NICE's 'hard to follow' depression guidance
By Cato Pedder
Mental health experts have welcomed new national guidelines on treatment of depression but warn they will be hard for GPs to follow without more education, training and greater support from specialist services.
A key requirement of the guidelines, currently in their second draft, will be for GPs to screen opportunistically for depression in a range of high-risk patients, including those with significant physical illness, the recently unemployed, new mothers and the bereaved.
This will be done using two simple questions: 'During the last month have you often been bothered by feeling down, depressed or hopeless?' and 'During the last month have you often been bothered by having little interest or pleasure in doing things?'.
However, a large study published in Family Practice (December) found GPs screening for depression in the elderly by asking a single question resulted in 'at best' almost half of cases being missed.
Researchers at the Centre for Ageing and Public Health, London School of Hygiene and Tropical Medicine, concluded: 'This highlights the problems of such simple approaches to routine screening.'
Dr Chris Manning, co-chair of Primary Care Mental Health and Education and a GP in south London, welcomed the idea of screening but warned: 'We need to realise any evaluative tool is no good on its own, we need to look at the situation as a whole.'
He said of the guidelines in general: 'There is a huge education and training agenda here, but this is a start.'
Other recommendations in the draft guidance (see below) include a guided self-help programme based on cognitive behaviour therapy (CBT) as first-line for mild depression.
Patients with mild to moderate depression should be offered alternatives to antidepressants, including CBT and problem-solving therapy, the guidance states. But mental health experts warned psychiatric services were stretched.
The guidelines warn the concept of depression is
seriously flawed as it is too broad and has limited use in treatment.
Dr Alan Cohen, RCGP mental health spokesman, said: 'The guidance supports what many GPs think anyway you don't need to treat every case with antidepressants.'
NICE depression guidelines: key proposals
· Antidepressants are not recommended for the initial treatment of mild depression
· Watchful waiting approach for patients with mild depression and follow-up after two weeks
· Prescribe an SSRI as first-choice antidepressant
· Patients who have two or more recent depressive episodes and significant functional impairment should continue antidepressants for two years
· Consider CBT for patients with recurrent depression, who relapsd despite antidepressants, or prefer psychological interventions