Final NICE guidance on depression advocates a wider choice of treatments and a move away from antidepressants in people whose condition is ‘less severe’.
It also contains stronger warnings on the risk of withdrawal symptoms with use of antidepressants and the need for careful tapering and monitoring when patients are stopping treatment.
GP should discuss the full range of treatments, taking into account patient preference and allowing time for conversations about what the patient hopes to gain from treatment and previous experiences, the guidelines state.
NICE also advises promoting continuity of care by ensuring the patient can see the same healthcare professional wherever possible.
The now final update to the 2009 guidelines has been in process since 2015 with multiple consultations after critics pointed to methodological flaws in previous versions of the document.
Treatment decisions should be shared with patients but GPs will also need to advise on waiting lists, the recommendations state.
The options for less severe depression – previously termed mild depression – in order of recommended use are:
- 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
People starting antidepressants should be warned about withdrawal symptoms and that this can sometimes last weeks or months.
In those who wish to stop taking their medication, doses should be slowly reduced at a pace dictated by patient need and choice, the guidelines state.
A coalition of 40 major mental health organisations, including Mind, the British Psychological Society, British Association for Counselling and Psychotherapy and the UK Council for Psychotherapy, had formed to raise objections to previous versions of the guidelines which as a result had been significantly delayed.
Concerns raised included that the guidelines failed to take into account patient experience of treatments.
Dr Felicitas Rost, former President of the Society for Psychotherapy Research UK who had led the coalition said the three consultations prior to the publication of the final guidelines had led to a shift away from medication in milder instances of depression, a greater number of different treatments being recommended, and a much-increased emphasis on the patient role in determining their course of treatment.
‘We welcome the enormous efforts made by NICE to engage with our coalition and the substantial additional work that has been carried out in response to our concerns. We now have a much-improved guideline with a far greater emphasis on personalised care, service user choice and shared decision-making, she said.
‘There are still, however, important methodological issues with this guideline that need to be addressed in the future, some of which are relevant to all mental health treatment guidelines.
‘We look forward to working with NICE to address these, to ensure that mental health care improves as demand continues to rise,’ she added.
Sir Norman Lamb, former health minister, who led the parliamentary support for the coalition, said: ‘I am pleased to see a depression guideline that puts emphasis on personalised care, providing a genuine choice of treatments, and encourages clinicians to think more carefully before prescribing medication.’
But he said alongside the renewed focus on patient choice must come investment in the mental health workforce.
‘The Government needs to ensure that there are practitioners available to meet both the increased choice of treatments and rising demand for support.’