NICE updates recommendations for treating adult depression


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.

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