Depression (update)Implementing NICE guidance

2009

NICE clinical guideline 90

Updated guidance

This guideline partially updates and replaces:•‘Depression: management of depression in primary and secondary care’ (NICE clinical guideline 23)

•The recommendations relating to depression made in:–‘Guidance on the use of electroconvulsive therapy’ (NICE technology appraisal guidance 59)–‘Computerised cognitive behavioural therapy for depression and anxiety (review)’ (NICE technology appraisal guidance 97).

What this presentation covers

Background

Scope and definitions

Key priorities for implementation

Costs and savings

Discussion

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Background

• Depression is a broad and heterogeneous diagnosis

• Central to it is depressed mood and/or loss of pleasure in most activities

• A wide range of biological, psychological and social factors have a significant impact on the course of depression and the response to treatment

Scope of guidance

The guideline covers:

•adults (aged 18 years and older) with a diagnosis of depression

•people in the above group who also have learning difficulties, acquired cognitive impairments or language difficulties.

Subthreshold depressive symptoms: fewer than five symptoms of depression.

Mild depression: few, if any, symptoms in excess of the five required to make the diagnosis and symptoms result in only minor functional impairment.

Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’.

Severe depression: Most symptoms and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.

Definitions (1)

Key symptoms Associated symptoms

• persistent sadness or low mood• and/or• marked loss of interests or

pleasure

• disturbed sleep (decreased or

increased compared to usual)• decreased or increased appetite and/or weight• fatigue or loss of energy• agitation or slowing of movements• poor concentration or indecisiveness• feelings of worthlessness or excessive or inappropriate guilt • suicidal thoughts or acts.

Definitions (2)

The areas identified as key priorities for implementation are:

• Principles for assessment

• Effective delivery of interventions for depression

• Case identification and recognition

• Low-intensity psychosocial interventions

• Drug treatment

• Treatment for moderate or severe depression

• Continuation and relapse prevention

• Psychological interventions for relapse prevention

Key priorities for implementation

• When assessing a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count.

• Take into account:– the degree of functional impairment and/or disability

associated with the possible depression and – the duration of the episode.

Principles for assessment

Effective delivery of interventions for depression (1)

• All interventions should be delivered by competent practitioners.

• Psychological and psychosocial interventions should be based on the relevant treatment manual(s).

• Practitioners should consider using competence frameworks.

Effective delivery of interventions for depression (2)

For all interventions, practitioners should:

• receive regular high-quality supervision

• use routine outcome measures

• ensure the patient with depression is involved in reviewing treatment efficacy

• engage in monitoring and evaluation of:

– treatment adherence

– practitioner competence.

STEP 1: All known and suspected presentations of depression

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

STEP 4: Severe and complex1 depression; risk to life; severe self-neglect

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Focus of the intervention

Nature of the intervention

Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions

1,2 see slide notes

The stepped-care model

• Be alert to possible depression – Particularly in people with a past history of depression

or a chronic physical health problem with associated functional impairment.

• Consider asking people who may have depression two questions, specifically:

– During the last month, have you often been bothered by feeling down, depressed or hopeless?

– During the last month, have you often been bothered by having little interest or pleasure in doing things?

Case identification and recognition

Low-intensity psychosocial interventions

• For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:

– individual guided self-help based on the principles of cognitive behavioural therapy (CBT)

– computerised cognitive behavioural therapy (CCBT)

– a structured group physical activity programme.

• Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor

• Consider antidepressants for people with: – a past history of moderate or severe depression or– subthreshold depressive symptoms present for a long time or– subthreshold depressive symptoms or mild depression that

persist(s) after other interventions.

Drug treatment

Treatment for moderate or severe depression

• For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention (cognitive behavioural therapy [CBT] or interpersonal therapy [IPT]).

• Support and encourage a person who has benefited from taking an antidepressant to continue medication for at least 6 months after remission of an episode of depression.

• Discuss with the person that: – this greatly reduces the risk of relapse– antidepressants are not associated with addiction.

Continuation and relapse prevention

People with depression who are considered to be at significant risk of relapse or who have residual symptoms, should be offered one of the following psychological interventions: •individual CBT: –for people who have relapsed despite antidepressant medication

–for people with a significant history of depression and residual symptoms despite treatment.

•mindfulness-based cognitive therapy:–for people who are currently well but have experienced three or more previous episodes of depression.

Psychological interventionsfor relapse prevention

• It has not been possible to determine costs or savings.• It is difficult to establish a national cost because of:– local circumstances – implementation of the previous depression guideline (NICE clinical

guideline 23)– other initiatives such as Improving Access to Psychological

Therapies

• It is anticipated that there will be:– an increase in people receiving low intensity interventions for

depression– a decrease in those receiving high intensity interventions.

Costs and savings

• What range of interventions are available for our patients?

• How do we monitor the effectiveness of case identification and recognition in our patients?

• How do we assure the quality of psychological and psychosocial interventions?

• How does our management of relapse prevention compare with the guidelines?

Discussion

Find out more

Visit www.nice.org.uk/CG90 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing statement•audit support.