Evidence

2023 exceptional surveillance of common mental health problems: identification and pathways to care (NICE guideline CG123)

Surveillance decision

Surveillance decision

We plan to temporarily withdraw the sections on stepped care, step 1: identification and assessment and steps 2 and 3: treatment and referral for treatment in the NICE guideline on common mental health problems.

Reason for the exceptional review

This exceptional review was prompted by an enquiry regarding inconsistencies between NICE's guideline on common mental health problems, NICE's guideline on post-traumatic stress disorder and the NHS guidance on Improving Access to Psychological Therapies (IAPT). Following this, a mapping exercise was undertaken to assess the overlaps and inconsistencies between NICE's guideline on common mental health problems and the following other common mental health guidelines:

Methods

The exceptional surveillance process consisted of:

  • Considering the new information that triggered the exceptional review.

  • Examining related NICE guidance.

We decided that full updated literature searches were not needed because the information we had from the initial enquiry and the mapping of mental health guidelines was enough to establish whether an update to the guideline was needed.

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Information considered in this exceptional surveillance review

An enquiry was raised regarding the classification of severity used in NICE's guideline on common mental health problems. It was highlighted that PTSD was included in both step 2 and step 3 of the stepped care pathway listed in section 1.2 and recommendations 1.4.2.7, 1.4.3.10 and 1.4.3.11. NICE's guideline on common mental health problems uses the classification 'mild, moderate and severe' and associated interventions for PTSD, however the enquirer highlighted that these terms are not used in clinical practice or the NHS guidance on IAPT.

It was also stated that in clinical practice the IAPT workforce is divided into low- and high-intensity staff. The low-intensity workforce consists mainly of psychological wellness practitioners (PWPs) who deliver low-intensity interventions for people with mild to moderate anxiety and depression, and who have limited IAPT training. The high-intensity workforce consists of high-intensity therapists with additional training, education and professional accreditation to deliver high-intensity interventions such as the trauma-focused CBT described in recommendations 1.4.3.10 and 1.4.3.11 in the NICE guideline on common mental health problems. Therefore, having recommendations on trauma-focused CBT in both step 2 (mild to moderate) and step 3 (moderate or severe) of the stepped care model in the guideline is not aligned with the level of training of the PWPs who deliver low-intensity interventions in step 2 care.

We further examined recommendations 1.6.15 to 1.6.23 in the NICE guideline on post-traumatic stress disorder and found that treatment recommendations are not based on the stepped care pathway, or on 'mild, moderate or severe' definitions of PTSD as described in NICE's guideline on common mental health problems.

Finding these inconsistencies between NICE's guideline on common mental health problems, NICE's guideline on post-traumatic stress disorder and the NHS guidance on IAPT, led to a mapping exercise for all mental health topics in NICE guidelines that are also covered by NICE's guideline on common mental health problems, including:

  • Depression in adults

  • Obsessive-compulsive disorder and body dysmorphic disorder

  • Generalised anxiety disorder and panic disorder in adults

  • Post-traumatic stress disorder

Inconsistencies and differences were found across all 4 individual guidelines when compared to NICE's guideline on common mental health problems, mainly regarding the stepped care model.

These are described in comparison to NICE's guideline on common mental health problems below:

  • Depression in adults:

    • NICE's guideline on depression in adults includes more detail for how to proceed if a person answers 'yes' to the 2 questions used to see if people may have depression (recommendation 1.2.1) and goes on to detail how to respond if the practitioner is competent in providing a mental health assessment.

    • NICE's guideline on common mental health problems includes 'possible somatic symptoms of depression' (recommendation 1.3.1) whereas NICE's guideline on depression in adults has removed this (recommendation 1.2.1).

    • NICE's guideline on common mental health problems includes the emergency services as an urgent referral option if the person presents considerable and immediate risk to themselves or others (recommendation 1.3.3.2) whereas this has been removed from NICE's guideline on depression in adults (recommendation 1.2.9).

    • NICE's guideline on depression in adults was published in June 2022 and therefore its terminology is more up to date than in NICE's guideline on common mental health problems, which was published in May 2011 and has not been updated to align with the newer guidance.

  • Obsessive-compulsive disorder and body dysmorphic disorder:

    • NICE's guideline on common mental health problems does not include any recommendations on body dysmorphic disorder, whereas NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder does.

    • NICE's guideline on common mental health problems briefly describes the use of exposure and response prevention in recommendation 1.4.2.6, whereas NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder gives more detail about the options for delivery and includes patient preference for treatment (recommendation 1.5.1.1)

    • NICE's guideline on common mental health problems recommends offering CBT or an antidepressant medication (recommendation 1.4.3.7), whereas NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder is more specific about the type of interventions, stating 'more intensive CBT or an SSRI' (recommendation 1.5.1.3).

    • NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder also has separate recommendations for moderate and severe functional impairment rather than a combined recommendation as in NICE's guideline on common mental health problems.

    • NICE's guideline on common mental health problems states 'offer home-based treatment...' NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder recommends that 'home-based treatment may be considered'. This difference may be due to more evidence becoming available when NICE's guideline on common mental health problems was published that allowed a stronger recommendation to be used, but this could still prove confusing for commissioners of services in this area.

    • NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder also includes 2 detailed recommendations regarding children and young people with OCD (recommendations 1.5.1.8 to 1.5.1.9) which is not present in NICE's guideline on common mental health problems.

    • NICE's guideline on common mental health problems (recommendation 1.4.3.9) states that people who have not seen benefit following 2 courses of CBT should be referred to a service with specialist expertise in OCD. NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder gives more detail on this over 3 recommendations (1.5.4.5, 1.5.5.1 and 1.5.5.4), expanding on the treatment options available before referral, and including details for children and young people.

  • Generalised anxiety disorder and panic disorder:

    • NICE's guideline on common mental health problems uses the generalised anxiety disorder (GAD)-2 scale to help guide further assessment options (recommendation 1.3.1.2) whereas NICE's guideline on generalised anxiety disorder and panic disorder focuses more broadly on the impact of the symptoms being experienced (recommendation 1.2.5)

    • For people with GAD and marked functional impairment that has not responded to low-intensity interventions, NICE's guideline on generalised anxiety disorder and panic disorder gives more information on how to provide information for individuals to make informed choices, whereas NICE's guideline on common mental health problems states the available options without any further detail.

  • Post-traumatic stress disorder:

    • NICE's guideline on common mental health problems states that people with common mental health disorders could be given information about self-help groups, but states this is not for people with PTSD. However, there are no 'do not do' recommendations in NICE's guideline on post-traumatic stress disorder regarding self-help groups and people with PTSD.

    • NICE's guideline on post-traumatic stress disorder does have recommendation 1.4.3 on peer support groups for people with PTSD, which appears to contradict NICE's guideline on common mental health problems.

    • NICE's guideline on common mental health problems, recommendation 1.4.3.11 states that drug treatment should be offered if psychological interventions are declined or there is a patient preference. However, unlike NICE's guideline on post-traumatic stress disorder, it does not give any details of what this drug treatment should include. NICE's guideline on post-traumatic stress disorder also gives further information on the use of the drugs and situations where they may be most suitable.

    • NICE's guideline on post-traumatic stress disorder has more up to date terminology than NICE's guideline on common mental health problems because it was published in December 2018. These 2 guidelines have not yet been aligned.

The differences in terminology used between NICE's guideline on common mental health problems and the individual guidelines may be confusing for service users, with different information given in several sections, or in the case of body dysmorphic disorder, no mention of the condition. This could also cause confusion for commissioners and healthcare providers because different guidance is being given for the same conditions.

See appendix A for the full mapping tables between the guidelines and NICE's guideline on common mental health problems.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

We plan to temporarily withdraw the sections on stepped care, step 1: identification and assessment and steps 2 and 3: treatment and referral for treatment in the NICE guideline on common mental health problems.

Work will then be undertaken on prioritisation and consolidation of NICE's common mental health guidelines to ensure consistency across the NICE mental health guidelines suite. This will also prevent confusion arising from discrepancies between the condition-specific guidelines.

ISBN: 978-1-4731-4908-3


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