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NICE advises GPs to prescribe anti-depressants for sub-clinical depression

By Nigel Praities

Huge numbers of patients with mild but sub-clinical symptoms of depression will be eligible for drug treatment under controversial new NICE guidelines.

Antidepressants are now to be advised in all patients with mild symptoms of depression that persists for two years, in a major extension of the current stepped-care model.

Updated guidance from the institute says patients with ‘persistent sub-threshold depressive symptoms' should be offered the same treatment options as those with mild to moderate depression if their symptoms continue in the long term.

But the move to extend drug treatment has been criticised as a further step towards mass medicalisation, following an analysis of UK prescribing that found rising numbers of people were on antidepressant drugs long term.

The new guidance says patients with fewer than five symptoms of depression – for at least two years – should receive low-intensity psychological interventions, medication or referral for further assessment.

It also encourages GPs to look at alternatives, including medication, in patients with chronic physical health problems, particularly if mobility problems restrict their access to psychological or psychosocial therapies.

Dr David Kessler, a GP in Bristol and a member of the development group for the depression guidelines, admitted the changes would lead to more patients being on antidepressants, but defended the evidence base behind the decision.

‘Clinicians are not always comfortable with labelling patients with a diagnosis of depression, but at the same time you can't pretend they are not there and will go away.

‘Extending the guidance to cover that group of patients gives a bit of clarity and the evidence suggests this is where we need to focus low-intensity interventions,' he said.

Yet an analysis published in the BMJ earlier this month found antidepressant prescribing in primary care nearly doubled between 1993 and 2005, largely because of rising numbers of patients taking antidepressants long term.

Professor Tony Kendrick, a GP in Southampton and one of the study authors, said the research showed the weakness of guidelines that did not give advice about when to stop treatment.

‘There is a whole generation, of young women in particular, who are being put on antidepressants and are staying on them on and off long term.

‘There is an imperative to look at whether they should be on them and whether they are coming to harm,' he said.

Dr Philip Bolitho-Jones, a GP in Watford, Hertfordshire, criticised the new NICE guidelines: ‘I don't think we should be going down the route of medicalising people who don't have full-blown depression. Low-level dissatisfaction is part of life and they should learn to put up with it.'

• The Government's Improving Access to Psychological Therapies scheme is having positive outcomes in patients, early pilot results suggest.

Three-quarters of patients with depression who completed treatment – mainly with cognitive behaviour therapy – in a pilot in Doncaster were recorded as being in recovery or remission.

The NICE recommendations will lead to more patients being prescribed antidepressants The NICE recommendations will lead to more patients being prescribed antidepressants What the guidance says

• Consider antidepressants routinely for people with subthreshold depressive symptoms present for at least two years. Also consider offering one or more low-intensity psychosocial interventions, guided by patient preference

• Discuss alternative treatments with patients who have a chronic physical health problem if it restricts their ability to engage with a psychosocial or psychological intervention for depression, such as taking antidepressants or receiving the intervention by telephone

• For patients with a chronic health problem, consider using citalopram or sertraline as these have a lower propensity for interactions

Source: Update of NICE clinical guideline 23

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