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NICE reconsults on depression guidelines after experts warn of 'significant flaws'

NICE has launched a second consultation on a new guideline for treating and managing depression in adults.

The advisory body said it took the unusual decision after listening to stakeholder comments on the guideline in development, which included new advice on referrals to psychological interventions and prescribing of drugs for moderate to severe depression.

The new consultation on a revised draft opened yesterday and will close on 12 June. Following the consultation, the guideline advisory group is to meet again to decide a new publication date, expected in 'the autumn'.

The revised guideline includes new advice on high-intensity psychological referral options for patients with severe depression, including psychotherapy.

It also includes updated advice on prescribing, monitoring and reducing pharmacological interventions.

An earlier consultation was completed in September last year, with the guideline publication date initially planned for January 2018.

But a group of mental health experts - including the medical director for the GP Practitioner Health Programme, Professor Clare Gerada - wrote to NICE in November 2017 to say they were 'extremely concerned about significant flaws in methodology, lack of transparency and inconsistencies in the document'.

The experts said that 'without a second consultation being granted to allow these serious concerns to be addressed, the guideline will not be fit for purpose and will seriously impede good patient care and patient choice'.

The experts claimed the guideline as proposed had 'an extremely narrow focus on symptom outcomes'; was 'completely out of step with US and European guideline methodologies'; and said its focus on 'very short-term outcomes' meant it failed to meet the NHS agenda of 'parity of esteem' for mental and physical health.

Professor Gerada - who had not had a chance to study the full revised guideline at the time of writing - told Pulse that although there was a 'short time frame' for responding, 'the launch of a second consultation is very good news'.

Professor Mark Baker, director of the NICE centre for guidelines said: 'We recognise the importance of our guideline on the management of depression in the NHS and we want to ensure it is actively put into practice.

'We listened to views from a wide range of stakeholders and have published a revised guideline for further consultation, as well as information on how earlier comments have been responded to by the advisory committee.

'We hope this will help to remove any potential barriers to implementation and we welcome further comments on this revised draft.'

It is very rare for NICE to re-consult on a draft guideline. However, it was forced to do so last year when GPs piloting a recommended algorithm for asthma diagnosis found it to be expensive, time consuming and ineffective.

Key updates in the 2018 draft guideline

1.4.11 When stopping antidepressant medication, take into account the pharmacokinetic profile (for example, the half-life of the medication) and slowly reduce the dose at a rate proportionate to the duration of treatment. For example, this could be over some months if the person has been taking antidepressant medication for several years.

1.4.12 Monitor people taking antidepressant medication while their dose is being reduced. If needed, adjust the speed and duration of dose reduction according to symptoms.

1.4.13 When reducing a person’s dose of antidepressant medication, be aware that paroxetine and venlafaxine are more likely to be associated with discontinuation symptoms, so particular care is needed with them.

1.4.18 Take into account toxicity in overdose when prescribing an antidepressant medication for people at significant risk of suicide, and do not routinely initiate treatment with:

  • tricyclic antidepressants (TCAs), except lofepramine, as they are associated with the greatest risk in overdose
  • venlafaxine as compared with other equally effective antidepressant medication recommended for routine use in primary care, it is associated with a greater risk of death from overdose.

1.4.20 – people taking lithium need to be monitored significantly (renal, thyroid, calcium levels) and regularly reviewed.

1.4.26 – people taking antipsychotics need their weight, blood sugar and heart monitored and symptoms reviewed regularly.

1.5.1 Offer individual self-help with support as an initial treatment for people with less severe depression.

1.5.3 Consider a physical activity programme specifically designed for people with depression as an initial treatment for people with less severe depression.

1.5.15 Consider a selective serotonin reuptake inhibitor (SSRI) for people with less severe depression who:

  • choose not to have high or low intensity psychological interventions or exercise, or
  • based on previous treatment history for confirmed depression had a positive response to SSRIs, or
  • had a poor response to psychological interventions, or
  • are at risk of developing more severe depression (for example, if they have a history of severe depression or the current assessment suggests a more severe depression is developing).

1.6.1 For people with more severe depression, offer:

  • an individual high intensity psychological intervention (CBT, BA or IPT) or
  • antidepressant medication

1.10.3 If a person with chronic depressive symptoms that significantly impair personal and social functioning cannot tolerate an SSRI, consider treatment with an alternative SSRI.

Source: Pulse analysis of changes between the 2017 and 2018 draft NICE guidelines

Readers' comments (3)

  • Come on now NICE guidelines are all about cost. You know that cheapest is best. New treatments are by definition more expensive but unless they are used then one will never know how much more efficacious they may be compared to older treatments.
    NICE guidelines seem to repeatedly be flawed as time goes by so who is funding the apparent specialists who make these decisions?
    At grassroots level (coal face GPs) we are chastised or penalised for using more expensive treatments even if they have better efficacy. Thanks for offering me a TCAD for my depression but if I have to take something then can I try a SSRI first but that is unlikely to work until the NHS is sorted!

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  • Vinci Ho

    Once , twice , three times and more.
    Second consultation is NOT unusual anymore for an establishment like NICE. Don't tell me there is nothing fundamentally wrong of how they 'work out' guidances . On top of that , is the question how much taxpayers' money being spent for their 'activities' to finish the end product. We already have had enough with regulatory bodies like GMC , CQC etc. NICE needs to think seriously how it should conduct itself . And the argument of NICE guidelines are only 'guidelines' is not sustainable as the court and legal system always consider them as references for the 'right' treatments patients entitled for .
    Call this a ranting.......

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  • More totally useless guidance from NICE that puts GPs at risk of complaints and litigation. Isn't it time we closed this malignant organisation and diverted its funding to primary care where it might be put to better use?

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