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Depression (update)
Implementing NICE guidance
2009
NICE clinical guideline 90
Updated guidance
This guideline partially updates and replaces:
• ‘Depression: management of depression in primary
and secondary care’ (NICE clinical guideline 23)
• The recommendations relating to depression made in:
– ‘Guidance on the use of electroconvulsive therapy’
(NICE technology appraisal guidance 59)
– ‘Computerised cognitive behavioural therapy for
depression and anxiety (review)’ (NICE
technology appraisal guidance 97).
What this presentation covers
Background
Scope and definitions
Key priorities for implementation
Costs and savings
Discussion
Find out more
Background
• Depression is a broad and heterogeneous diagnosis
• Central to it is depressed mood and/or loss of pleasure
in most activities
• A wide range of biological, psychological and social
factors have a significant impact on the course of
depression and the response to treatment
Scope of guidance
The guideline covers:
• adults (aged 18 years and older) with a diagnosis of
depression
• people in the above group who also have learning
difficulties, acquired cognitive impairments or
language difficulties.
Definitions (1)
Subthreshold depressive symptoms: fewer than five
symptoms of depression.
Mild depression: few, if any, symptoms in excess of the
five required to make the diagnosis and symptoms result
in only minor functional impairment.
Moderate depression: Symptoms or functional
impairment are between ‘mild’ and ‘severe’.
Severe depression: Most symptoms and the symptoms
markedly interfere with functioning. Can occur with or
without psychotic symptoms.
Definitions (2)
Key symptoms
• persistent sadness or low mood
• and/or
• marked loss of interests or
pleasure
Associated symptoms
• disturbed sleep (decreased or
increased compared to usual)
• decreased or increased
appetite and/or weight
• fatigue or loss of energy
• agitation or slowing of
movements
• poor concentration or
indecisiveness
• feelings of worthlessness or
excessive or inappropriate guilt
• suicidal thoughts or acts.
Key priorities for
implementation
The areas identified as key priorities for implementation are:
• Principles for assessment
• Effective delivery of interventions for depression
• Case identification and recognition
• Low-intensity psychosocial interventions
• Drug treatment
• Treatment for moderate or severe depression
• Continuation and relapse prevention
• Psychological interventions for relapse prevention
Principles for assessment
• When assessing a person who may have depression,
conduct a comprehensive assessment that does not
rely simply on a symptom count.
• Take into account:
– the degree of functional impairment and/or disability
associated with the possible depression and
– the duration of the episode.
Effective delivery of
interventions for depression (1)
• All interventions should be delivered by competent
practitioners.
• Psychological and psychosocial interventions should be
based on the relevant treatment manual(s).
• Practitioners should consider using competence
frameworks.
Effective delivery of
interventions for depression (2)
For all interventions, practitioners should:
• receive regular high-quality supervision
• use routine outcome measures
• ensure the patient with depression is involved in
reviewing treatment efficacy
• engage in monitoring and evaluation of:
– treatment adherence
– practitioner competence.
The stepped-care model
Focus of the
intervention
STEP 4: Severe and complex1
depression; risk to life; severe selfneglect
STEP 3: Persistent subthreshold depressive
symptoms or mild to moderate depression with
inadequate response to initial interventions;
moderate and severe depression
STEP 2: Persistent subthreshold depressive
symptoms; mild to moderate depression
STEP 1: All known and suspected presentations of
depression
1,2
see slide notes
Nature of the
intervention
Medication, high-intensity psychological
interventions, electroconvulsive therapy,
crisis service, combined treatments,
multiprofessional and inpatient care
Medication, high-intensity psychological
interventions, combined treatments, collaborative
care2, and referral for further assessment and
interventions
Low-intensity psychosocial interventions, psychological
interventions, medication and referral for further
assessment and interventions
Assessment, support, psycho-education, active monitoring
and referral for further assessment and interventions
Case identification and
recognition
• Be alert to possible depression
– Particularly in people with a past history of depression
or a chronic physical health problem with associated
functional impairment.
• Consider asking people who may have depression
two questions, specifically:
– During the last month, have you often been bothered by
feeling down, depressed or hopeless?
– During the last month, have you often been bothered by
having little interest or pleasure in doing things?
Low-intensity psychosocial
interventions
• For people with persistent subthreshold depressive
symptoms or mild to moderate depression, consider
offering one or more of the following interventions,
guided by the person’s preference:
– individual guided self-help based
on the principles of cognitive
behavioural therapy (CBT)
– computerised cognitive
behavioural therapy (CCBT)
– a structured group physical
activity programme.
Drug treatment
• Do not use antidepressants routinely to treat persistent
subthreshold depressive symptoms or mild depression
because the risk–benefit ratio is poor
• Consider antidepressants for people with:
– a past history of moderate or severe depression or
– subthreshold depressive symptoms present for a long time or
– subthreshold depressive symptoms or mild depression that
persist(s) after other interventions.
Treatment for moderate or
severe depression
• For people with moderate or severe depression,
provide a combination of antidepressant medication
and a high-intensity psychological intervention
(cognitive behavioural therapy [CBT] or interpersonal
therapy [IPT]).
Continuation and relapse
prevention
• Support and encourage a person who has benefited
from taking an antidepressant to continue medication
for at least 6 months after remission of an episode of
depression.
• Discuss with the person that:
– this greatly reduces the risk of relapse
– antidepressants are not associated with addiction.
Psychological interventions
for relapse prevention
People with depression who are considered to be at
significant risk of relapse or who have residual symptoms,
should be offered one of the following psychological
interventions:
• individual CBT:
– for people who have relapsed despite antidepressant medication
– for people with a significant history of depression and residual
symptoms despite treatment.
• mindfulness-based cognitive therapy:
– for people who are currently well but have experienced three
or more previous episodes of depression.
Costs and savings
• It has not been possible to determine costs or savings.
• It is difficult to establish a national cost because of:
– local circumstances
– implementation of the previous depression guideline (NICE
clinical guideline 23)
– other initiatives such as Improving Access to Psychological
Therapies
• It is anticipated that there will be:
– an increase in people receiving low intensity interventions for
depression
– a decrease in those receiving high intensity interventions.
Discussion
• What range of interventions are available for our
patients?
• How do we monitor the effectiveness of case
identification and recognition in our patients?
• How do we assure the quality of psychological and
psychosocial interventions?
• How does our management of relapse
prevention compare with the guidelines?
Find out more
Visit www.nice.org.uk/CG90 for:
•
•
•
•
•
the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support.