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NICE depression guidelines signal move away from medication

GPs warn recommendations fail to address lack of access. Rachel Carter reports

GPs are facing a change in the way they treat depression.

Under the latest draft of a new NICE depression guideline, the key recommendation states that antidepressants should not be routinely offered as first-line treatment for ‘less severe’ cases of depression – defined as ‘subthreshold symptoms and mild depression’ – unless this is the patient’s preference. 

Instead, it lists a ‘menu’ of treatment options that GPs could offer to patients as alternatives, including cognitive behavioural therapy (CBT) and exercise.

For new episodes of ‘more severe’ depression – the term that covers the traditional categories of moderate and severe depression – patients should also be offered a range of different options of first-line treatments, the guideline says. 

The consultation, which ends on 12 January, is the third such consultation of the draft guidelines since 2018. Mental health leaders criticised previous drafts as having ‘serious methodological flaws’ and warned that the guidance could ‘seriously impede the care of millions of people’ living with depression. 

This draft’s greater focus on patient choice has been welcomed by the UK Council of Psychotherapy (UKCP) and the Society for Psychotherapy Research UK (SPR UK), who led the criticism of the earlier versions. However, they do warn other concerns have not been addressed, including ‘the use of unproven methods to determine treatment effectiveness’ and the ‘unprecedented binary categorisation of depression severity’. 

Draft guidance on reducing antidepressant doses

  • Withdrawal symptoms can be experienced with a wide range of antidepressant medication, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs)
  • Some commonly used antidepressants such as paroxetine and venlafaxine are ‘more likely’ to be associated with withdrawal symptoms, says the guidance, so ‘particular care is needed’
  • Fluoxetine’s ‘prolonged duration of action’ means it ‘can sometimes be safely stopped over a shorter period’

Lack of access
For GPs, however, the central criticism is how realistic the recommendations are. The focus on alternatives to medication was no surprise. But access to non-pharmaceutical treatments remains impossible for many patients. Between April 2020 and March 2021, IAPT services received almost 1.5 million referrals

NICE does appear to acknowledge this, stating that GPs should inform people ‘if there are waiting lists and how long the wait is likely to be.’ 

But the alternative seems to be self-care. NICE recommends: ‘Ensure people are kept informed, are aware of how to access help if their condition worsens, and consider providing self-help material in the interim.’  

NICE says these recommendations reflect current practice, and ‘may reduce variation in practice across the NHS’. It adds that commissioners and services will need to ‘ensure that a meaningful choice of all recommended therapies is available, and depending on current availability, this may need an increase in resource use’. 

RCGP chair Professor Martin Marshall says the guidance should help facilitate shared decision-making on treatment between patients and GPs but adds that access to some treatments is ‘patchy across the country’. 

‘It is vital that GPs have access to a wide variety of treatments for their patients with depression, so that they can benefit from them regardless of where they live,’ he says. 

Dr Richard Van Mellaerts, a GP in Kingston, London, and a GPSI in mental health, says GPs have known for some time that ‘medication as a first line for mild depression is not the best way to go’ so this recommendation is not a ‘big surprise’. But he says access to alternative treatment, such as CBT and IAPT services, is an ‘ongoing problem’. 

‘It’s a good move but it does require investment in those kind of services in order to make sure that [access to support] is timely – because if there is a six-to-nine month wait, as can often be the case, that is often not very helpful for the patient,’ he says. 

The latest version of the guideline also includes a new section on ‘choice of treatments’. This advises GPs on what to discuss with the patient, involving family or carers if requested, and to allow adequate time for the initial discussion about treatment options, including the gender of the healthcare professional, or seeing a particular professional they already have a relationship with. 

Dr Van Mellaerts says this is not ‘unreasonable’ for patients to expect, but with the current pressures it can be ‘difficult in a real-world scenario’. 

Antidepressants withdrawal 
In this latest draft, terminology has also changed – the use of the word ‘discontinuation’ when describing stopping antidepressants has been replaced with ‘withdrawal’ throughout. 

A spokesperson for NICE told Pulse there are two reasons for the change in wording – first, withdrawal is ‘plainer English than discontinuation’. But second, and more importantly, this is also consistent with another new guideline on safe prescribing and management of medicines associated with dependence or withdrawal symptoms for adults. ‘The depression guideline links to this, and it refers to withdrawal,’ they added.

The safe prescribing and withdrawal management guideline (expected April 2022), says that ‘antidepressants, although historically not classified as dependence-forming medicines, can cause withdrawal symptoms when they are stopped’. 

This focus on withdrawal is significant. In 2019, the Royal College of Psychiatrists issued a position statement recommending that NICE guidelines should acknowledge the potential for severe withdrawal symptoms from antidepressants and provide evidence-based guidance for gradual withdrawal. 

NICE consequently revised the existing guideline to warn of ‘severe’ and lengthy withdrawal symptoms – it had previously said such symptoms were ‘mild’. In the latest draft, the recommendations on stopping antidepressants are ‘much more comprehensive’ than those issued in 2019, a spokesperson for NICE told Pulse. 

The new depression guideline also highlights that GPs should warn patients about the problems associated with withdrawal from antidepressants. This includes ensuring they give information about withdrawal symptoms when prescribing. A statement advising GPs that ‘addiction does not occur with antidepressants’ has been removed. 

The new guideline also makes changes to withdrawal timescales. The existing document says doses should be tapered ‘normally over a four-week period’, but the latest draft stresses that patient need and choice should dictate the pace of withdrawal. And it advises GPs that withdrawal could take ‘weeks or months’. 

However, it also says GPs should ‘take into account the broader clinical context such as the potential benefit of more rapid withdrawal where there are significant side-effects’. 

NICE has made new recommendations on tapering, including that liquid preparations should be used ‘if necessary to allow slow tapering’ at small doses and that doses should be slowly reduced to a ‘proportion’ of the previous dose rather than by a ‘fixed’ amount.  

Dr Peter Bagshaw, a locum GP and Somerset CCG clinical lead for mental health, dementia, learning disabilities and autism, says he welcomes the advice on joint decision-making and withdrawal, adding that the advice on using liquid preparations is ‘interesting’. 

But he adds: ‘I was hoping for something clearer on timescales.’

Treatment options for patients with depression

Less severe depression, listed in order of recommended use

  • Group CBT
  • Group behavioural activation (BA) 
  • Individual CBT
  • Individual BA
  • Self-help with support
  • Group exercise
  • Group mindfulness or meditation
  • Interpersonal psychotherapy (IPT)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP)

More severe depression, listed in order of recommended use

  • Combination of individual CBT and an antidepressant
  • Individual CBT
  • Individual BA
  • Antidepressant medication, which could be an SSRI, SNRI or ‘other antidepressant if indicated based on previous clinical and treatment history’
  • Individual problem-solving
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP)
  • IPT
  • Self-help with support
  • Group exercise

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David Banner 4 January, 2022 9:38 pm

How lucky they are on Planet NICE to have a plethora of psychiatric services to which GPs can refer depressed patients. CBT, BA, IPT, STPP…..all available in your area with ample empty appointment slots just waiting to be filled. Wow, I feel happier already!

But we’re stuck on Planet Earth, where these magical sounding services are either non existent or have waiting times of several years and no staff. So it’s more SSRIs, sorry, They may be a bit crap, but even a placebo beats a phantom psychological therapy.

Patrufini Duffy 4 January, 2022 10:37 pm

Like the love of cocaine, gin and prosecco, opiods and nannying. The West created these SSRIs and embedded them as an “anti” depressant…superb marketing, and now their populations are hooked and partial zombies on the cheap “way out” of raw introspection. Nevertheless, you can contact NICE by telephone on +44 (0)300 323 0140; email for group CBT in their boardroom.

Vinci Ho 5 January, 2022 2:16 pm

NICE does appear to acknowledge this, stating that GPs should inform people ‘if there are waiting lists and how long the wait is likely to be.’

Seriously ?🤨👿
Shouldn’t be the system (NHSE/I or ICS) which will responsible party to inform these patients how long they will have to wait , hah?🤨
Is the GP going to be sued if they ‘guessed’ the wrong time a patient had to wait , otherwise ?
This is a post Covid new world and we still have a bunch of academics ,living in the summit of the old Ivory Tower in an ‘old’ era , who do not have the guts to challenge the government directly but instead look for scapegoats. Disgracing .

Dave Haddock 6 January, 2022 7:27 pm

A small step back on the long march towards the medicalisation of everything, good news.
High rates of SSRI prescribing will no doubt remain a useful marker for crap GP.

Dylan Summers 8 January, 2022 11:33 am

@Dave Haddock

I don’t think more SSRI prescriptions = crap GP.

It’s true the evidence is not very convincing for SSRI vs placebo in mild to moderate mood disorders, but… placebo works.

And SSRIs are cheap, widely available and relatively safe, all good features for a placebo.

So I will still consider offering them, even knowing that any benefits might not be due to their specific pharmacology.

David jenkins 9 January, 2022 12:50 pm

did anyone see the programme on prof dave nutt’s approach to the problem ?

i was in university with this guy, and he is an extremely clever and wise bloke.

not surprisingly, some of his ideas seem a bit “off the wall”, but if you take the time to read what he says, you’ll probably think at least some of it is worth a try.

unfortunately, the politicians don’t like him, probably because he speaks up, and is an awful lot cleverer than them – which is why he was sacked by a retired postman – alan johnson, ex home secretary !