Earlier this year, NICE published the final version of the update to its 2009 guidelines on managing and treating depression in adults, NG222.
This follows five years of consultations during which a coalition of stakeholders raised serious concerns about the methodology underpinning recommendations outlined in the previous two drafts.
The final version outlines several treatment options for patients presenting with a new episode of depression that is ‘less severe’ (formerly termed ‘mild’) and ‘more severe’ (previously ‘moderate’ and ‘severe’).
It also offers advice on managing long-term depression, depression with psychosis, and depression with coexisting personality disorder.
For patients with less severe depression, NICE recommends in order of strength of recommendation (based on clinical and cost-effectiveness, and how easily implemented) the following:
- Guided self-help
- Group cognitive behaviour therapy (CBT)
- Group behavioural activation (BA)
- Individual CBT
- Individual BA
- Group exercise
- Group mindfulness and meditation
- Interpersonal therapy
- SSRI antidepressants
- Short-term psychodynamic psychotherapy.
Patients with a new episode of more severe depression may be offered a combination of individual CBT and an antidepressant in the first instance. The guidance recommends non-pharmacological options like those available for less severe depression, ranked differently.
Where medication is prescribed, GPs should counsel patients about the risk and potential longevity of withdrawal symptoms associated with coming off some antidepressants. For that reason, patients who want to stop taking antidepressant medication should be supported to taper their dose at their preferred speed.
Key points for GPs
- New in this updated guideline is the move away from pharmacological treatment for new cases of less severe depression. Some people will prefer medication in the first instance and resistant to the therapy-based options, so the patient-centred approach is crucial here.
- GPs are now tasked with providing written information, especially on the risks of withdrawal, when initiating treatment with antidepressants. NICE is not prescriptive on what materials GP should supply, though information leaflets that come in medication boxes is unlikely to be sufficient. Resources like those provided by the NHS and Mind might be useful.
- GPs should ask patients with any degree of depression about suicide ideation and thoughts of self-harm. To assess the patient’s risk, it’s also important to establish what support they have at home and their ability to access other sources of help.
- It is recommended that GPs discuss the possibility of relapse with patients before discontinuing treatment. The guidance describes factors that increase a person’s risk of relapsing, and advises GPs to suggest those patients continue taking antidepressants for up to two years, at a constant dose unless there is good reason to modify the dose.
- There is greater clarity on review intervals. Specifically, new advice states to review after one week patients who start antidepressants if they are under 25 and/or have an increased risk of suicide. Otherwise, GPs should review after two to four weeks.
- NICE emphasises the importance of continuity of care, and recommends patients are able to see the same healthcare professional wherever possible.
The sharpened focus on non-pharmacological treatments is welcomed by many but there are several difficulties, the most obvious being accessibility. NHS Digital figures show that among patients referred to talking therapies, 12.2% fewer actually accessed those services in 2020-21 than did in 2019-20.
Patients can often wait up to nine months to access support, leaving them in limbo meanwhile. That will also inevitably place further demand on general practice.
Continuity of care is intuitive and well-intended, but hugely problematic given the scale of the workforce crisis. It’s undoubtedly important that patients with depression have consistency during their treatment and recovery, including being able to see the same healthcare professional at each visit. However, it’s logistically difficult, especially since many of the recommendations necessitate longer consultations.
Some criticism has been levelled at the guidance for failing to consider patients’ experiences of different depression treatments. Many may have found CBT or BA ineffective in the past, for example. Patient expectations may conflict with the guidance and the GP’s instincts – and the GP will have to deal with any backlash.
Dr Felicitas Rost, research lead at The Tavistock and Portman NHS Foundation Trust and former President of the Society for Psychotherapy Research UK, led the coalition of stakeholders who consulted on the previous drafts of the guidance.
Dr Rost says: ‘It is crucial that evidence-based treatment is available to anyone who needs it, and we know that not all patients benefit from all therapies.
‘Previously, GPs might not have known where to refer if patients come back, having tried IAPT and group CBT, because the choice wasn’t there. We now have a menu of treatment options, which is positive.
‘But with record-setting demand and considerable waiting times for treatments in many parts of the UK, the challenge GPs can face in implementing the guideline is that the therapies may not be available. What is needed now is funding to make them available.
‘In comparison with the original draft proposed to stakeholders, the final guideline should help improve outcomes for patients, based on patients having choice and making an informed decision about treatment.
‘However, there are still some methodological issues underpinning the guideline that haven’t been ironed out, and a lot of work still needs to be done.
‘Importantly, the guideline falls short of providing options for adequate treatment for those with treatment-resistant chronic depression.’
NICE. Depression in adults: treatment and management. 2022. NG222