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Manage Depression According to Symptom Severity
Dr Emma Nash
Dr Emma Nashdiscusses the approaches to recognising and treating depression outlined in NICE Guideline 222, which advocates use of the least intrusive therapies first
Read This Article to Learn More About:
the symptoms and impact of depression, and the new grading system introduced by NICE
identifying and diagnosing depression, and the importance of risk assessment
therapeutic options for depression according to severity and patient choice, and monitoring response to treatment.
Key points and implementation actions for integrated care systems and for clinical pharmacists in general practice can be found at the end of the article.
The original NICE guideline on depression in adults was published in 2009,1 and has been superseded by NICE Guideline (NG) 222—Depression in adults: treatment and management.2 Depression is a common presentation in primary care, and is associated with significant personal and socioeconomic impairment.2 It is established that the COVID-19 pandemic has adversely affected people’s mental health, and we are continuing to see the effects in our patients today.3 In addition to depression-related morbidity, the associated mortality statistics are stark.4 These, and other key contextual statistics on depression, are provided in Box 1.3–8
Box 1: Key Statistics on Depression3–8
According to the most recent data, in summer 2021 in Great Britain, around one in six people (17%) aged 16 years or older was experiencing depression as defined by the PHQ-8;3,5 this is higher than the pre-pandemic figure in adults of 10%3
Registrations of death by suicide in England in the first 6 months of 2022 stood at roughly 10 per 100,000 people, and the suicide rate in men was approximately three times that of women in this timeframe4
Mental illness is the fourth most common cause of sickness-related absence from work, behind minor illnesses and musculoskeletal problems6
When looking specifically at work-related ill health, 50% of new and long-standing cases of work-related ill health in 2020/2021 were as a result of stress, depression, or anxiety7
SSRIs are the most commonly prescribed type of antidepressant, with almost 3.8 million prescriptions issued in June 2022.8
PHQ-8=Eight-Item Patient Health Questionnaire; SSRI=selective serotonin reuptake inhibitor
Diagnosing Depression
According to the World Health Organization’s International classification of diseases 11th revision, depressive disorders are characterised by ‘depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioural, or neurovegetative symptoms that significantly affect the individual’s ability to function.’9 The Diagnostic and statistical manual of mental disorders: DSM-5 5th edition (DSM-5) is more prescriptive in its descriptors (see Box 2), specifying the timeframe and the number of symptoms that should be present.10
Box 2: DSM-5 Diagnostic Criteria for Major Depressive Disorder10
A. Five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
DSM-5=Diagnostic and statistical manual of mental disorders: DSM-5 5th edition
In primary care, we rarely need to refer to such criterion-based diagnostic manuals. NICE recognises the limitations of these criteria, and the individuality of the experience, articulation, and self-labelling of depression.2 Therefore, the recommendations made in NG222 apply equally to those without a clinical diagnosis but with self-defined depression or depressive symptoms.2
Grading Depression
NICE Guideline 222 has moved away from a finer grading of depression, instead favouring the terms ‘less severe’ and ‘more severe’.2 A threshold score of 16 or more using the Nine-Item Patient Health Questionnaire (PHQ-9)11 has been used as the definition of ‘more severe’.2
Many tools exist to aid us in the identification of depression and assessment of its severity. The most common is the PHQ-9, which broadly reflects the DSM-5 criteria for depression.10,11 The score, out of 27, is split into five outcomes, ranging from no depression to severe depression.11 However, NICE has elected to step back from these thresholds, instead adopting a simple split into less severe and more severe depression.2 The hope is that this simplification will help to increase uptake of the recommendations in routine clinical practice.
Although decreasing, there is still a stigma around mental illness,2 so a proactive approach to the detection of depression is recommended—particularly for higher-risk groups, such as those with a chronic physical illness or a history of depression. These screening questions will be familiar to clinicians, having previously been part of the Quality and Outcomes Framework (QOF):2
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?
If the answer to either of these questions is ‘yes’, then further evaluation of the person’s mental state is needed, including exploration of the impact on daily functioning and relationships.2
Initial Assessment and First Steps
Conversations about depression should be conducted in a way that engenders optimism for recovery.2 This can be challenging, especially with someone who is profoundly depressed. A careful and sensitive approach is needed to avoid appearing dismissive of their current distress, but offering hope for the future is important; stigma can present an obstacle to a person’s acceptance of their symptoms.2 Upholding the parity of esteem between physical and mental illness is also important.12
Assessment is about more than just mood. In my experience, patients come to us saying that their mood is low or that they are irritable, and that this is impacting their lives and functioning. Exploring the finer details of the impairment and symptom burden is helpful not only in terms of clarifying the diagnosis,2 but also to identify key areas of need, and the services that are best placed to support the person and those close to them. So many facets contribute to a person’s mental wellbeing that exploring and addressing just one in isolation is unlikely to be as successful as a whole-person approach. Figure 1 shows the areas that should be considered in a mental health assessment.
Figure 1: Dimensions of a Mental Health Assessment2
Unfortunately, time pressures mean that covering all of the areas shown in Figure 1 in a single appointment is unlikely. Practices may wish to consider how they can achieve this within their own ways of working—for instance, through a series of longer appointments with allied health professionals (for example, mental health workers or social prescribers) or via the involvement of external agencies (for example, wellbeing centres). The resources available vary by location, as does need, so it is likely that the approach will be developed in a way that suits a practice’s or primary care network’s population and locality.
Risk Assessment
Although eliciting some aspects of the history can be deferred, asking about risk is essential at some stage during the initial consultation.2 Questioning must be direct, so it is clear what you are asking; it does not increase the risk of the person acting on thoughts of suicide or self-harm, and offers you the opportunity to plan mitigating interventions.2 Agitation, negativity, and hopelessness prompt particular concern, along with active suicidal planning or expressions of intent; in this situation, urgent referral to specialist mental health services is warranted.2 If you do not deem the person to be at immediate risk, identifying protective factors (for example, family, friends, upcoming positive events), planning additional and more frequent support, and working out a safety plan for what to do if things deteriorate can be helpful options.2,13 More information on risk assessment and strategies to reduce risk can be found in NG225, Self-harm: assessment, management and preventing recurrence.14
Approach to Treatment
The NICE guideline on depression is aligned with other NICE guidelines that place emphasis on autonomy and patient choice and the need for shared decision making.2,15,16 NG222 also recommends that advance decisions are made in line with the provisos in the Mental Capacity Act 2005,2,17 especially for people with a history of severe or psychotic depression, and for those who have previously received treatment under the Mental Health Act 2007.2,18
Given the focus on patient collaboration, communication is key. Barriers resulting from disability, language, or other needs must be recognised, and steps taken to overcome them.2 Depression frequently co-occurs with other mental health conditions; advice on the assessment and management of depression in the context of autism,19 dementia,20 and learning disabilities21 is provided in specific NICE guidelines.
Deciding on Treatment
When treatment is being discussed, identifying precipitating and perpetuating factors for depression is helpful.2 Although addressing these may be beneficial to recovery, resolution will not always be possible, and acceptance of this can be difficult.
The person should be asked about any preferences they have for management, their previous experiences of any treatments, and what their expectations are of interventions and its effects.2 The discussion should cover the NICE-recommended options (see Tables 1 and 2), their potential benefits and harms, and current waiting times for treatments.2 Given the importance of a good therapeutic relationship with a healthcare professional and of continuity of care, NICE endorses the opportunity for a patient to express a preference regarding the gender of their treating healthcare professional.2
Table 1: Treatment Options for Less Severe Depression in Order of the Committee’s Interpretation of Their Clinical and Cost Effectiveness and Consideration of Implementation Factors2
Treatment
How is This Delivered?
Key Features
Other Things to Think About
Guided self-help
Printed or digital materials that follow the principles of guided self-help including structured cognitive behavioural therapy (CBT), structured behavioural activation (BA), problem-solving or psychoeducation materials. These can be delivered in person, by telephone, or online
Support from a trained practitioner who facilitates the self-help intervention, encourages completion and reviews progress and outcomes
Usually consists of 6 to 8 structured regular sessions.
Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently
Goal-oriented and structured
Focuses on resolving current issues.
May suit people who do not like talking about their depression in a group
Needs self-motivation and willingness to work alone (although regular support is provided)
Allows flexibility in terms of fitting sessions in around other commitments
Need to consider access, and ability to engage with computer programme for digital formats
Less capacity for individual adaptations than individual psychological treatments
Avoids potential side effects of medication.
Group cognitive behavioural therapy (CBT)
A group intervention delivered by 2 practitioners, at least 1 of whom has therapy-specific training and competence
Usually consists of 8 regular sessions
Usually 8 participants in the group
Delivered in line with current treatment manuals.
Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently
Goal-oriented and structured
Focuses on resolving current issues.
May be helpful for people who can recognise negative thoughts or unhelpful patterns of behaviour they wish to change
May allow peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Group behavioural activation (BA)
A group intervention delivered by 2 practitioners, at least 1 of whom has therapy-specific training and competence
Usually consists of 8 regular sessions
Usually 8 participants in the group
Delivered in line with current treatment manuals.
Focuses on identifying the link between an individual’s activities and their mood. Helps the person to recognise patterns and plan practical changes that reduce avoidance and focus on behaviours that are linked to improved mood
Goal-oriented and structured
Focuses on resolving current issues
Does not directly target thoughts and feelings.
May be helpful for people whose depression has led to social withdrawal, doing fewer things, inactivity, or has followed a change of circumstances or routine
May allow peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Individual CBT
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 8 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals
Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently
Goal-oriented and structured
Focuses on resolving current issues.
May be helpful for people who can recognise negative thoughts or unhelpful patterns of behaviour they wish to change
May suit people who do not like talking about their depression in a group
No opportunity to receive peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Individual BA
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 8 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals.
Focuses on identifying the link between an individual’s activities and their mood. Helps the person to recognise patterns and plan practical changes that reduce avoidance and focus on behaviours that are linked to improved mood
Goal-oriented and structured
Focuses on resolving current issues
Does not directly target thoughts and feelings.
May be helpful for people whose depression has led to social withdrawal, doing fewer things, inactivity, or has followed a change of circumstances or routine
May suit people who do not like talking about their depression in a group
No opportunity to receive peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Group Exercise
A group physical activity intervention provided by a trained practitioner
Uses a physical activity programme specifically designed for people with depression
Usually consists of more than 1 session per week for 10 weeks
Usually 8 participants in the group.
Includes moderate intensity aerobic exercise
Does not directly target thoughts and feelings.
May allow peer support from others who may be having similar experiences
May need to be adapted if the person has physical health problems that make it difficult to exercise
May need to be adapted to accommodate psychological aspects, for example anxiety or shame which may act as barriers to engagement
Needs a considerable time commitment
Can help with physical health too
Avoids potential side effects of medication.
Group mindfulness and meditation
A group intervention provided preferably by 2 practitioners, at least 1 of whom has therapy-specific training and competence
Uses a programme such as mindfulness-based cognitive therapy specifically designed for people with depression
Usually consists of 8 regular sessions
Usually, 8 to 15 participants in the group.
Focus is on concentrating on the present, observing and sitting with thoughts and feelings and bodily sensations, and breathing exercises
Involves increasing awareness and recognition of thoughts and feelings, rather than on changing them
Does not directly help with relationship, employment or other stressors that may contribute to depression.
May be helpful for people who want to develop a different perspective on negative thoughts, feelings or bodily sensations
May be difficult for people experiencing intense or highly distressing thoughts, or who find focusing on the body difficult
May allow peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments, including using mindfulness recordings at home in between sessions.
Interpersonal psychotherapy (IPT)
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 8 to 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals.
Focus is on identifying how interpersonal relationships or circumstances are related to feelings of depression, exploring emotions and changing interpersonal responses
Structured approach
Focuses on resolving current issues
The goal is to change relationship patterns rather than directly targeting associated depressive thoughts.
May be helpful for people with depression associated with interpersonal difficulties, especially adjusting to transitions in relationships, loss, or changing interpersonal roles
May suit people who do not like talking about their depression in a group
Needs a willingness to examine interpersonal relationships
Avoids potential side effects of medication.
Selective serotonin reuptake inhibitors (SSRIs)
A course of antidepressant medication
Usually taken for at least 6 months (including after symptoms remit)
See the recommendations on starting and stopping antidepressant medication for more details.
Modify neuronal transmission in the brain.
Minimal time commitment although regular reviews needed (especially when starting and stopping treatment)
Benefits should be felt within 4 weeks
There may be side effects from the medication, and some people may find it difficult to later stop antidepressant medication.
Counselling
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 8 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Uses an empirically validated protocol developed specifically for depression.
Focus is on emotional processing and finding emotional meaning, to help people find their own solutions and develop coping mechanisms
Provides empathic listening, facilitated emotional exploration and encouragement
Collaborative use of emotion focused activities to increase self-awareness, to help people gain greater understanding of themselves, their relationships, and their responses to others, but not specific advice to change behaviour.
May be useful for people with psychosocial, relationship or employment problems contributing to their depression
May suit people who do not like talking about their depression in a group
Avoids potential side effects of medication.
Short-term psychodynamic psychotherapy (STPP)
Individual sessions delivered by a practitioner with therapy-specific training and competence
Usually consists of 8 to 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Uses an empirically validated protocol developed specifically for depression.
Focus is on recognising difficult feelings in significant relationships and stressful situations, and identifying how patterns can be repeated
Both insight-oriented and affect focused
Relationship between therapist and person with depression is included as a focus to help support working through key current conflicts.
May be useful for people with emotional and developmental difficulties in relationships contributing to their depression
May be less suitable for people who do not want to focus on their own feelings, or who do not wish or feel ready to discuss any close and/or family relationships
May suit people who do not like talking about their depression in a group
Focusing on painful experiences in close and/or family relationships could initially be distressing
All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
Table 2: Treatment Options for More Severe Depression in Order of the Committee's Interpretation of their Clinical and Cost Effectiveness and Consideration of Implementation Factors2
Treatment
How is This Delivered?
Key Features
Other Things to Think About
Combination of individual cognitive behavioural therapy (CBT) and an antidepressant
A combination of individual CBT and a course of antidepressant medication (see details below).
Combines the benefits of regular CBT sessions with a therapist and medication.
Sessions with a therapist provide immediate support while the medication takes time to work or medication can be started immediately, and then CBT started as soon as possible afterwards to obtain combined effects
There may be side effects from the medication, and some people may find it difficult to later stop antidepressant medication.
Individual CBT
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals.
Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently
Goal-oriented and structured
Focuses on resolving current issues.
May be helpful for people who can recognise negative thoughts or unhelpful patterns of behaviour they wish to change
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Individual behavioural activation (BA)
Individual intervention delivered by a practitioner with therapy-specific training and competence
Usually consists of 12 to 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals.
Focuses on identifying the link between an individual’s activities and their mood. Helps the person to recognise patterns and plan practical changes that reduce avoidance and focus on behaviours that are linked to improved mood
Goal-oriented and structured
Focuses on resolving current issues
Does not directly target thoughts and feelings.
May be helpful for people whose depression has led to social withdrawal, doing fewer things, inactivity, or has followed a change of circumstances or routine
May suit people who do not like talking about their depression in a group
No opportunity to receive peer support from others who may be having similar experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Antidepressant medication
Usually taken for at least 6 months (and for some time after symptoms remit)
Can be a selective serotonin reuptake inhibitor (SSRI), serotonin–norepinephrine reuptake inhibitor (SNRI), or other antidepressant if indicated based on previous clinical and treatment history
See the recommendations on starting and stopping antidepressant medication for more details.
SSRIs are generally well tolerated, have a good safety profile and should be considered as the first choice for most people
Tricyclic antidepressant (TCAs) are dangerous in overdose, although lofepramine has the best safety profile.
Choice of treatment will depend on preference for specific medication effects such as sedation, concomitant illnesses or medications, suicide risk and previous history of response to antidepressant medicines
Minimal time commitment, although regular reviews needed (especially when starting and stopping treatment)
Benefits should be felt within 4 weeks
There may be side effects from the medication, and some people may find it difficult to later stop antidepressant medication.
Individual problem-solving
Individual sessions delivered by a practitioner with therapy-specific training and competence
Usually consists of 6 to 12 regular sessions
Delivered in line with current treatment manuals.
Focus is on identifying problems, generating alternative solutions, selecting the best option, developing a plan and evaluating whether it has helped solve the problem
Goal-oriented and structured
Focuses on resolving current issues.
May be helpful for people who want to tackle current difficulties and improve future experiences
Avoids potential side effects of medication
The person will need to be willing to complete homework assignments.
Counselling
Individual sessions delivered by a practitioner with therapy-specific training and competence.
Usually consists of 12 to 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Uses an empirically validated protocol developed specifically for depression.
Focus is on emotional processing and finding emotional meaning, to help people find their own solutions and develop coping mechanisms
Provides empathic listening, facilitated emotional exploration and encouragement
Collaborative use of emotion focused activities to increase self-awareness, to help people gain greater understanding of themselves, their relationships, and their responses to others, but not specific advice to change behaviour.
May be useful for people with psychosocial, relationship or employment problems contributing to their depression
May suit people who do not like talking about their depression in a group
Avoids potential side effects of medication.
Short-term psychodynamic psychotherapy (STPP)
Individual sessions delivered by a practitioner with therapy-specific training and competence
Usually consists of 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Uses an empirically validated protocol developed specifically for depression.
Focus is on recognising difficult feelings in significant relationships and stressful situations, and identifying how patterns can be repeated
Both insight-oriented and affect focused
Relationship between therapist and person with depression is included as a focus to help support working through key current conflicts.
May be useful for people with emotional and developmental difficulties in relationships contributing to their depression
May be less suitable for people who do not want to focus on their own feelings, or who do not wish or feel ready to discuss any close and/or family relationships
May suit people who do not like talking about their depression in a group
Focusing on painful experiences in close and/or family relationships could initially be distressing
Avoids potential side effects of medication.
Interpersonal psychotherapy (IPT)
Individual sessions delivered by a practitioner with therapy-specific training and competence
Usually consists of 16 regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms
Delivered in line with current treatment manuals.
Focus is on identifying how interpersonal relationships or circumstances are related to feelings of depression, exploring emotions and changing interpersonal responses
Structured approach
Focuses on resolving current issues
The goal is to change relationship patterns rather than directly targeting associated depressive thoughts.
May be helpful for people with depression associated with interpersonal difficulties, especially adjusting to transitions in relationships, loss, or changing interpersonal roles
May suit people who do not like talking about their depression in a group
Needs a willingness to examine interpersonal relationships
Avoids potential side effects of medication.
Guided self-help
Printed or digital materials that follow the principles of guided self-help including structured CBT, structured BA, problem-solving or psychoeducation materials. These can be delivered in person, by telephone, or online
Support from a trained practitioner who facilitates the self-help intervention, encourages completion and reviews progress and outcome
Support usually consists of 6 to 8 structured, regular sessions.
Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently
Goal-oriented and structured
Focuses on resolving current issues.
In more severe depression, the potential advantages of providing other treatment choices with more therapist contact should be carefully considered first
Needs self-motivation and willingness to work alone (although regular support is provided)
Allows flexibility in terms of fitting sessions in around other commitments
Need to consider access, and ability to engage with computer programme for digital formats
Less capacity for individual adaptations than individual psychological treatments
Avoids potential side effects of medication.
Group exercise
A group physical activity intervention provided by a trained practitioner
Uses a physical activity programme specifically designed for people with depression
Usually consists of more than 1 session per week for 10 weeks
Usually 8 participants in the group.
Includes moderate intensity aerobic exercise
Does not directly target thoughts and feelings.
In more severe depression, the potential advantages of providing other treatment choices with more therapist contact should be carefully considered first
May allow peer support from others who are may be having similar experiences
May need to be adapted if the person has physical health problems that prevent exercise
May need to be adapted to accommodate psychological aspects, for example anxiety or shame which may act as barriers to engagement
All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
It is worth remembering that, just because a patient has presented to you, it does not necessarily mean that they want medical treatment for their depression. In the event that a patient does not want treatment, a follow-up assessment is recommended, and the patient should be provided with guidance on how to seek further help if they change their mind.2 Discussing their vulnerabilities and potential to address precipitating or perpetuating factors is also useful.
Some patients may have considered St John’s Wort in an attempt to self-manage. The latest guidance reiterates previous advice that St John’s Wort should not be recommended because of variation in the potencies of preparations and potentially serious interactions with other drugs.2
Treatment Options
For patients who do want treatment, the options recommended by the guideline are split between less severe and more severe depression (see Tables 1 and 2), although there is overlap between these categories.2 For each severity of depression, the least intrusive and least resource-intensive treatment should be considered first.2 The guideline contains some useful diagrams that show the treatment options recommended for less severe and more severe depression in order of recommendation.2
Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice, followed by lofepramine if SSRIs are not suitable.2 There is no recommended first-line SSRI, but various factors come into play in choosing a drug of this class, such as physical comorbidities and previous responses to treatment.2 Generally, setraline is preferred because it has a lower risk of drug interactions, and is considered safe in people with certain cardiovascular conditions.22,23 Fluoxetine and paroxetine should not be used by someone taking tamoxifen for breast cancer, as these agents impair the formation of tamoxifen’s active metabolite, endoxifen.24 Paroxetine and venlafaxine are associated with a higher risk of discontinuation symptoms than other SSRIs,24 whereas fluoxetine—which has a relatively long half-life—is easier to stop.25 In line with the recent NICE guideline Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults (NG215), patients should be given verbal and written information about the medicine, and agree a medicines management plan.26 It is important to ensure that patients are aware that treatment continuation is recommended for at least 6 months following remission.2
Both lithium and antipsychotics are included in the guidance for augmentation of antidepressant therapy, with the recommendation that they are used with the principle of shared care between general practice and specialist services.2 Monitoring will often happen in primary care, however. For lithium, it is recommended that practitioners assess weight, renal and thyroid function, and calcium levels before treatment, then monitor at least every 6 months during treatment, or more frequently in certain circumstances.2 For antipsychotics, monitoring would include assessment of weight, full blood count, renal function, liver function, prolactin, glycated haemoglobin, and lipids, with an electrocardiogram needed in some circumstances.2
Treatment Delivery
There is considerable local variation in how and where treatments are delivered to patients. In the primary care setting, psychological interventions will typically be delivered by referral to a local Improving Access to Psychological Therapies provider, and the decision regarding the most appropriate treatment and mode of delivery will be made by them. Some practices may have specialist mental health practitioners in place, particularly in light of the expansion of the Additional Roles Reimbursement Scheme, or access to third-sector wellbeing centres that are able to provide these treatments.
Patients may not always be receptive to the concept of psychological interventions, especially when they are delivered in groups or remotely. Having a conversation about expectations and experiences of treatment is beneficial in establishing the patient’s beliefs and goals.2 In primary care, we do need to have some awareness of the nature of these ‘talking therapies’ to be able to discuss them properly with patients. Tables 1 and 2 offer a succinct summary.2
Monitoring and Reviewing Treatment
Patients should be reviewed between 2 and 4 weeks after starting treatment for depression to assess how well the therapy is working.2 In patients receiving medication, concordance and any side effects should be discussed.2 Suicide risk needs to be particularly carefully monitored,2 as it can transiently increase. Extra vigilance is needed in those at risk of suicide and in people aged 18–25 years who are taking antidepressants.2 Higher-risk patients should be reviewed 1 week after starting treatment or having a dose adjustment, and reviewed again within 4 weeks.2
Treatment should be continued for at least 4 weeks (6 weeks in elderly patients) before deciding there is no response.23 At this point, the dose may be increased, an alternative medication can be tried, or the addition or replacement of a medication with a psychological therapy can be considered.2 In accordance with the QOF indicators for depression,27 once a new diagnosis is coded, a review should take place 10–56 days from diagnosis, regardless of whether or not pharmacological treatment is started. A timelier review, as described here, is recommended.2
The provision of psychological interventions is usually time limited. If there is not complete remission, other treatments may be considered, active review can be adopted, or a repeat course of treatment may be recommended.2 This depends very much on local provision and service availability, and eligibility may be a blocker. A number of support groups are detailed on the NHS website.28
Treatment Continuation and Cessation
In some patients, pharmacological treatment will be continued for several years; in others, the treatment period may be just months. Many factors influence the decision on how long to treat, such as the number and severity of previous episodes, and personal circumstances. Discussion at the start of treatment is best practice, in addition to intermittent reviews during the course of medication.2
When the time comes for cessation of treatment, gradual withdrawal is prudent. Common withdrawal symptoms include nausea, sweating, palpitations, ‘electric shock’ sensations, dizziness, restlessness, and insomnia.29 A slow dose reduction (a 50% reduction from the previous dose [possibly a 25% reduction at lower doses], and no more often than fortnightly) will reduce the chances of problematic discontinuation.26 Withdrawal symptoms usually resolve within 1–2 weeks, and reassurance may be all that is needed. Occasionally, they can persist longer, and withdrawal can take several weeks or months, using smaller and slower incremental dose reduction.
Summary
Much of the new NICE guidance is familiar territory, but there is a stronger emphasis on autonomy, patient information and choice, and self-help in the latest version; this should be reflected in our practice.
Key Points
Depression is a common presentation in primary care, with considerable associated morbidity and mortality
Diagnostic manuals such as ICD-11 or DSM-5 may be used to define the criteria for depression, but the NICE guideline is just as applicable to people with self-defined depression or depressive symptoms as it is to those who meet the diagnostic threshold
NG222 classifies depression as ‘less severe’ or ‘more severe’, using a threshold score of 16 or more on the PHQ-9 to indicate more severe depression
Patient information, therapeutic relationships, and autonomy are key to the management of depression
Verbal and written information, along with forward care planning for treatment strategies, is recommended
Nonpharmacological treatments include a range of psychological therapies, guided self-help, and lifestyle optimisation, as well as addressing individual precipitating or perpetuating factors
SSRIs remain the first-line option when pharmacological treatment is indicated; the choice of antidepressant needs to be made at an individual level
A number of factors need to be considered when deciding on the duration of pharmacological treatment, such as previous episodes and their frequency and severity, life stressors, and the availability of personal and social supportive factors.
ICD-11=International classification of diseases 11th revision; DSM-5=Diagnostic and statistical manual of mental disorders: DSM-5 5th edition; NG=NICE Guideline; PHQ-9=Nine-Item Patient Health Questionnaire; SSRI=selective serotonin reuptake inhibitor
Implementation Actions for ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.
Review local services to ensure that there is access to talking therapies, as recommended by NICE, with clear pathways and thresholds for referral to specialist services
Publish antidepressant choices, with guidance on discontinuation and cross-tapering when changing drugs, in local formularies
Ensure that there is a rapid-response service available for those with thoughts or a risk of self-harm or suicide
Explore options for building mental health practitioners working in PCNs (in England) into local care pathways, with appropriate supervision from specialist services
Consider education programs for primary care practitioners to help them recognise and identify depression in people presenting with other issues, or in chronic disease monitoring appointments.
ICS=integrated care system; PCN=primary care network
Implementation Actions for Clinical Pharmacists in General Practice
By Shivangee Maurya, Clinical Pharmacist, Soar Beyond
In England, one in four people experience a mental health problem of some kind every year, and one in six people report experiencing a common mental health condition (like anxiety or depression) in any given week.[A] When conducting structured medication reviews, GP clinical pharmacists can support patients experiencing mental ill health in the following ways:
upskill and refresh your knowledge by keeping abreast of the most up-to-date guidelines and applying them to your practice
approach mental health conditions sensitively, as they can lead to stigmatisation and often make patients feel discriminated against; ensure that you are open, engaging, and nonjudgemental in your manner[B]
share decision making and explore various management options, both pharmacological and nonpharmacological, that are individualised for each patient
be alert for any possible symptoms of depression and consider asking patients:[B]
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?
consider referring the patient to an appropriate professional for a mental health assessment if a patient answers yes to the above questions[B] and it is outside of your competence
ensure that, if within your competence to assess the patient, you are asking all the appropriate questions—for example, regarding thoughts on suicide or self-harm—and are utilising appropriate tools and resources (such as the PHQ-9 questionnaire)
maintain clear and accurate documentation for the benefit of other healthcare professionals who will be reviewing the patient
follow up and enter diary date alerts to ensure that patients are reviewed in a timely fashion
utilise the multidisciplinary team to ensure that the patient receives the best care from the most appropriate healthcare professional, such as a mental health nurse
signpost to organisations and websites that can introduce self-help methods and support mental health.
The i2i Network stands for insight-to-implementation. The network brings together clinical pharmacists from across the UK to help support, upskill, and equip pharmacists to manage long-term conditions. To sign up for free, or find out more, visit www.i2ipharmacists.co.uk
