Polypharmacy Guidance: appropriate prescribing, making medicines safe, effective and sustainable 2025 - 2028

Antidepressants

• For mild depressive illness, the risk-benefit ratio is poor for mild depression, therefore consider non-pharmacological options
• A trial of antidepressant treatment may be appropriate for people with:
  • a history of moderate or severe depression
  • initial presentation of sub-threshold depressive symptoms existing over a long period (typically at least two years)
  • sub-threshold depressive symptoms or mild depression that persists after other interventions
• For moderate to severe depressive illness the use of antidepressants in combination with psychological therapies, is more effective, with lower discontinuation rates, than treatment with antidepressants alone. 
• For people who are at significant risk of relapse, or have a history of recurrent depression, discuss treatments to reduce the risk or recurrence, such as continuing medication, augmentation of medication or psychological treatment.
• Non-pharmacological management of symptoms of stress and distress in dementia should be considered and implemented as first line approaches.
• In anxiety: consider non-pharmacological options as the effectiveness of antidepressants in mild anxiety disorders is uncertain
• Review antidepressant use regularly and consider reducing or stopping, if appropriate. This should be done gradually

Benzodiazepines and z-drugs

These are considered non-essential medicines in most cases:

z-drugs: long-term use (more than four weeks) in insomnia

benzodiazepines: long-term use (more than four weeks) in insomnia, anxiety and back pain

• For insomnia, prior to starting, discuss with the individual the potential underlying causes and the use of non-pharmacological options,
• B-Z may be effective for the short-term treatment of insomnia, and/or anxiety disorders but use should be limited to less than two weeks on an ‘as required’ basis.
• In anxiety disorders, there are limited indications for the use of benzodiazepines, with increased risk of adverse effects
• Practitioners should proactively review benzodiazepine use and need when individuals are stable and well, with a focus on higher risk groups of people.
• For those who do not or cannot reduce/stop schedule more frequent reviews to detect and manage problems

Antipsychotics

Antipsychotic prescribing should be appropriate and safe, and any withdrawal/reduction is tailored to the individual and their circumstances.

• Potentially non-essential indications:
  • Anxiety and/ or psychomotor agitation
  • Symptoms of stress and distress in dementia (SSDD)
  • Delirium 

• If antipsychotics are required:
  • discuss the evidence base of antipsychotic use
  • agree the therapeutic objectives, balancing benefits and risks of treatment
  • use the lowest effective dose for the shortest time-period, except in life-long psychotic illness
• Regularly monitor efficacy and safety of treatment, e.g. for SSDD in care homes