Guidelines on Depression

Before we Begin:

If you think you may have depression – Please Consult your GP immediately.

If your pain is urgent, or if you feel in danger of harming yourself or others here are some links to help:

  • Samaritans
  • Depression Helpline
  • Charities which deal with Depression
  • Emergency Services

N.I.C.E GUIDELINE ON DEPRESSION TREATMENT

  • Computerised CBT Guidelines: http://www.nice.org.uk/TA97
  • Depression Care Overview: http://pathways.nice.org.uk/pathways/depression
  • N.I.C.E LINK: publications.nice.org.uk/depression-in-adults-cg90/guidance
  • N.I.C.E PDF: http://guidance.nice.org.uk/CG90/NICEGuidance/pdf/English

CARE IN ADULTS

Excerpts from the Nice Guidelines for Depression.

1.4.2 Low-intensity psychosocial interventions

1.4.2.1 For people with persistent sub-threshold 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)[10]
  • a structured group physical activity programme.

Delivery of low-intensity psychosocial interventions

1.4.2.2 Individual guided self-help programmes based on the principles of CBT (and including behavioural activation and problem-solving techniques) for people with persistent sub-threshold 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 selfhelp 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.

1.4.2.3 CCBT for people with persistent sub-threshold 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 behaviour, 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.

1.4.2.4 Physical activity programmes for people with persistent sub-threshold 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).

1.4.3 Group Cognitive Behavioural Therapy

1.4.3.1 Consider group-based CBT for people with
  • persistent sub-threshold depressive symptoms
  • or mild to moderate depression who decline low intensity psychosocial interventions (see 1.4.2.1).

1.4.3.2 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.
1.5.1 Treatment options
1.5.1.1 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])
or
A high-intensity psychological intervention (CBT usually)
This is 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.

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

1.5.1.3 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 treatmentlikelihood
  • of adherence to treatment and any potential adverse effectsperson’s treatment preference and priorities
1.5.1.4 For people with depression who decline an antidepressant, CBT, IPT, behavioural activation and behavioural couples therapy, consider:
  • counselling for people with persistent sub-threshold 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 counselling and psychodynamic psychotherapy in treating depression.
Combined psychological and drug treatment
1.8.1.10 For a person whose depression has not responded to either pharmacological or psychological interventions, consider combining antidepressant medication with CBT.
1.9 Continuation and relapse prevention
  • 1.9.1.1 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.

1.9.1.2 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.

1.9.1.3 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.

Psychological interventions for relapse prevention

1.9.1.8 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

1.9.1.9 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.

1.9.1.10 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.