and calcium monitoring, plus education about toxicity, hydration and interacting medicines.

Valproate - major 2026 safety point: UK safety restrictions are much stronger than in the 2025 source. Valproate must not be started for the first time in a person under 55 unless 2 specialists independently consider and document that no other effective or tolerated treatment exists, or compelling reasons mean reproductive risks do not apply. Women and girls who could become pregnant remain subject to the Pregnancy Prevention Programme. NICE was updated in September 2025 to reflect MHRA advice that boys and men should use effective contraception (condoms plus contraception used by a female sexual partner) during treatment and for 3 months after stopping. Do not stop valproate abruptly without specialist advice.

8. Attention-deficit/hyperactivity disorder (ADHD)

Adults. NICE recommends methylphenidate or lisdexamfetamine as first-line pharmacological treatment for adults with ADHD when medication is indicated. Atomoxetine is the routine non-stimulant alternative after intolerance or inadequate response to stimulants.

Medicine	Typical dosing approach*	Common adverse effects	Key considerations
Methylphenidate	IR or modified-release; titrate to response within formulation-specific licensed limits	Reduced appetite, insomnia, headache, abdominal symptoms, increased pulse/BP	Adults: first-line option. Prefer modified-release once-daily preparations when adherence, stigma or diversion are concerns. Different MR brands have different release profiles and are not automatically interchangeable.
Lisdexamfetamine	Usually start 30 mg each morning; 20 mg may be used in some circumstances; max 70 mg/day	Reduced appetite, insomnia, dry mouth, weight loss, increased pulse/BP, irritability	Adults: first-line option. Prodrug of dexamfetamine. Controlled drug. Assess cardiovascular and substance-misuse risk.
Dexamfetamine	Individualized divided dosing	As for amphetamine stimulants	Consider in adults who respond to lisdexamfetamine but cannot tolerate its longer duration profile.
Atomoxetine	Adults commonly 40 mg/day initially, increasing to 80 mg/day; up to 100 mg/day if needed	Nausea, appetite reduction, insomnia/somnolence, increased pulse/BP, sexual adverse effects	Non-stimulant option when methylphenidate/lisdexamfetamine are not tolerated or after adequate trials of both are ineffective. Effects build over weeks.
Guanfacine MR	Licensed paediatric dosing is weight/age dependent	Sedation, fatigue, hypotension, bradycardia	Not licensed for adults. NICE advises not to offer guanfacine to adults without advice from a tertiary ADHD service. Taper rather than stop abruptly.

Assessment and monitoring

· Before medication: confirm ongoing diagnostic impairment and review mental health, substance use/diversion risk, current medication, weight, pulse, blood pressure and cardiovascular history. ECG is not routinely required unless clinical risk factors or interacting medicines indicate it.
· During titration: record symptoms, impairment and adverse effects at each dose change. Monitor pulse and BP before and after each dose change and at least every 6 months thereafter; monitor weight/BMI as clinically appropriate.

· Stimulants are Schedule 2 controlled drugs in the UK. Prescribing quantity, safe storage, travel and diversion risk require explicit attention.

· If appetite suppression is problematic, consider timing meals when stimulant effects are lower, taking medication with/after food when appropriate, dietary advice, dose/medicine review, and planned treatment breaks only when clinically appropriate.

· Shared care can be used once treatment is stable where the GP accepts the arrangement and local shared-care requirements are met.

Cardiovascular safety: Do not describe stimulants as simply 'contraindicated in heart problems'. The decision depends on the specific cardiac condition, symptoms, family history, examination findings, BP/pulse and specialist advice where indicated.

9. Historical and declining-use treatments

Treatment	Current interpretation
MAOIs	Still effective, but now specialist/later-line because of interaction burden, dietary restrictions and switching complexity.
Dosulepin	NICE advises against starting it because of cardiac toxicity and danger in overdose.
Barbiturates for anxiety/insomnia	Largely obsolete because of dependence, respiratory depression and narrow therapeutic index.
Long-term benzodiazepines	Much less favoured for chronic anxiety/insomnia because of tolerance, dependence, falls/cognitive effects and withdrawal risk.
Thioridazine	Withdrawn because of serious cardiac toxicity; no routine modern role.
Routine antipsychotic polypharmacy	Avoided where possible; monotherapy is preferred except for defined switching or specialist augmentation situations.
Pemoline for ADHD	Withdrawn because of serious hepatotoxicity.
Routine clonidine for ADHD	Now a specialist paediatric option in selected situations; guanfacine has a clearer modern role in children and young people.

10. High-yield monitoring summary

Class / medicine	Monitoring priorities
SSRIs/SNRIs	Suicide/self-harm risk early in treatment where relevant; side effects; adherence; sexual function; sodium if clinically indicated; BP particularly with SNRIs; withdrawal on discontinuation.
Lithium	Plasma level; renal function/eGFR; thyroid function; calcium; weight/BMI; interacting drugs; hydration and toxicity education.
Valproate	Reproductive-safety eligibility and documentation; PPP where applicable; LFT/CBC as indicated; weight; adverse effects; contraception advice for males per current MHRA/NICE guidance.
Antipsychotics	Weight/BMI, waist, BP/pulse, HbA1c/glucose, lipids, prolactin, movement disorders; ECG when indicated; sedation and sexual/endocrine effects.
Clozapine	Mandatory haematological monitoring plus active surveillance for myocarditis, severe constipation/ileus, seizures, infection, metabolic adverse effects and smoking-related pharmacokinetic changes.
Stimulants	Pulse/BP, weight/BMI, sleep, appetite, mood, misuse/diversion, adherence and cardiovascular symptoms; growth in children.
Atomoxetine	Pulse/BP, weight, tolerability, mood; consider liver injury symptoms; sexual adverse effects in adults.
Pregabalin/benzodiazepines	Sedation, falls, cognitive effects, respiratory depressant combinations, misuse/dependence and withdrawal risk.

11. References and guidance sources

NICE. Depression in adults: treatment and management (NG222). Published 2022; reviewed January 2026.
NICE. Generalised anxiety disorder and panic disorder in adults: management (CG113). Current version includes April 2026 update links on dependence/withdrawal guidance.
NICE. Social anxiety disorder: recognition, assessment and treatment (CG159).
NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31). 2025 surveillance review concluded no guideline update was required.
NICE. Post-traumatic stress disorder (NG116).
NICE. Psychosis and schizophrenia in adults: prevention and management (CG178).
NICE. Bipolar disorder: assessment and management (CG185). Last updated September 2025, including updated valproate precautions.
NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87).
MHRA. Valproate safety measures and National Patient Safety Alert; updated regulatory position from January 2024, with subsequent 2025 advice for males.
BNF and current Summary of Product Characteristics (SmPC) for formulation-specific dosing, contraindications, interactions and monitoring.

The supplied February 2025 document provided the original structure and drug/condition coverage. The 2026 revision prioritizes current NICE and MHRA positions where these altered or qualified the earlier wording. The source document itself stated that it drew on NICE and related authoritative sources, but it also contained several secondary or non-authoritative web citations; these have not been carried forward as primary references.

Medication Choices in Mental Health