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Guideline Summary
Guideline Title
Depression. The treatment and management of depression in adults.
Bibliographic Source(s)
National Collaborating Centre for Mental Health. Depression. The treatment and management of depression in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Oct. 64 p. (Clinical guideline; no. 90). 
Guideline Status

This is the current release of the guideline.

This guideline updates previous versions: National Collaborating Centre for Mental Health. Depression: management of depression in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE); 2004. 67 p. [634 references]

National Collaborating Centre for Mental Health. Depression: management of depression in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE); 2007 Apr. 67 p. (Clinical guideline; no. 23).

Scope

Disease/Condition(s)

Depression

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Nursing
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Health Care Providers
Patients
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
  • To update the 2007 guidelines on treatment and management of depression
  • The guideline aims to:
    • Improve access and engagement with treatment and services for people with depression
    • Evaluate the role of specific psychological and psychosocial interventions in the treatment of depression
    • Evaluate the role of specific pharmacological interventions in the treatment of depression
    • Evaluate the role of specific service level interventions for people with depression
    • Integrate the above to provide best-practice advice on the care of people with depression and their family and carers
    • Promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the National Health Service (NHS) in England and Wales.
Target Population

Adults (18 years and older) whose depression occurs as the primary diagnosis

Interventions and Practices Considered

General Management (Care of All People with Depression)

  1. Provision of information and support to patients, carers, and families
  2. Obtaining informed consent
  3. Development and documentation of advanced directives
  4. Comprehensive assessment (symptoms, functional impairment, history, ethnic and cultural background, cognitive impairment, learning disabilities, suicide risk)
  5. Delivery of care by competent professionals

Management/Treatment (Stepped Care)

  1. Step 1: Recognition, assessment, and initial management
    • Case identification and recognition
    • Risk assessment and monitoring
  2. Step 2: Management of persistent subthreshold depressive symptoms or mild to moderate depression
    • Treatment of coexisting anxiety
    • Advice on sleep hygiene
    • Active monitoring
    • Low-intensity psychosocial interventions (cognitive behavioral therapy [CBT], computerized cognitive behavioral therapy [CCBT])
    • Group cognitive behavioral therapy
    • Antidepressant drug treatment in limited cases
    • Advice against using St. John's wort
  3. Step 3: Management of persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
    • Antidepressant drug treatment (selective serotonin reuptake inhibitor [SSRI])
    • High-intensity psychological intervention (CBT, interpersonal therapy, behavioral activation, behavioral couples therapy)
    • Combined antidepressant medication and high-intensity psychological intervention
    • Counseling
    • Short-term psychodynamic psychotherapy
    • Choice of antidepressant medication other than SSRI (e.g., venlafaxine, duloxetine, and tricyclic antidepressants [TCAs])
    • Monitoring the initial phase of drug treatment (e.g., suicide risk, side effects)
    • Treatment choice based on depression subtypes and personal characteristics
    • Enhanced care for depression: referral to specialist mental health services
    • Switching antidepressants
    • Combining and augmenting medications (e.g., addition of lithium, an antipsychotic, another antidepressant)  
    • Continuation and relapse prevention
  4. Step 4: Management of complex and severe depression
    • Referral to specialist mental health services
    • Inpatient care
    • Crisis resolution
    • Home treatment teams
    • Pharmacological management of depression with psychotic symptoms
    • Electroconvulsive therapy (ECT)
    • Transcranial magnetic stimulation (not recommended outside of research studies)
Major Outcomes Considered
  • Remission rate
  • Side effects of medication and therapy
  • Morbidity and mortality
  • Cost effectiveness of treatment
  • Rates of relapse

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

A stepwise, hierarchical approach was taken to locating and presenting evidence to the Guideline Development Group (GDG). The NCCMH developed this process based on methods set out in The Guidelines Manual (NICE, 2007c) and after considering recommendations from a range of other sources. These included:

  • Clinical Policy and Practice Program of the New South Wales Department of Health (Australia)
  • Clinical Evidence online
  • The Cochrane Collaboration
  • New Zealand Guidelines Group
  • NHS Centre for Reviews and Dissemination
  • Oxford Centre for Evidence-Based Medicine
  • Scottish Intercollegiate Guidelines Network (SIGN)
  • United States Agency for Healthcare Research and Quality
  • Oxford Systematic Review Development Programme

During the development of the scope, a more extensive search was undertaken for systematic reviews and guidelines published since the previous depression guideline. These were used to inform the development of review protocols for each topic group. Review protocols included the relevant clinical question(s), the search strategy, the criteria for assessing the eligibility of studies, and any additional assessments.

The initial approach taken to locating primary-level studies depended on the type of clinical question and potential availability of evidence. Based on the previous guideline and GDG knowledge of the literature, a decision was made about which questions were best addressed by good practice based on expert opinion, which questions were likely to have a good evidence base and which questions were likely to have little or no directly relevant evidence. Recommendations based on good practice were developed by informal consensus of the GDG. For questions with a good evidence base, the review process depended on the type of key question. For questions that were unlikely to have a good evidence base, a brief descriptive review was initially undertaken by a member of the GDG.

Searches for evidence were updated between 6 and 8 weeks before the guideline consultation. After this point, studies were included only if they were judged by the GDG to be exceptional (for example, the evidence was likely to change a recommendation).

Search Strategies

The Search Process for Questions Concerning Interventions

For questions related to interventions, the initial evidence base (or updated evidence base) was formed from well-conducted randomised controlled trials (RCTs) that addressed at least one of the clinical questions. Although there are a number of difficulties with the use of RCTs in the evaluation of interventions in mental health, the RCT remains the most important method for establishing treatment efficacy. For other clinical questions, searches were for the appropriate study design.

The search was exhaustive, using several databases and other sources. For RCTs the search consisted of terms relating to the clinical condition (i.e., depression) and study design only, thereby yielding the largest number of relevant papers that might otherwise be missed by more specific searches, formed around additional elements of the question, including interventions and the outcomes of interest. The search was not limited to any particular therapeutic modality. Standard mental health related bibliographic databases (that is, CINAHL, Cochrane Library, EMBASE, MEDLINE, and PsycINFO) were used for the initial search for all studies potentially relevant to the guideline. Where the evidence base was large, recent high-quality English-language systematic reviews were used primarily as a source of RCTs (see Appendix 10 in the full version of the original guideline for quality criteria used to assess systematic reviews). However, in some circumstances existing data sets were utilised. Where this was the case, data were cross-checked for accuracy before use. New RCTs meeting inclusion criteria set by the GDG were incorporated into the existing reviews and fresh analyses performed.

After the initial search results were scanned liberally to exclude irrelevant papers, the review team used a purpose-built 'study information' database to manage both the included and the excluded studies (eligibility criteria were developed after consultation with the GDG). Double checking of all excluded studies was not done routinely, but a selection of abstracts was checked to ensure reliability of the sifting. For questions without good-quality evidence (after the initial search), a decision was made by the GDG about whether to (a) repeat the search using subject-specific databases (for example, AMED, ERIC, OpenSIGLE or Sociological Abstracts), (b) conduct a new search for lower levels of evidence or (c) adopt a consensus process.

In addition, searches were made of the reference lists of all eligible systematic reviews and included studies. Known experts in the field (see Appendix 5 of the original full version of the guideline), based both on the references identified in early steps and on advice from GDG members, were sent letters requesting relevant studies that were in the process of being published. In addition, the tables of contents of appropriate journals were periodically checked for relevant studies.

Search Filters

Search filters developed by the review team consisted of a combination of subject heading and free-text phrases. Specific filters were developed for the guideline topic and, where necessary, for each clinical question. In addition, the review team used filters developed for systematic reviews, RCTs and other appropriate research designs (see Appendix 8 in the full version of the original guideline).

Study Selection

All primary-level studies included after the first scan of citations were acquired in full and re-evaluated for eligibility (based on the relevant review protocol) at the time they were being entered into the study database. Eligible systematic reviews and primary-level studies were critically appraised for methodological quality (see Appendix 10 for the quality checklists, and Appendix 17 of the full version of the original guideline for characteristics of each study including quality assessment). The eligibility of each study was confirmed by consensus during topic group meetings.

For some clinical questions, it was necessary to prioritise the evidence with respect to the UK context (that is, external validity). To make this process explicit, the topic groups took into account the following factors when assessing the evidence:

  • Participant factors (for example, gender, age and ethnicity)
  • Provider factors (for example, model fidelity, the conditions under which the intervention was performed and the availability of experienced staff to undertake the procedure)
  • Cultural factors (for example, differences in standard care and differences in the welfare system)

It was the responsibility of each topic group to decide which prioritization factors were relevant to each clinical question in light of the UK context and then decide how they should modify their recommendations.

Unpublished Evidence

The GDG used a number of criteria when deciding whether or not to accept unpublished data. First, the evidence must have been accompanied by a trial report containing sufficient detail to properly assess the quality of the research. Second, where evidence was submitted directly to the GDG, it must have been done so with the understanding that details would be published in the full guideline. However, the GDG recognised that unpublished evidence submitted by investigators might later be retracted by those investigators if the inclusion of such data would jeopardise publication of their research.

Economic Evidence

Search Strategy

For the systematic review of economic evidence the standard mental-health-related bibliographic databases (EMBASE, MEDLINE, CINAHL and PsycINFO) were searched. For these databases, a health economics search filter adapted from the Centre for Reviews and Dissemination at the University of York was used in combination with a general search strategy for depression. Additional searches were performed in specific health economics databases (National Health Service Economic Evaluation Database [NHS EED], Office of Health Economic Health Economic Evaluations Database [OHE HEED]), as well as in the Health Technology Assessment (HTA) database. For the HTA and NHS EED databases, the general strategy for depression was used. OHE HEED was searched using a shorter, database-specific strategy. Initial searches were performed in November 2007. The searches were updated regularly, with the final search performed in December 2008. Details of the search strategy for economic studies on interventions for people with depression are provided in Appendix 12 of the full version of the original guideline.

In parallel to searches of electronic databases, reference lists of eligible studies and relevant reviews were searched by hand. Studies included in the clinical evidence review were also screened for economic evidence.

The systematic search of the literature identified approximately 35 thousand references (stage 1). Publications that were clearly not relevant were first excluded (stage 2). The abstracts of all potentially relevant publications were then assessed against a set of selection criteria by the health economist (stage 3). Full texts of the studies potentially meeting the selection criteria (including those for which eligibility was not clear from the abstract) were obtained (stage 4). Studies that did not meet the inclusion criteria, were duplicates, were secondary publications to a previous study, or had been updated in more recent publications were subsequently excluded (stage 5). Finally, all papers eligible for inclusion were assessed for internal validity and critically appraised (stage 6). The quality assessment was based on the checklists used by the British Medical Journal to assist referees in appraising full and partial economic analysis (see Appendix 13 of the full version of the original guideline).

Selection Criteria

The following inclusion criteria were applied to select studies identified by the economic searches for further analysis:

  • Only papers published in English language were considered.
  • Studies published from 1998 onwards were included. This date restriction was imposed in order to obtain data relevant to current healthcare settings and costs.
  • Only economic evaluations conducted in the UK were selected, so as to reflect healthcare resource use and unit costs directly relevant to the UK context. This criterion was in line with selection criteria from the previous depression guideline. However, this criterion was not applied to studies reporting utility weights that could be potentially used in cost-utility analysis.
  • Selection criteria based on types of clinical conditions and patients were identical to the clinical literature review.
  • Studies were included provided that sufficient details regarding methods and results were available to enable the methodological quality of the study to be assessed, and provided that the study's data and results were extractable. Poster presentations and abstracts were excluded from the review.
  • Full economic evaluations that compared two or more relevant options and considered both costs and consequences (that is, cost–consequence analysis, cost-effectiveness analysis, cost–utility analysis or cost–benefit analysis) were included in the review.
  • Studies were included if they used clinical effectiveness data from an RCT, a prospective cohort study, or a systematic review and meta-analysis of clinical studies. Studies were excluded if they had a mirror-image or other retrospective design, or if they utilised efficacy data that were based mainly on assumptions.
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The quality of the evidence was based on the quality assessment components (study design, limitations to study quality, consistency, directness and any other considerations) and graded using the following definitions:

  • High = Further research is very unlikely to change our confidence in the estimate of the effect
  • Moderate = Further research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate
  • Low = Further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate
  • Very low = Any estimate of effect is very uncertain
Methods Used to Analyze the Evidence
Meta-Analysis
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Clinical Evidence

Data Extraction

Outcome data were extracted from all eligible studies, which met the minimum quality criteria, using Review Manager 4.2.10 (Cochrane Collaboration, 2003) or Review Manager 5 (Cochrane Collaboration, 2008).

For each major area reviewed, the GDG distinguished between outcomes that they considered critical and ones that are important but not critical for the purposes of updating the guideline. Only critical outcomes were initially extracted for data analysis (further details about the critical outcomes can be found in the evidence chapters of the full version of the original guideline).

In most circumstances, for a given outcome (continuous and dichotomous), where more than 50% of the number randomised to any group were lost to follow up, the data were excluded from the analysis (except for the outcome 'leaving the study early', in which case, the denominator was the number randomised). Where possible, dichotomous efficacy outcomes were calculated on an intention-to-treat basis (that is, a 'once-randomised-always-analyse' basis). Where there was good evidence that those participants who ceased to engage in the study were likely to have an unfavourable outcome, early withdrawals were included in both the numerator and denominator. Adverse events were entered into Review Manager as reported by the study authors because it was usually not possible to determine whether early withdrawals had an unfavourable outcome. Where there was limited data for a particular review, the 50% rule was not applied. In these circumstances the evidence was downgraded due to the risk of bias.

Where necessary, standard deviations were calculated from standard errors, confidence intervals or p-values according to standard formulae (see the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1., Higgins & Green, 2008). Data were summarised using the generic inverse variance method using Review Manager.

Consultation with another reviewer or members of the GDG was used to overcome difficulties with coding. Data from studies included in existing systematic reviews were extracted independently by one reviewer and cross-checked with the existing data set. Where possible, data extracted by one reviewer was checked by a second reviewer. Disagreements were resolved with discussion. Where consensus could not be reached, a third reviewer or GDG members resolved the disagreement. Masked assessment (that is, blind to the journal from which the article comes, the authors, the institution and the magnitude of the effect) was not used since it is unclear that doing so reduces bias.

Synthesizing the Evidence

Where possible, meta-analysis was used to synthesis the evidence using Review Manager. If necessary, re-analysis of the data or sub-analysis were used to answer clinical questions not addressed in the original studies or reviews. Studies were given a study ID to make them easier to identify in the text, tables and appendices of this guideline. Study IDs are composed of the first author's surname followed by the year of publication. When studies were found and included in the first NICE guideline on depression (NCCMH, 2004a) the study ID was in title case and when studies were found and included in this guideline update they were labelled in all capital letters.

Dichotomous outcomes were analysed as relative risks (RR) with the associated 95% confidence interval (CI) (for an example, see Figure 2 of the full version of this guideline).

Continuous outcomes were analysed as weighted mean differences (WMD), or as a standardised mean difference (SMD) when different measures were used in different studies to estimate the same underlying effect (for an example, see Figure 3 in the full version of the original guideline). If provided, intention-to-treat data, using a method such as 'last observation carried forward', were preferred over data from completers.

To check for consistency between studies, both the I2 test of heterogeneity and a visual inspection of the forest plots were used. The I2 statistic describes the proportion of total variation in study estimates that is due to heterogeneity. The I2 statistic was interpreted in the follow way:

  • >50%: notable heterogeneity (an attempt was made to explain the variation by conducting sub-analyses to examine potential moderators. In addition, studies with effect sizes greater than two standard deviations from the mean of the remaining studies were excluded using sensitivity analyses. If studies with heterogeneous results were found to be comparable with regard to study and participant characteristics, a random-effects model was used to summarise the results. In the random-effects analysis, heterogeneity is accounted for both in the width of CIs and in the estimate of the treatment effect. With decreasing heterogeneity the random-effects approach moves asymptotically towards a fixed-effects model)
  • 30 to 50%: moderate heterogeneity (both the chi-squared test of heterogeneity and a visual inspection of the forest plot were used to decide between a fixed and random-effects model)
  • <30%: mild heterogeneity (a fixed-effects model was used to synthesize the results)

Presenting the Data to the GDG

Study characteristics tables and, where appropriate, forest plots generated with Review Manager were presented to the GDG in order to prepare a GRADE evidence profile table for each review and to develop recommendations.

Evidence Profile Tables

A GRADE evidence profile was used to summarise, with the exception of diagnostic studies (methods for these studies are at present not sufficiently developed), both the quality of the evidence and the results of the evidence synthesis (see Table 5 for an example of an evidence profile). For each outcome, quality may be reduced depending on the following factors:

  • Study design (randomised trial, observational study, or any other evidence
  • Limitations (based on the quality of individual studies; see Appendix 10 of the full version of the original guideline for the quality checklists)
  • Inconsistency (see section 3.5.4 of the full version of the original guideline for how consistency was measured)
  • Indirectness (that is, how closely the outcome measures, interventions and participants match those of interest)
  • Imprecision (based on the confidence interval around the effect size)

For observational studies, the quality may be increased if there is a large effect, plausible confounding would have changed the effect, or there is evidence of a dose-response gradient (details would be provided under the other considerations column). Each evidence profile also included a summary of the findings: number of patients included in each group, an estimate of the magnitude of the effect, and the overall quality of the evidence for each outcome.

See Table 4 in the full version of the original guideline for an example of GRADE evidence profile.

For further information about the process and the rationale of producing an evidence profile table, see: Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group (2004) Grading quality of evidence and strength of recommendations. British Medical Journal, 328: 1490-1497.

Health Economics Methods

The aim of the health economics was to contribute to the guideline's development by providing evidence on the cost effectiveness of interventions for people with depression covered in the guideline. This was achieved by:

  • Systematic literature review of existing economic evidence
  • Economic modelling, where economic evidence was lacking or was considered inadequate to inform decisions; areas for further economic analysis were prioritised based on anticipated resource implications of the respective recommendations as well as on the quality and availability of respective clinical data.

In addition to the systematic review of economic literature, the following economic issues were identified by the GDG in collaboration with the health economist as key-priorities for further economic analysis (either costing of interventions or full economic modelling) in the guideline update:

  • Cost analysis of Low-intensity psychological interventions
  • Cost-utility of pharmacological interventions
  • Cost-utility of pharmacological therapy versus combined psychological and pharmacological therapy

These topics were selected after considering potential resource implications of the respective recommendations.

Methods employed in de novo economic modelling carried out for this guideline (update) are described in the respective sections of the full version of the original guideline.

Data Extraction

Data were extracted by the health economist using a standard economic data extraction form (see Appendix 14 of the full version of the original guideline).

Methods for Reviewing Experience of Care

The chapter on experience of care (Chapter 4 of the full version of the original guideline) presents three different types of evidence: personal accounts that were collected by the service user and carer members of the GDG; interviews from the healthtalkonline website (www.healthtalkonline.org External Web Site Policy); and review of the qualitative literature. See Section 3.7 of the full version of the guideline document for details on the methods used.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

The Guideline Development Group (GDG)

The GDG consisted of: professionals in psychiatry, psychiatric pharmacy, clinical psychology, nursing, and general practice; academic experts in psychiatry and psychology; and people with depression (one of whom was also a carer). The GDG were recruited according to the specification set out in the scope and in line with the process set out in the NICE guideline manual (NICE, 2007c). The guideline development process was supported by staff from the NCCMH, who undertook the clinical and health economics literature searches, reviewed and presented the evidence to the GDG, managed the process, and contributed to drafting the guideline.

Guideline Development Group Meetings

Fourteen GDG meetings were held between November 2007 and January 2009. During each day-long GDG meeting, in a plenary session, clinical questions and clinical and economic evidence were reviewed and assessed, and recommendations formulated. At each meeting, all GDG members declared any potential conflicts of interest, and the concerns of people with depression and carers were routinely discussed as part of a standing agenda item.

Topic Groups

The GDG divided its workload along clinically relevant lines to simplify the guideline development process, and GDG members formed smaller topic groups to undertake guideline work in that area of clinical practice. Three topic groups were formed to cover: 1) pharmacological and physical interventions, 2) psychological and psychosocial interventions, and 3) services. These groups were designed to efficiently manage the large volume of evidence appraisal prior to presenting it to the GDG as a whole. Each topic group was chaired by a GDG member with expert knowledge of the topic area (one of the healthcare professionals). Topic groups refined the clinical questions, refined the clinical definitions of treatment interventions, reviewed and prepared the evidence with the systematic reviewer before presenting it to the GDG as a whole and helped the GDG to identify further expertise in the topic. Topic group leaders reported the status of the group’s work as part of the standing agenda. They also introduced and led the GDG discussion of the evidence review for that topic and assisted the GDG Chair in drafting the section of the guideline relevant to the work of each topic group.

People with Depression and Carers

Individuals with direct experience of services gave an integral service-user focus to the GDG and the guideline. The GDG included 3 people with depression, one of whom was also a carer. They contributed as full GDG members to writing the clinical questions, helping to ensure that the evidence addressed their views and preferences, highlighting sensitive issues and terminology relevant to the guideline, and bringing service-user research to the attention of the GDG. In drafting the guideline, they contributed to writing the guideline's introduction and identified recommendations from the service user and carer perspective.

Special Advisors

Special advisors, who had specific expertise in one or more aspects of treatment and management relevant to the guideline, or provided expertise in methodological aspects of evidence synthesis, assisted the GDG, commenting on specific aspects of the developing guideline and, where necessary, making presentations to the GDG. Appendix 3 of the full version of the original guideline lists those who agreed to act as special advisors.

National and International Experts

National and international experts in the area under review were identified through the literature search and through the experience of the GDG members. These experts were contacted to recommend unpublished or soon-to-be published studies in order to ensure up-to-date evidence was included in the development of the guideline. They informed the group about completed trials at the pre-publication stage, systematic reviews in the process of being published, studies relating to the cost effectiveness of treatment and trial data if the GDG could be provided with full access to the complete trial report. Appendix 6 of the full guideline version lists researchers who were contacted.

Forming the Clinical Summaries and Recommendations

Once the GRADE profile tables relating to a particular clinical question were completed, summary tables incorporating important information from the GRADE profiles were developed (these tables are presented in the evidence chapters of the full version of the original guideline).

The systematic reviewer in conjunction with the topic group lead produced a clinical evidence summary. Once the GRADE profiles and clinical summaries were finalised and agreed by the GDG and the evidence from depression in the general populations were taken into account, the associated recommendations were drafted, taking into account the trade-off between the benefits and downsides of treatment as well as other important factors. These included economic considerations, values of the development group and society, and the group's awareness of practical issues. The confidence surrounding the evidence in the depression guideline also influenced the GDG's decision to extrapolate.

Method Used to Answer a Clinical Question in the Absence of Appropriately Designed, High-Quality Research

In the absence of appropriately designed, high-quality research, or where the GDG were of the opinion (on the basis of previous searches or their knowledge of the literature) that there were unlikely to be such evidence, either an informal or formal consensus process was adopted. This process focused on those questions that the GDG considered a priority.

Informal Consensus

The starting point for the process of informal consensus was that a member of the topic group identified, with help from the systematic reviewer, a narrative review that most directly addressed the clinical question. Where this was not possible, a brief review of the recent literature was initiated.

This existing narrative review or new review was used as a basis for beginning an iterative process to identify lower levels of evidence relevant to the clinical question and to lead to written statements for the guideline. The process involved a number of steps:

  • A description of what is known about the issues concerning the clinical question was written by one of the topic group members
  • Evidence from the existing review or new review was then presented in narrative form to the GDG and further comments were sought about the evidence and its perceived relevance to the clinical question
  • Based on the feedback from the GDG, additional information was sought and added to the information collected. This may include studies that did not directly address the clinical question but were thought to contain relevant data
  • If, during the course of preparing the report, a significant body of primary-level studies (of appropriate design to answer the question) were identified, a full systematic review was done
  • At this time, subject possibly to further reviews of the evidence, a series of statements that directly addressed the clinical question were developed
  • Following this, on occasions and as deemed appropriate by the development group, the report was then sent to appointed experts outside of the GDG for peer review and comment. The information from this process was then fed back to the GDG for further discussion of the statements
  • Recommendations were then developed and could also be sent for further external peer review
  • After this final stage of comment, the statements and recommendations were again reviewed and agreed upon by the GDG
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The economic evidence identified by the health economics systematic review is summarised in the respective chapters of the full version of the guideline, following presentation of the clinical evidence. The references to included studies at stage 5 of the review, as well as the evidence tables with the characteristics and results of economic studies included in the review, are provided in Appendix 15 in full version of the guideline. Methods and results of economic modelling are reported in the economic sections of the respective evidence chapters.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (including the full guideline and Quick Reference Guide) were consulted with Stakeholders and comments were considered by the Guideline Development Group (GDG).
  2. The final consultation draft of the full guideline and the Information for the Public were submitted to stakeholders for final comments.

Following the consultation period, the GDG finalised the recommendations and the National Collaborating Centre for Mental Health (NCCMH) produced the final documents. These were then submitted to the National Institute for Health and Clinical Excellence (NICE) then formally approved the guideline and issued its guidance to the National Health Service (NHS) in England and Wales.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Box 1: Depression Definitions (taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision [DSM-IV])

Subthreshold depressive symptoms: Fewer than 5 symptoms of depression.

Mild depression: Few, if any, symptoms in excess of the 5 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.

Note that a comprehensive assessment of depression should not rely simply on a symptom count, but should take into account the degree of functional impairment and/or disability (see "Principles for Assessment, Coordination of Care, and Choosing Treatments" below).

This guideline is published alongside NICE guideline 91 Depression in adults with a chronic physical health problem External Web Site Policy (see the NGC summary), which makes recommendations on the identification, treatment and management of depression in adults aged 18 years and older who also have a chronic health problem.

Care of All People with Depression

Providing Information and Support, and Obtaining Informed Consent

When working with people with depression and their families or carers:

  • Build a trusting relationship and work in an open, engaging and non-judgmental manner
  • Explore treatment options in an atmosphere of hope and optimism, explaining the different courses of depression and that recovery is possible
  • Be aware that stigma and discrimination can be associated with a diagnosis of depression
  • Ensure that discussions take place in settings in which confidentiality, privacy and dignity are respected

When working with people with depression and their families or carers:

  • Provide information appropriate to their level of understanding about the nature of depression and the range of treatments available
  • Avoid clinical language without adequate explanation
  • Ensure that comprehensive written information is available in the appropriate language and in audio format if possible
  • Provide and work proficiently with independent interpreters (that is, someone who is not known to the person with depression) if needed

Inform people with depression about self-help groups, support groups and other local and national resources.

Make all efforts necessary to ensure that a person with depression can give meaningful and informed consent before treatment starts. This is especially important when a person has severe depression or is subject to the Mental Health Act.

Ensure that consent to treatment is based on the provision of clear information (which should also be available in written form) about the intervention, covering:

  • What it comprises
  • What is expected of the person while having it
  • Likely outcomes (including any side effects)

Advance Decisions and Statements

For people with recurrent severe depression or depression with psychotic symptoms and for those who have been treated under the Mental Health Act, consider developing advance decisions and advance statements collaboratively with the person. Record the decisions and statements and include copies in the person's care plan in primary and secondary care. Give copies to the person and to their family or carer, if the person agrees.

Supporting Families and Carers

When families or carers are involved in supporting a person with severe or chronic depression, consider:

  • Providing written and verbal information on depression and its management, including how families or carers can support the person
  • Offering a carer’s assessment of their caring, physical and mental health needs if necessary
  • Providing information about local family or carer support groups and voluntary organisations, and helping families or carers to access these
  • Negotiating between the person and their family or carer about confidentiality and the sharing of information

Note: Depression is described as 'chronic' if symptoms have been present more or less continuously for 2 years or more.

Principles for Assessment, Coordination of Care and Choosing Treatments

When assessing a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode.

In addition to assessing symptoms and associated functional impairment, consider how the following factors may have affected the development, course and severity of a person's depression:

  • Any history of depression and co-morbid mental health or physical disorders
  • Any past history of mood elevation (to determine if the depression may be part of bipolar disorder) (Refer if necessary to the NICE guideline 'Bipolar Disorder')
  • Any past experience of, and response to, treatments
  • The quality of interpersonal relationships
  • Living conditions and social isolation

Be respectful of, and sensitive to, diverse cultural, ethnic and religious backgrounds when working with people with depression, and be aware of the possible variations in the presentation of depression. Ensure competence in:

  • Culturally sensitive assessment
  • Using different explanatory models of depression
  • Addressing cultural and ethnic differences when developing and implementing treatment plans
  • Working with families from diverse ethnic and cultural backgrounds

When assessing a person with suspected depression, be aware of any learning disabilities or acquired cognitive impairments, and if necessary consider consulting with a relevant specialist when developing treatment plans and strategies.

When providing interventions for people with a learning disability or acquired cognitive impairment who have a diagnosis of depression:

  • Where possible, provide the same interventions as for other people with depression.
  • If necessary, adjust the method of delivery or duration of the intervention to take account of the disability or impairment.

Always ask people with depression directly about suicidal ideation and intent. If there is a risk of self-harm or suicide:

  • Assess whether the person has adequate social support and is aware of sources of help.
  • Arrange help appropriate to the level of risk (see "Risk Assessment and Monitoring" below).
  • Advise the person to seek further help if the situation deteriorates.

Effective Delivery of Interventions for Depression

All interventions for depression should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

  • Receive regular high-quality supervision.
  • Use routine outcome measures and ensure that the person with depression is involved in reviewing the efficacy of the treatment.
  • Engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny where appropriate.

Consider providing all interventions in the preferred language of the person with depression where possible.

Stepped Care

The stepped-care model provides a framework in which to organize the provision of services, and supports patients, carers and practitioners in identifying and accessing the most effective interventions (see figure 1 below). In stepped care the least intrusive, most effective intervention is provided first; if a person does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.

Figure 1: The Stepped-Care Model

Focus of the Intervention Nature of the Intervention
STEP 4: Severe and complexa depression; risk to life; severe self-neglect Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care
STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression Medication, high-intensity psychological interventions, combined treatments, collaborative careb and referral for further assessment and interventions
STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions
STEP 1: All known and suspected presentations of depression Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions

a Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors.
b Only for depression where the person also has a chronic physical health problem and associated functional impairment (see the NGC summary Depression in adults with a chronic physical health problem: treatment and management [NICE clinical guideline 91]).

Step 1: Recognition, Assessment and Initial Management

Case Identification and Recognition

Be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment) and 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?

If a person answers 'yes' to either of the depression identification questions but the practitioner is not competent to perform a mental health assessment, they should refer the person to an appropriate professional. If this professional is not the person's general practitioner (GP), inform the GP of the referral.

If a person answers 'yes' to either of the depression identification questions, a practitioner who is competent to perform a mental health assessment should review the person's mental state and associated functional, interpersonal and social difficulties.

When assessing a person with suspected depression, consider using a validated measure (for example, for symptoms, functions and/or disability) to inform and evaluate treatment.

For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer and/or asking a family member or carer about the person’s symptoms to identify possible depression. If a significant level of distress is identified, investigate further.

Note: The Distress Thermometer is a single-item question screen that will identify distress coming from any source. The person places a mark on the scale answering: 'How distressed have you been during the past week on a scale of 0 to 10?' Scores of 4 or more indicate a significant level of distress that should be investigated further. [Roth AJ, Kornblith AB, Batel-Copel L, et al. (1998) Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82: 1904-8.]

Risk Assessment and Monitoring

If a person with depression presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services.

Advise people with depression of the potential for increased agitation, anxiety and suicidal ideation in the initial stages of treatment; actively seek out these symptoms and:

  • Ensure that the person knows how to seek help promptly.
  • Review the person's treatment if they develop marked and/or prolonged agitation.

Advise a person with depression and their family or carer to be vigilant for mood changes, negativity and hopelessness, and suicidal ideation, and to contact their practitioner if concerned. This is particularly important during high-risk periods, such as starting or changing treatment and at times of increased personal stress.

If a person with depression is assessed to be at risk of suicide:

  • Take into account toxicity in overdose if an antidepressant is prescribed or the person is taking other medication; if necessary, limit the amount of drug(s) available
  • Consider increasing the level of support, such as more frequent direct or telephone contacts
  • Consider referral to specialist mental health services.

Step 2: Recognized Depression – Persistent Subthreshold Depressive Symptoms or Mild to Moderate Depression

General Measures

Depression with Anxiety

When depression is accompanied by symptoms of anxiety, the first priority should usually be to treat the depression. When the person has an anxiety disorder and comorbid depression or depressive symptoms, consult the NICE guideline for the relevant anxiety disorder (see Section 6 of the original guideline document) and consider treating the anxiety disorder first (since effective treatment of the anxiety disorder will often improve the depression or the depressive symptoms).

Sleep Hygiene

Offer people with depression advice on sleep hygiene if needed, including:

  • Establishing regular sleep and wake times
  • Avoiding excess eating, smoking or drinking alcohol before sleep
  • Creating a proper environment for sleep
  • Taking regular physical exercise

Active Monitoring

For people who, in the judgment of the practitioner, may recover with no formal intervention, or people with mild depression who do not want an intervention, or people with subthreshold depressive symptoms who request an intervention:

  • Discuss the presenting problem(s) and any concerns that the person may have about them
  • Provide information about the nature and course of depression
  • Arrange a further assessment, normally within 2 weeks
  • Make contact if the person does not attend follow-up appointments

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)
  • Computerized cognitive behavioural therapy (CCBT)
  • A structured group physical activity programme

Delivery of Low-Intensity Psychosocial Interventions

Individual guided self-help programmes based on the principles of CBT (and including behavioral activation and problem-solving techniques) for people with persistent subthreshold depressive symptoms or mild to moderate depression should:

  • Include the provision of written materials of an appropriate reading age (or alternative media to support access)
  • Be supported by a trained practitioner, who typically facilitates the self-help programme and reviews progress and outcome
  • Consist of up to six to eight sessions (face-to-face and via telephone) normally taking place over 9 to 12 weeks, including follow-up

CCBT for people with persistent subthreshold depressive symptoms or mild to moderate depression should:

  • Be provided via a stand-alone computer-based or web-based programme
  • Include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behavior, thought patterns and outcomes
  • Be supported by a trained practitioner, who typically provides limited facilitation of the programme and reviews progress and outcome
  • Typically take place over 9 to 12 weeks, including follow-up

Physical activity programmes for people with persistent subthreshold depressive symptoms or mild to moderate depression should:

  • Be delivered in groups with support from a competent practitioner
  • Consist typically of three sessions per week of moderate duration (45 minutes to 1 hour) over 10 to 14 weeks (average 12 weeks)

Group Cognitive Behavioral Therapy

Consider group-based CBT for people with persistent subthreshold depressive symptoms or mild to moderate depression who decline low-intensity psychosocial interventions.

Group-based CBT for people with persistent subthreshold depressive symptoms or mild to moderate depression should:

  • Be based on a structured model such as 'Coping with Depression'
  • Be delivered by two trained and competent practitioners
  • Consist of 10 to 12 meetings of eight to ten participants
  • Normally take place over 12 to 16 weeks, including follow-up

Drug Treatment

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor, but consider them for people with:

  • A past history of moderate or severe depression
  • Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years
  • Subthreshold depressive symptoms or mild depression that persist(s) after other interventions

Although there is evidence that St John's wort may be of benefit in mild or moderate depression, practitioners should:

  • Not prescribe or advise its use by people with depression because of uncertainty about appropriate doses, persistence of effect, variation in the nature of preparations and potential serious interactions with other drugs (including oral contraceptives, anticoagulants and anticonvulsants)
  • Advise people with depression of the different potencies of the preparations available and of the potential serious interactions of St John's wort with other drugs.

Step 3: Persistent Subthreshold Depressive Symptoms or Mild to Moderate Depression with Inadequate Response to Initial Interventions, and Moderate and Severe Depression

Treatment Options

For people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, discuss the relative merits of different interventions with the person and provide:

  • An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI])
  • A high-intensity psychological intervention, normally one of the following options:
    • CBT
    • Interpersonal therapy (IPT)
    • Behavioural activation (but note that the evidence is less robust than for CBT or IPT)
    • Behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.

For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT or IPT).

The choice of intervention should be influenced by the:

  • Duration of the episode of depression and the trajectory of symptoms
  • Previous course of depression and response to treatment
  • Likelihood of adherence to treatment and any potential adverse effects
  • Person's treatment preference and priorities

For people with depression who decline an antidepressant, CBT, IPT, behavioral activation and behavioral couples therapy, consider:

  • Counseling for people with persistent subthreshold depressive symptoms or mild to moderate depression
  • Short-term psychodynamic psychotherapy for people with mild to moderate depression

Discuss with the person the uncertainty of the effectiveness of counseling and psychodynamic psychotherapy in treating depression.

Antidepressant Drugs

Choice of Antidepressant*

Discuss antidepressant treatment options with the person with depression, covering:

  • The choice of antidepressant, including any anticipated adverse events, for example side effects and discontinuation symptoms (see "Stopping or Reducing Antidepressants" below), and potential interactions with concomitant medication or physical health problems**
  • Their perception of the efficacy and tolerability of any antidepressants they have previously taken

*For additional considerations on the use of antidepressants and other medications (including the assessment of the relative risks and benefits) for women who may become pregnant, please refer to the British National Formulary (BNF) and individual drug Summary of Product Characteristics (SPCs). For women in the antenatal and postnatal periods, see also the NICE clinical guideline 45 'Antenatal and postnatal mental health'.

**Consult appendix 1 of the BNF for information on drug interactions and the NGC summary Depression in adults with a chronic physical health problem: treatment and management (NICE clinical guideline 91).

When an antidepressant is to be prescribed, it should normally be an SSRI in a generic form because SSRIs are equally effective as other antidepressants and have a favourable risk–benefit ratio. Also take the following into account:

  • SSRIs are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting. In particular, consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin.
  • Fluoxetine, fluvoxamine and paroxetine are associated with a higher propensity for drug interactions than other SSRIs**
  • Paroxetine is associated with a higher incidence of discontinuation symptoms than other SSRIs.

Take into account toxicity in overdose when choosing an antidepressant for people at significant risk of suicide. Be aware that:

  • Compared with other equally effective antidepressants recommended for routine use in primary care, venlafaxine is associated with a greater risk of death from overdose
  • Tricyclic antidepressants (TCAs), except for lofepramine, are associated with the greatest risk in overdose

When prescribing drugs other than SSRIs, take the following into account:

  • The increased likelihood of the person stopping treatment because of side effects (and the consequent need to increase the dose gradually) with venlafaxine, duloxetine and TCAs.
  • The specific cautions, contraindications and monitoring requirements for some drugs. For example:
    • The potential for higher doses of venlafaxine to exacerbate cardiac arrhythmias and the need to monitor the person's blood pressure
    • The possible exacerbation of hypertension with venlafaxine and duloxetine
    • The potential for postural hypotension and arrhythmias with TCAs
    • The need for hematological monitoring with mianserin in elderly people**
  • Non-reversible monoamine oxidase inhibitors (MAOIs), such as phenelzine, should normally be prescribed only by specialist mental health professionals.
  • Dosulepin should not be prescribed.

Starting and Initial Phase of Treatment

When prescribing antidepressants, explore any concerns the person with depression has about taking medication, explain fully the reasons for prescribing, and provide information about taking antidepressants, including:

  • The gradual development of the full antidepressant effect
  • The importance of taking medication as prescribed and the need to continue treatment after remission
  • Potential side effects
  • The potential for interactions with other medications
  • The risk and nature of discontinuation symptoms with all antidepressants, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine), and how these symptoms can be minimized
  • The fact that addiction does not occur with antidepressants.

Offer written information appropriate to the person's needs.

For people started on antidepressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter, for example at intervals of 2 to 4 weeks in the first 3 months, and then at longer intervals if response is good.

A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important.

If a person with depression develops side effects early in antidepressant treatment, provide appropriate information and consider one of the following strategies:

  • Monitor symptoms closely where side effects are mild and acceptable to the person
  • Stop the antidepressant or change to a different antidepressant if the person prefers
  • In discussion with the person, consider short-term concomitant treatment with a benzodiazepine if anxiety, agitation and/or insomnia are problematic (except in people with chronic symptoms of anxiety); this should usually be for no longer than 2 weeks in order to prevent the development of dependence

People who start on low-dose TCAs and who have a clear clinical response can be maintained on that dose with careful monitoring.

If the person's depression shows no improvement after 2 to 4 weeks with the first antidepressant, check that the drug has been taken regularly and in the prescribed dose.

If response is absent or minimal after 3 to 4 weeks of treatment with a therapeutic dose of an antidepressant, increase the level of support (for example, by weekly face-to-face or telephone contact) and consider:

  • Increasing the dose in line with the SPC if there are no significant side effects or
  • Switching to another antidepressant as described in the section "Switching Antidepressants" below if there are side effects or if the person prefers.

If the person's depression shows some improvement by 4 weeks, continue treatment for another 2 to 4 weeks. Consider switching to another antidepressant if:

  • Response is still not adequate
  • There are side effects
  • The person prefers to change treatment

Psychological Interventions

Delivering High-Intensity Psychological Interventions

For all high-intensity psychological interventions, the duration of treatment should normally be within the limits indicated in this guideline. As the aim of treatment is to obtain significant improvement or remission the duration of treatment may be:

  • Reduced if remission has been achieved
  • Increased if progress is being made, and there is agreement between the practitioner and the person with depression that further sessions would be beneficial (for example, if there is a comorbid personality disorder or significant psychosocial factors that impact on the person's ability to benefit from treatment).

For all people with depression having individual CBT, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. Also consider providing:

  • Two sessions per week for the first 2 to 3 weeks of treatment for people with moderate or severe depression
  • Follow-up sessions typically consisting of three to four sessions over the following 3 to 6 months for all people with depression.

For all people with depression having IPT, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. For people with severe depression, consider providing two sessions per week for the first 2 to 3 weeks of treatment.

For all people with depression having behavioural activation, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. Also consider providing:

  • Two sessions per week for the first 3 to 4 weeks of treatment for people with moderate or severe depression
  • Follow-up sessions typically consisting of three to four sessions over the following 3 to 6 months for all people with depression.

Behavioral couples therapy for depression should normally be based on behavioral principles, and an adequate course of therapy should be 15 to 20 sessions over 5 to 6 months.

Delivering Counseling

For all people with persistent sub-threshold depressive symptoms or mild to moderate depression having counseling, the duration of treatment should typically be in the range of six to ten sessions over 8 to 12 weeks.

Delivering Short-Term Psychodynamic Psychotherapy

For all people with mild to moderate depression having short-term psychodynamic psychotherapy, the duration of treatment should typically be in the range of 16 to 20 sessions over 4 to 6 months.

Treatment Choice Based on Depression Subtypes and Personal Characteristics

There is little evidence to guide prescribing in relation to depression subtypes or personal characteristics. The main issue concerns the impact of other physical disorders on the treatment of depression. Refer to the NGC summary Depression in adults with a chronic physical health problem: treatment and management (NICE clinical guideline 91) for further information.

Do not routinely vary the treatment strategies for depression described in this guideline either by depression subtype (for example, atypical depression or seasonal depression) or by personal characteristics (for example, sex or ethnicity) as there is no convincing evidence to support such action.

Advise people with winter depression that follows a seasonal pattern and who wish to try light therapy in preference to antidepressant or psychological treatment that the evidence for the efficacy of light therapy is uncertain.

When prescribing antidepressants for older people:

  • Prescribe at an age-appropriate dose taking into account the effect of general physical health and concomitant medication on pharmacokinetics and pharmacodynamics
  • Carefully monitor for side effects.

For people with long-standing moderate or severe depression who would benefit from additional social or vocational support, consider:

  • Befriending as an adjunct to pharmacological or psychological treatments; befriending should be by trained volunteers providing, typically, at least weekly contact for between 2 and 6 months
  • A rehabilitation programme if a person's depression has resulted in loss of work or disengagement from other social activities over a longer term.

Enhanced Care for Depression

Medication management as a separate intervention for people with depression should not be provided routinely by services. It is likely to be effective only when provided as part of a more complex intervention.

For people with severe depression and those with moderate depression and complex problems, consider:

Sequencing Treatments after Initial Inadequate Response

Some people have depression that does not respond well to initial treatment. This section describes strategies to adopt if this occurs.

Drug Treatments

When reviewing drug treatment for a person with depression whose symptoms have not adequately responded to initial pharmacological interventions:

  • Check adherence to, and side effects from, initial treatment.
  • Increase the frequency of appointments using outcome monitoring with a validated outcome measure.
  • Be aware that using a single antidepressant rather than combination medication or augmentation (see "Combining and Augmenting Medications" below) is usually associated with a lower side-effect burden.
  • Consider reintroducing previous treatments that have been inadequately delivered or adhered to, including increasing the dose.
  • Consider switching to an alternative antidepressant.

Switching Antidepressants

When switching to another antidepressant, be aware that the evidence for the relative advantage of switching either within or between classes is weak. Consider switching to:

  • Initially a different SSRI or a better tolerated newer-generation antidepressant
  • Subsequently an antidepressant of a different pharmacological class that may be less well tolerated, for example venlafaxine, a TCA or an MAOI.

Do not switch to, or start, dosulepin because evidence supporting its tolerability relative to other antidepressants is outweighed by the increased cardiac risk and toxicity in overdose.

When switching to another antidepressant, which can normally be achieved within 1 week when switching from drugs with a short half-life, consider the potential for interactions in determining the choice of a new drug and the nature and duration of the transition. Exercise particular caution when switching:

  • From fluoxetine to other antidepressants, because fluoxetine has a long half-life (approximately 1 week)
  • From fluoxetine or paroxetine to a TCA, because both of these drugs inhibit the metabolism of TCAs; a lower starting dose of the TCA will be required, particularly if switching from fluoxetine because of its long half-life
  • To a new serotonergic antidepressant or MAOI, because of the risk of serotonin syndrome (features of serotonin syndrome include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus)
  • From a non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed routinely during this period).

Combining and Augmenting Medications

'Augmentation' is when an antidepressant is used with a non-antidepressant drug and 'combination' is when two antidepressants are used together.

When using combinations of medications (which should only normally be started in primary care in consultation with a consultant psychiatrist):

  • Select medications that are known to be safe when used together
  • Be aware of the increased side-effect burden this usually causes
  • Discuss the rationale for any combination with the person with depression, follow General Medical Council (GMC) guidance if off-label medication is prescribed, and monitor carefully for adverse effects
  • Be familiar with primary evidence and consider obtaining a second opinion when using unusual combinations, the evidence for the efficacy of a chosen strategy is limited or the risk–benefit ratio is unclear
  • Document the rationale for the chosen combination.

If a person with depression is informed about, and prepared to tolerate, the increased side-effect burden, consider combining or augmenting an antidepressant with:

  • Lithium or
  • An antipsychotic such as aripiprazole*, olanzapine*, quetiapine* or risperidone* or
  • Another antidepressant such as mirtazapine or mianserin.

When prescribing lithium:

  • Monitor renal and thyroid function before treatment and every 6 months during treatment (more often if there is evidence of renal impairment)
  • Consider electrocardiogram (ECG) monitoring in people with depression who are at high risk of cardiovascular disease
  • Monitor serum lithium levels 1 week after initiation and each dose change until stable, and every 3 months thereafter.

When prescribing an antipsychotic, monitor weight, lipid and glucose levels, and side effects (for example, extrapyramidal side effects and prolactin-related side effects with risperidone).

The following strategies should not be used routinely:

  • Augmentation of an antidepressant with a benzodiazepine for more than 2 weeks as there is a risk of dependence
  • Augmentation of an antidepressant with buspirone,# carbamazepine,# lamotrigine# or valproate# as there is insufficient evidence for their use
  • Augmentation of an antidepressant with pindolol# or thyroid hormones# as there is inconsistent evidence of effectiveness.

Note: In this guideline, drug names are marked with a # if they do not have UK marketing authorisation for the indication in question at the time of publication (October 2009). Informed consent should be obtained and documented.

Combined Psychological and Drug Treatment

For a person whose depression has not responded to either pharmacological or psychological interventions, consider combining antidepressant medication with CBT.

Referral

For a person whose depression has failed to respond to various strategies for augmentation and combination treatments, consider referral to a practitioner with a specialist interest in treating depression, or to a specialist service.

Continuation and Relapse Prevention

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.

Review with the person with depression the need for continued antidepressant treatment beyond 6 months after remission, taking into account:

  • The number of previous episodes of depression
  • The presence of residual symptoms
  • Concurrent physical health problems and psychosocial difficulties

For people with depression who are at significant risk of relapse or have a history of recurrent depression, discuss with the person treatments to reduce the risk of recurrence, including continuing medication, augmentation of medication or psychological treatment (CBT). Treatment choice should be influenced by:

  • Previous treatment history, including the consequences of a relapse, residual symptoms, response to previous treatment and any discontinuation symptoms
  • The person's preference

Using Medication for Relapse Prevention

Advise people with depression to continue antidepressants for at least 2 years if they are at risk of relapse. Maintain the level of medication at which acute treatment was effective (unless there is good reason to reduce the dose, such as unacceptable adverse effects) if:

  • They have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
  • They have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
  • The consequences of relapse are likely to be severe (for example, suicide attempts, loss of functioning, severe life disruption, and inability to work).

When deciding whether to continue maintenance treatment beyond 2 years, re-evaluate with the person with depression, taking into account age, comorbid conditions and other risk factors.

People with depression on long-term maintenance treatment should be regularly re-evaluated, with frequency of contact determined by:

  • Comorbid conditions
  • Risk factors for relapse
  • Severity and frequency of episodes of depression

People who have had multiple episodes of depression, and who have had a good response to treatment with an antidepressant and an augmenting agent, should remain on this combination after remission if they find the side effects tolerable and acceptable. If one medication is stopped, it should usually be the augmenting agent. Lithium should not be used as a sole agent to prevent recurrence.

Psychological Interventions for Relapse Prevention

People with depression who are considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, should be offered one of the following psychological interventions:

  • Individual CBT for people who have relapsed despite antidepressant medication and 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

Delivering Psychological Interventions for Relapse Prevention

For all people with depression who are having individual CBT for relapse prevention, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. If the duration of treatment needs to be extended to achieve remission it should:

  • Consist of two sessions per week for the first 2 to 3 weeks of treatment
  • Include additional follow-up sessions, typically consisting of four to six sessions over the following 6 months.

Mindfulness-based cognitive therapy should normally be delivered in groups of 8 to 15 participants and consist of weekly 2-hour meetings over 8 weeks and four follow-up sessions in the 12 months after the end of treatment.

Stopping or Reducing Antidepressants

Advise people with depression who are taking antidepressants that discontinuation symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. Explain that symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly. (Discontinuation symptoms include increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating, abdominal symptoms and altered sensations.)

When stopping an antidepressant, gradually reduce the dose, normally over a 4-week period, although some people may require longer periods, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine). This is not required with fluoxetine because of its long half-life.

Inform the person that they should seek advice from their practitioner if they experience significant discontinuation symptoms. If discontinuation symptoms occur:

  • Monitor symptoms and reassure the person if symptoms are mild
  • Consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms.

Step 4: Complex and Severe Depression

Referral to specialist mental health services should normally be for people with depression who are at significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care, or where an expert opinion on treatment and management is needed.

The assessment of a person with depression referred to specialist mental health services should include:

  • Their symptom profile, suicide risk and, where appropriate, previous treatment history
  • Associated psychosocial stressors, personality factors and significant relationship difficulties, particularly where the depression is chronic or recurrent
  • Associated comorbidities including alcohol and substance misuse, and personality disorders.

In specialist mental health services, after thoroughly reviewing previous treatments for depression, consider reintroducing previous treatments that have been inadequately delivered or adhered to.

Use crisis resolution and home treatment teams to manage crises for people with severe depression who present significant risk, and to deliver high-quality acute care. The teams should monitor risk as a high-priority routine activity in a way that allows people to continue their lives without disruption.

Medication in secondary care mental health services should be started under the supervision of a consultant psychiatrist.

Teams working with people with complex and severe depression should develop comprehensive multidisciplinary care plans in collaboration with the person with depression (and their family or carer, if agreed with the person). The care plan should:

  • Identify clearly the roles and responsibilities of all health and social care professionals involved
  • Develop a crisis plan that identifies potential triggers that could lead to a crisis and strategies to manage such triggers
  • Be shared with the GP and the person with depression and other relevant people involved in the person’s care.

Inpatient Care, and Crisis Resolution and Home Treatment Teams

Consider inpatient treatment for people with depression who are at significant risk of suicide, self-harm or self-neglect.

The full range of high-intensity psychological interventions should normally be offered in inpatient settings. However, consider increasing the intensity and duration of the interventions and ensure that they can be provided effectively and efficiently on discharge.

Consider crisis resolution and home treatment teams for people with depression who might benefit from early discharge from hospital after a period of inpatient care.

Pharmacological Management of Depression with Psychotic Symptoms

For people who have depression with psychotic symptoms, consider augmenting the current treatment plan with antipsychotic medication (although the optimum dose and duration of treatment are unknown).

Electroconvulsive Therapy (ECT)

The recommendations in this section update the depression aspects only of 'Guidance on the use of electroconvulsive therapy' (NICE technology appraisal guidance 59).

Consider ECT for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed.

Do not use ECT routinely for people with moderate depression but consider it if their depression has not responded to multiple drug treatments and psychological treatment.

For people whose depression has not responded well to a previous course of ECT, consider a repeat trial of ECT only after:

  • Reviewing the adequacy of the previous treatment course
  • Considering all other options
  • Discussing the risks and benefits with the person and/or, where appropriate, their advocate or carer.

When considering ECT as a treatment choice, ensure that the person with depression is fully informed of the risks associated with ECT, and with the risks and benefits specific to them. Document the assessment and consider:

  • The risks associated with a general anaesthetic.
  • Current medical comorbidities
  • Potential adverse events, notably cognitive impairment
  • The risks associated with not receiving ECT.

The risks associated with ECT may be greater in older people; exercise particular caution when considering ECT treatment in this group.

A decision to use ECT should be made jointly with the person with depression as far as possible, taking into account, where applicable, the requirements of the Mental Health Act 2007. Also be aware that:

  • Valid informed consent should be obtained (if the person has the capacity to grant or refuse consent) without the pressure or coercion that might occur as a result of the circumstances and clinical setting.
  • The person should be reminded of their right to withdraw consent at any time.
  • There should be strict adherence to recognized guidelines about consent, and advocates or carers should be involved to facilitate informed discussions.
  • If informed consent is not possible, ECT should only be given if it does not conflict with a valid advance decision, and the person's advocate or carer should be consulted.

The choice of electrode placement and stimulus dose related to seizure threshold should balance efficacy against the risk of cognitive impairment. Take into account that:

  • Bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment.
  • With unilateral ECT, a higher stimulus dose is associated with greater efficacy, but also increased cognitive impairment compared with a lower stimulus dose.

Assess clinical status after each ECT treatment using a formal valid outcome measure, and stop treatment when remission has been achieved, or sooner if side effects outweigh the potential benefits.

Assess cognitive function before the first ECT treatment and monitor at least every three to four treatments, and at the end of a course of treatment.

Assessment of cognitive function should include:

  • Orientation and time to reorientation after each treatment
  • Measures of new learning, retrograde amnesia and subjective memory impairment carried out at least 24 hours after a treatment.

If there is evidence of significant cognitive impairment at any stage consider, in discussion with the person with depression, changing from bilateral to unilateral electrode placement, reducing the stimulus dose or stopping treatment depending on the balance of risks and benefits.

If a person's depression has responded to a course of ECT, antidepressant medication should be started or continued to prevent relapse. Consider lithium augmentation of antidepressants.

Transcranial Magnetic Stimulation

Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure's clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors. (This recommendation is taken from 'Transcranial magnetic stimulation for severe depression' [NICE interventional procedure guidance 242]).

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

Recommendations are based on clinical and cost effectiveness evidence, and where this is insufficient, the Guideline Development Group (GDG) used all available information sources and experience to make consensus recommendations.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate treatment and management of depression in adults

Potential Harms

Side-effects of Antidepressive Medication

  • Selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting.
  • Fluoxetine, fluvoxamine and paroxetine are associated with a higher propensity for drug interactions than other SSRIs.
  • Paroxetine is associated with a higher incidence of discontinuation symptoms than other SSRIs.
  • Venlafaxine is associated with a greater risk of death from overdose.
  • The potential for higher doses of venlafaxine to exacerbate cardiac arrhythmias and the need to monitor the person’s blood pressure
  • Possible exacerbation of hypertension with venlafaxine and duloxetine
  • The potential for postural hypotension and arrhythmias with TCAs
  • The need for haematological monitoring with mianserin in elderly people
  • Tricyclic antidepressants (TCAs), except for lofepramine, are associated with the greatest risk in overdose.

People Receiving Maintenance Electroconvulsive Therapy

  • Electroconvulsive therapy (ECT) is associated with the risk of cognitive impairment.
  • The risks associated with ECT may be greater in older people; exercise particular caution when considering ECT treatment in this group.

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Implementation of the Guideline

Description of Implementation Strategy

The Healthcare Commission assesses the performance of National Health Service (NHS) organisations in meeting core and developmental standards set by the Department of Health in 'Standards for better health' (available from www.dh.gov.uk External Web Site Policy). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (see http://guidance.nice.org.uk/CG90 External Web Site Policy; see also the "Availability of Companion Documents" field).

Key Priorities for Implementation

Principles for Assessment

When assessing a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode.

Effective Delivery of Interventions for Depression

All interventions for depression should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

  • Receive regular high-quality supervision
  • Use routine outcome measures and ensure that the person with depression is involved in reviewing the efficacy of the treatment
  • Engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny where appropriate.

Case Identification and Recognition

Be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment) and 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?

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

Drug Treatment

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor, but consider them for people with:

  • A past history of moderate or severe depression or
  • Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
  • Subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

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 (CBT or IPT).

Continuation and Relapse Prevention

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.

Psychological Interventions for Relapse Prevention

People with depression who are considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, should be offered one of the following psychological interventions:

  • Individual CBT for people who have relapsed despite antidepressant medication and 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.
Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Collaborating Centre for Mental Health. Depression. The treatment and management of depression in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Oct. 64 p. (Clinical guideline; no. 90). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 (revised 2009 Oct)
Guideline Developer(s)
National Collaborating Centre for Mental Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

The Guideline Development Group: Professor Ian Anderson (Chair, Guideline Development Group), Professor of Psychiatry, University of Manchester; Professor Stephen Pilling, Joint Director, National Collaborating Centre for Mental Health; Director, Centre for Outcomes Research and Effectiveness, University College London; Ms Alison Barnes, Service user member; Ms Linda Bayliss, Research Assistant (May 2008 to August 2008), National Collaborating Centre for Mental Health; Ms Victoria Bird, Research Assistant, National Collaborating Centre for Mental Health; Ms Rachel Burbeck, Lead Systematic Reviewer, National Collaborating Centre for Mental Health; Dr Carolyn Chew-Graham, General Practitioner, Senior Lecturer in Primary Care, University of Manchester; Mr Jeremy Clarke, Psychological therapist, Lambeth Primary care Trust; Mr Matthew Dyer, Health Economist, National Collaborating Centre for Mental Health; Ms Esther Flanagan, Project Manager (2009), National Collaborating Centre for Mental Health; Ms Catherine Harris, Carer member and Local Councillor; Ms Sarah Hopkins, Project Manager (until 2008), National Collaborating Centre for Mental Health; Dr Mark Kenwright, Consultant Cognitive Behavioural Psychotherapist; Ealing Cognitive Behavioural Therapy Service; Professor Willem Kuyken, Professor of Clinical Psychology and Co-Director Mood Disorders Centre, University of Exeter Psychology; Ms Angela Lewis, Research Assistant, National Collaborating Centre for Mental Health; Professor Glyn Lewis, Professor of Psychiatric Epidemiology, University of Bristol; Mr Ryan Li, Project Manager (2008), National Collaborating Centre for Mental Health; Mr Brendan Masterson, Clinical Nurse Leader, Affective Disorders Unit, Bethlem Royal Hospital; Dr Nick Meader, Systematic Reviewer, National Collaborating Centre for Mental Health; Mr Alan Meudell, Service user member, Healthy Minds at Work; Dr Alex Mitchell, Consultant Psychiatrist and Honorary lecturer in liaison psychiatry, University of Leicester; Dr Richard Moore, Clinical Psychologist, Cambridge; Dr Suffiya Omarjee, Health Economist, National Collaborating Centre for Mental Health; Ms Carol Paton, Chief Pharmacist, Oxleas NHS Foundation Trust; Dr Alejandra Perez, Systematic Reviewer, National Collaborating Centre for Mental Health; Ms Maria Rizzo, Research Assistant, National Collaborating Centre for Mental Health; Ms Peny Retsa, Health Economist (until 2008), National Collaborating Centre for Mental Health; Ms Jennie Robertson, Research Assistant (from September 2008), National Collaborating Centre for Mental Health; Mr Rob Saunders, Research Assistant, National Collaborating Centre for Mental Health (2008); Ms Christine Sealey, Centre Manager, National Collaborating Centre for Mental Health; Ms Beth Shackleton, Project Manager, National Collaborating Centre for Mental Health (until 2008); Dr Thomas Shackleton, General Practitioner, Suffolk; Ms Sarah Stockton, Senior Information Scientist, National Collaborating Centre for Mental Health; Dr Clare Taylor Editor, National Collaborating Centre for Mental Health; Ms Jane Wood, Nurse, Strategic Development Manager, Mental Health, Leeds Primary Care Trust

Guideline Review Panel: Mr Peter Robb (Chair), Consultant Ear, Nose and Throat Surgeon, Epsom and St Helier University Hospitals and The Royal Surrey County NHS Trusts; Mr John Seddon, Lay member; Dr Christine Hine, Consultant in Public Health (Acute Commissioning), Bristol and South Gloucestershire Primary Care Trusts (PCTs); Dr Greg Rogers, GP, Kent; Dr John Harley, Clinical Governance and Prescribing Lead and GP, North Tees PCT

Financial Disclosures/Conflicts of Interest

With a range of practical experience relevant to depression in the Guideline Development Group (GDG), members were appointed because of their understanding and expertise in healthcare for people with depression and support for their families and carers, including: scientific issues; health research; the delivery and receipt of healthcare, along with the work of the healthcare industry; and the role of professional organisations and organisations for people with depression and their families and carers.

To minimise and manage any potential conflicts of interest, and to avoid any public concern that commercial or other financial interests have affected the work of the GDG and influenced guidance, members of the GDG must declare as a matter of public record any interests held by themselves or their families which fall under specified categories. These categories include any relationships they have with the healthcare industries, professional organisations and organisations for people with depression and their families and carers.

Individuals invited to join the GDG were asked to declare their interests before being appointed. To allow the management of any potential conflicts of interest that might arise during the development of the guideline, GDG members were also asked to declare their interests at each GDG meeting throughout the guideline development process. The interests of all the members of the GDG are listed in Appendix 2 of the full version of the original guideline document (see "Availability of Companion Documents" field), including interests declared prior to appointment and during the guideline development process.

Guideline Status

This is the current release of the guideline.

This guideline updates previous versions: National Collaborating Centre for Mental Health. Depression: management of depression in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE); 2004. 67 p. [634 references]

National Collaborating Centre for Mental Health. Depression: management of depression in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE); 2007 Apr. 67 p. (Clinical guideline; no. 23).

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Depression: treatment and management of depression in adults, including adults with a chronic physical health problem. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence; 2009 Oct. 27 p. (Clinical guideline; no. 90 and 91). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Depression: the treatment and management of depression in adults. Full guideline. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009. 585 p. (Clinical guideline; no. 90). Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Depression in adults. Appendices to full version. London (UK): National Institute for Health and Clinical Excellence; 2009 Oct. Various p. (Clinical guideline; no. 90). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Depression in adults. Costing statement. London (UK): National Institute for Health and Clinical Excellence; 2009 Oct. Various p. (Clinical guideline; no. 90). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Depression in adults. Slide set. London (UK): National Institute for Health and Clinical Excellence; 2009. 21 p. (Clinical guideline; no. 90). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Depression in adults. Audit support. London (UK): National Institute for Health and Clinical Excellence; 2009. 20 p. (Clinical guideline; no. 90). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • The guidelines manual 2009. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

  • Treating depression in adults: understanding NICE guidance--information for people who use NHS services. National Institute for Clinical Excellence (NICE), 2009 Oct. 24 p. Available in English External Web Site Policy and Welsh External Web Site Policy from the National Institute for Health and Clinical Excellence (NICE) Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on February 14, 2005. The information was verified by the guideline developer on September 5, 2006. This summary was updated by ECRI on November 22, 2006, following the FDA advisory on Effexor (venlafaxine HCl). This NGC summary was updated by ECRI Institute on April 16, 2010. This summary was updated by ECRI Institute on May 20, 2011 following the U.S. Food and Drug Administration advisory on antipsychotic drugs.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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