Depression (update)

1. Depression (update) Implementing NICE guidance 2009 NICE clinical guideline 90

2. Updated guidance • This guideline partially updates and replaces: • ‘Depression: management of depression in primary and secondary care’ (NICE clinical guideline 23) • The recommendations relating to depression made in: • ‘Guidance on the use of electroconvulsive therapy’ (NICE technology appraisal guidance 59) • ‘Computerised cognitive behavioural therapy for depression and anxiety (review)’ (NICE technology appraisal guidance 97).

3. What this presentation covers • Background • Scope and definitions • Key priorities for implementation • Costs and savings • Discussion • Find out more

4. Background • Depression is a broad and heterogeneous diagnosis • Central to it is depressed mood and/or loss of pleasure in most activities • A wide range of biological, psychological and social factors have a significant impact on the course of depression and the response to treatment

5. Scope of guidance • The guideline covers: • adults (aged 18 years and older) with a diagnosis of depression • people in the above group who also have learning difficulties, acquired cognitive impairments or language difficulties.

6. Definitions (1) • Subthreshold depressive symptoms: fewer than five symptoms of depression. • Mild depression: few, if any, symptoms in excess of the five required to make the diagnosis and symptoms result in only minor functional impairment. • Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’. • Severe depression: Most symptoms and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.

7. Definitions (2)

8. Key priorities for implementation • The areas identified as key priorities for implementation are: • Principles for assessment • Effective delivery of interventions for depression • Case identification and recognition • Low-intensity psychosocial interventions • Drug treatment • Treatment for moderate or severe depression • Continuation and relapse prevention • Psychological interventions for relapse prevention

9. 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: • the degree of functional impairment and/or disability associated with the possible depression and • the duration of the episode.

10. Effective delivery of interventions for depression (1) • All interventions should be delivered by competent practitioners. • Psychological and psychosocial interventions should be based on the relevant treatment manual(s). • Practitioners should consider using competence frameworks.

11. Effective delivery of interventions for depression (2) • For all interventions,practitioners should: • receive regular high-quality supervision • use routine outcome measures • ensure the patient with depression is involved in reviewing treatment efficacy • engage in monitoring and evaluation of: • treatment adherence • practitioner competence.

12. The stepped-care model Focus of the intervention Nature of the intervention STEP 4: Severe and complex1 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 care2, 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, psycho-education, active monitoring and referral for further assessment and interventions 1,2 see slide notes

13. 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. • 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?

14. 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.

15. Drug treatment • Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor • Consider antidepressants for people with: • a past history of moderate or severe depression or • subthreshold depressive symptoms present for a long time or • subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

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

17. 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.

18. Psychological interventionsfor relapse prevention • People with depression who are considered to be at significant risk of relapse or who have residual symptoms, should be offered one of the following psychological interventions: • individual CBT: • for people who have relapsed despite antidepressant medication • for people with a significant history of depression and residual symptoms despite treatment. • mindfulness-based cognitive therapy: • for people who are currently well but have experienced three or more previous episodes of depression.

19. Costs and savings • It has not been possible to determine costs or savings. • It is difficult to establish a national cost because of: • local circumstances • implementation of the previous depression guideline (NICE clinical guideline 23) • other initiatives such as Improving Access to Psychological Therapies • It is anticipated that there will be: • an increase in people receiving low intensity interventions for depression • a decrease in those receiving high intensity interventions.

20. Discussion • What range of interventions are available for our patients? • How do we monitor the effectiveness of case identification and recognition in our patients? • How do we assure the quality of psychological and psychosocial interventions? • How does our management of relapse prevention compare with the guidelines?

21. Find out more • Visit www.nice.org.uk/CG90 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing statement • audit support.