NICE
updates recommendations for treating adult depression
A
new recommendation from NICE for treating adult depression has been released
(NG222). The guidance provides new recommendations on service delivery,
treating various types of depression, and preventing relapse. It also updates
and supersedes NICE guideline CG90, which was first published in October 2009.
Healthcare
professionals should inform patients about the NICE-recommended treatment
options that are available as well as their advantages, disadvantages, and
expected outcomes. They should then collaborate with the patient to decide on
the best course of action, taking into account the patient's preferences and
the clinical situation (while respecting the patient's right to refuse
treatment). People should be informed that stopping antidepressant medication
might cause withdrawal symptoms and that most often dose reduction is required
before stopping, even though most patients are able to discontinue effectively.
Less
severe depression, as defined by NICE, is subthreshold or moderate depression
with a PHQ-9 score of less than 16. For less severe depression, antidepressant
medication shouldn't often be prescribed first, unless the patient specifically
requests it. Following guided self-help, group cognitive behavioural therapy
(CBT), group behavioural activation, individual CBT, individual behavioural
activation, group exercise intervention, group mindfulness and meditation,
interpersonal psychotherapy, SSRIs, counselling, and short-term psychodynamic
psychotherapy are the first-line treatment options for a new episode of less
severe depression, in that order.
The
phrase "more severe depression" refers to both moderate and severe
depression, which is indicated by a PHQ-9 score of 16 or above. A combination
of individual CBT and an antidepressant, individual CBT, individual behavioural
activation, individual antidepressant medication (an SSRI being the first
choice for most patients), individual problem solving delivered by a trained
practitioner, counselling, and short-term psychodynamic psychotherapy are the
first-line treatment options for patients with a new episode of more severe
depression, again in order of clinical and financial effectiveness and ease of
implementation. To assist in decision-making, the recommendation contains
detailed tables that describe how each choice is offered, its benefits and
drawbacks, and the potential beneficiaries of each.
If
full or partial remission has been attained following a period of depression
treatment, NICE offers recommendations for avoiding return. They should be
supported to stop taking antidepressants safely if they choose to do so. The
dangers and advantages of continuing or quitting antidepressant treatment for a
patient should be discussed at least every six months.
If
they have not improved after four to six weeks of first-line therapy, the
recommendation also offers recommendations on second-line therapy. Options
include changing to a different antidepressant, trying an alternative psychological
treatment, or combining an antidepressant with psychological therapy after
addressing any issues that might affect response and evaluating the diagnosis.
Combining antidepressants raises the burden of adverse effects, thus consulting
a specialist is advisable.
For
patients with personality disorders and depression, NICE offers specific
recommendations, advising combining antidepressant medication with
psychological therapies like behavioural activation, cognitive behavioural
therapy (CBT), interpersonal psychotherapy, or short-term psychodynamic
psychotherapy, which can be extended up to one year if necessary. Referrals to
specialised mental health services should be made available to people who have
depression along with psychotic symptoms. Possible treatments include combining
an antidepressant with an antipsychotic medication and adding psychological
counselling once the acute symptoms have subsided. CBT, an SSRI, an SNRI, a
tricyclic antidepressant, or CBT with an SSRI or tricyclic can be considered as
initial treatment for individuals who present with chronic depression symptoms
that considerably impede personal and social functioning. If these treatments
or subsequent lines of treatment are ineffective, a specialist's opinion on alternative
treatment alternatives should be sought.