Quality standard on depression in adults

1. People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
2. Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.
3. Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust delivery of interventions.
4. People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.
5. People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.
6. People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
7. People with moderate depression and a chronic physical health problem receive an appropriate high-intensity psychological intervention.
8. People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual cognitive behavioural therapy.
9. People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.
10. People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for people at risk of relapse.
11. People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first 3 months of treatment.
12. People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.
13. People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.

• Full depression in adults quality standard (PDF format)

This NICE quality standard defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide patients and the public, health and social care professionals, commissioners and service providers with definitions of high-quality care.

Rationale for developing this quality standard

Depression is a broad and heterogeneous diagnosis. Central to it is depressed mood and/or loss of pleasure in most activities. Severity of the disorder is determined by both the number of and severity of symptoms, as well as the degree of functional impairment. Mild depression accounts for 70%, moderate depression 20% and severe depression 10% of all cases. Estimates of the incidence of depression within the population range from 3-6% of adults and the number of people identified with and requiring treatment for depression is estimated to increase by 17% to 1.45 million in 2026. It is estimated that depression is two to three times more common in people with a chronic physical health problem (such as cancer, heart disease, diabetes or a musculoskeletal, respiratory or neurological disorder), occurring in about 20% of this population. The annual service costs to treat people with depression in 2007 were estimated to be £1.7 billion, far less than the cost to the economy attributed to depression (£7.5 billion). This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with depression.

Scope of the quality standard

The assessment and clinical management of persistent subthreshold depressive symptoms, or mild, moderate or severe depression in adults (including people with a chronic physical health problem).

Note: NICE is aware that there is a wider social context to depression that this quality standard does not directly address but which is acknowledged in the development of this standard. The focus of the standard is on the clinical assessment and management of depression and persistent subthreshold depressive symptoms.

Depression in adults quality statements

The quality standard for depression in adults requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole depression care pathway. An integrated approach to provision of services is fundamental to the delivery of high quality care to people with depression.

It is also noted that patient preference and choice need to be taken into account, and practitioners should offer appropriate evidence-based interventions in their consultations with individual service users. Reflecting patient choice will be particularly important when measuring achievement against statements using the process measures. However, the quality standard uses the term 'receive' so as to facilitate measurability, audit and reporting.

Depression in adults areas of care map: click here to see the quality statements mapped against the areas of care for depression in adults.

Policy context

Department of Health (2009) New Horizons: a shared vision for mental health. Available from www.dh.gov.uk

Improving Access to Psychological Therapies programme. Available from www.iapt.nhs.uk

Department of Health (2007) Mental health ten years on: progress on mental health care reform. Available from www.dh.gov.uk

Department of Health (1999) National service framework for mental health: modern standards and service models. Available from www.dh.gov.uk

Key development sources

Depression: the treatment and management of depression in adults. NICE clinical guideline 90 (2009; NHS Evidence accredited source). Available from www.nice.org.uk/guidance/CG90

Depression in adults with a chronic physical health problem. NICE clinical guideline 91 (2009; NHS Evidence accredited source). Available from www.nice.org.uk/guidance/CG91

Development team

Director Fergus Macbeth

Associate Director Nicola Bent

Consultant Clinical Adviser Tim Stokes

Lead Analyst Craig Grime

• Topic Expert Group: Depression in adults

Field testing and consultation feedback

Consultation and field testing of the depression quality standard took place from 2 August to 13 September 2010. 274 stakeholders were contacted during consultation and the NICE field team visited eight organisations to discuss the draft standard in detail. All eligible comments were reviewed by the Topic Expert Group and the standard was updated accordingly.

• Depression in adults field testing and consultation report

Implementation support materials

• Patient information
• Cost impact and commissioning assessment
• Commissioning guide for common mental health disorders

Publication partners

Many organisations share NICE's commitment to improve quality by making it clear what quality care is for patients and the public, health and social care professionals, commissioners and service providers.

So that these standards reach the widest possible audience, some of the organisations who have been involved in the development process, and who endorse the depression in adults quality standard, have become partners in its publication.

These organisations are:

The British Association for Psychopharmacology
The British Psychological Society
College of Mental Health Pharmacy
College of Occupational Therapists
Depression Alliance
MIND
Royal College of Nursing
Royal College of Psychiatrists

Issued: March 2011