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NICE: Antidepressants should not be first-line treatment for ‘less severe’ depression

NICE: Antidepressants should not be first-line treatment for ‘less severe’ depression

New NICE draft guidance has recommended that GPs do not routinely offer patients with ‘less severe’ depression antidepressants as the first line of treatment.

It said this should only be the case if this is their ‘preference’ and that GPs could first offer alternatives such as cognitive behavioural therapy (CBT); counselling; group mindfulness or meditation; or group exercise.

The guidance, published today and currently out for consultation, said: ‘Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference.’

It added that those with ‘more severe’ depression should also be offered a range of different options of first-line treatments, depending on their ‘clinical needs and preference’.

The guidance said that GPs should ‘discuss treatment options with people who have a new episode of less severe depression’ – defined as ‘subthreshold symptoms and mild depression’ – and reach a ‘shared decision’ based on their ‘clinical needs and preferences’.

They should take into account that all treatments listed in the guidance ‘can be used as first-line treatments’, it added.

The options, listed ‘in order of recommended use’, are:

  • 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)

GPs should not prescribe or advise the use of St John’s Wort to those with depression because of ‘uncertainty’ about appropriate doses and persistence of effect and ‘potential serious interactions’ with other drugs, it added.

Those with a new episode of ‘more severe’ depression – defined as ‘moderate and severe depression’ – should also be offered a range of potential first-line treatments with a shared decision reached based on their needs and preference, the guidance said.

Treatment options for ‘more severe’ depression in order of ‘recommended use’ are:

  • Combination of individual CBT and an antidepressant 
  • Individual CBT
  • Individual behavioural activation (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) 
  • Interpersonal psychotherapy (IPT)
  • Self-help ‘with support’
  • Group exercise

GPs should recognise that people with all severities of depression ‘have a right to decline treatment, the guidance added.

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘People with depression deserve and expect the best treatment from the NHS which is why this guideline is urgently required.

‘The Covid-19 pandemic has shown us the impact depression has had on the nation’s mental health. People with depression need these evidence-based guideline recommendations available to the NHS, without delay.’

Nav Kapur, professor of psychiatry and population health at the University of Manchester and chair of the guideline committee, added that the ‘broad-ranging’ was ‘an enormous challenge to produce’.

He said: “In particular we’ve emphasised the role of patient choice – suggesting that practitioners should offer people a choice of evidence-based treatments and understanding that not every treatment will suit every person. 

‘We now need stakeholders’ help to make the recommendations as good as they can possibly be.’

The consultation on the guideline, which would be the first in 12 years on identifying, treating and managing depression in adults, will close on 12 January with final publication expected on 12 May 2022.

The guideline – which will update and replace NICE guideline CG90 published in 2009 – is now out for its third consultation.

Previous versions had met with fierce opposition from a coalition of 50 mental health organisations – led by a set of organisations, the Society for Psychotherapy Research UK (SPR UK) and the UK Council for Psychotherapy (UKCP) – who raised fundamental scientific concerns with the methods used to determine treatment recommendations.

UKCP chief executive Sarah Niblock and former president of the SPR UK Dr Felicitas Rost said: ‘While some of our concerns have finally been addressed in the latest draft, including the importance of patient choice in their treatment, others have not, including the unprecedented binary categorisation of depression severity and the use of unproven methods to determine treatment effectiveness.’

It comes as an Office for National Statistics analysis last month revealed that around one in six (17%) of UK adults experienced ‘some form of depression’ in summer 2021 – almost double the levels observed before the Covid pandemic (10%).

And the new Office for Health Improvement and Disparities (OHID) launched a mental health campaign as half of adults in England said the pandemic negatively impacted their mental wellbeing.

Meanwhile, NICE last month recommended that GPs should provide regular reviews for patients on antidepressants and drugs for chronic pain that may be addictive in draft guidance on managing withdrawal.

A 2019 report from Public Health England (PHE) warned that one in four patients had been given a prescription for a potentially addictive medicine, including antidepressants.


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Please note, only GPs are permitted to add comments to articles

John Glasspool 23 November, 2021 1:43 pm

Most GPs would find it helpful if someone were to define “mild depression”.

John Glasspool 23 November, 2021 1:44 pm

“GPs should recognise that people with all severities of depression ‘have a right to decline treatment, the guidance added.” Hmmm….so no one will ever agina be sectioned for Depression. Interesting.

Patrufini Duffy 23 November, 2021 3:55 pm

The down sides to human life, like splitting up with your boyfriend, your hate of alcohol binges and cocaine, or hating your damp flat and boss, do not require GP humour or medicalistion. First world privileges, lack of gratitude and awareness sadly choke a grey and inert system of blah.

Marie Williams 23 November, 2021 5:44 pm

Blah Blah Blah standard NICE guidance :
Don’t offer antidepressants for “less severe” depression unless of course patient wants it
Refer for a series of “evidence based” therapies which take months to access.

Continue to medicalise life’s misery of which unfortunately there is a lot and which we will all experience.
One man’s mild depression is another man’s end of the world. How to define?

How about starting to embed some resilience and coping strategies in schools as part of PHSE which would help to manage the mental health epidemic.

But what has been missed out in the guidance is the importance to patients of the compassion, support and understanding that medical colleagues give which should never be underestimated in aiding recovery. Speaking from both sides of the table.

Michael Crow 23 November, 2021 7:41 pm

The problem with much of NICE guidance is that it is devised bt consultants living in the ideal world. They do not factor in the real world. Is there access to all of these different options, and if there is what is the wait? Without these options and only being able to able to give anyone 10 minutes in an appointment these options diminish rapidly.

The truth is that many people’s lives have been absolutely awful Even the most resilient of people would crumble with the physical, psychological and social issues they have to put up with, not to mention the effects of the pandemic +/- Brexit. Nothing we could do can help with those.

GPs are doing their best in a system that is broken. It is like wading through treacle. If we had the resources both we and the patients deserve we could follow NICE

Thomas Robinson 23 November, 2021 8:07 pm

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘People with depression deserve and expect the best treatment from the NHS

No Paul, absolutely not, not in the real world, back to the drawing board, suggest actually meeting a patient might help avoid such nonsense.

These are guidelines for clinical GP’s not psychiatrists, or academics, yet there is no clinical GP on the panel, 64,000 members of the college, 30,000 WTE, 4000 registrars, yet they could not find a single clinical GP to provide a counterbalance to academic fantasy, no one to anchor the team in reality,

The eminent GP academics list their posts, titles, directorships leadership roles, and add a token GP appointment, possibly for shame sake. All in order to establish validity, as do all such people in all such roles, the BMA, and Health authorities being no different.

But it does not work the other way around, a GP who actually saw patients, possibly at ten times the rate of his academic colleagues would have no credibility, he would have only one title GP, more a mark of shame than eminence.

Perhaps the title GP should require qualification , a postscript, 1/10 denoting seeing patients on
one session a week, or 10 denoting the number of patients they saw last year, such a postscript would qualify the title GP enabling readers to understand just how utterly meaningless it can be.

If you have a meaningless title, you are apt to produce meaningless guidelines

Turn out The Lights 24 November, 2021 6:02 am

Hear hear Tom.

Mike Baverstock 24 November, 2021 9:27 am

NICE Guidance would be fine if it wasn’t just ‘nice’ but, sadly, they often seem to be on another planet from planet GP land. CBT takes many weeks here – if they get it at all. Counselling is at least 6 months and 30 miles away. So much for IAPT. Forget all the other suggestions – they don’t exist here in sunny Herts. One thing that has helped is social prescribing – Oh dear – it’s not on the list!!

Kevlar Cardie 24 November, 2021 10:28 am

Getting rid of this foetid government would improve the national PHQ-9 score considerably.

Patrufini Duffy 24 November, 2021 4:51 pm

Funny how the maximum dose of sertraline is 200mg. 200 hey.

paul cundy 25 November, 2021 2:52 pm

Dear All,
OK thanks for telling us what we already know, really useful.
Go any views on whether the world is round or flat?
Paul C

paul cundy 25 November, 2021 2:59 pm

sorry should be “got” not go.

paul cundy 25 November, 2021 3:03 pm

Dear All,
Has ever been thus, research showed that 75% of NICE guidance (sic) had no data or evidence from primary care. Ivory tower sitters pontificating on anecdote from outside the tent.
Paul C