‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.

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   1. The MHRA (May 2006) recommend: The NICE advice that venlafaxine should be reserved as a second-line treatment (after SSRIs) still stands. Venlafaxine acts in a dose-dependent way on neurotransmitter pathways. At low doses it resembles a SSRI, whilst at higher doses it also interferes with noradrenaline reuptake. Prescribers should also note its higher propensity for withdrawal symptoms if stopped abruptly, its toxicity in overdose and its higher cost at high doses. Specialist supervision (including shared care arrangements) is now only required for initiation of venlafaxine treatment in those severely depressed or hospitalised patients who require doses of 300 mg daily, or above. Venlafaxine is contraindicated in patients with an identified high risk of a serious cardiac ventricular arrhythmia or uncontrolled hypertension. Regular measurement of blood pressure is recommended for patients receiving venlafaxine.

   2. Duloxetine is an SNRI antidepressant and, like venlafaxine, is an appropriate choice as third line agent.  Duloxetine is contraindicated in patients with uncontrolled hypertension that could expose patients to a potential risk of hypertensive crisis. In patients with known hypertension and/or other cardiac disease, blood pressure monitoring is recommended, especially during the first month of treatment.