Rationale and impact
- Choice of treatments
- Starting and stopping antidepressants
- Use of lithium as augmentation
- Use of oral antipsychotics as augmentation
- Activities to help wellbeing
- Treatment for a new episode of less severe depression
- Treatment for a new episode of more severe depression
- Behavioural couples therapy
- Preventing relapse
- Further-line treatment
- Chronic depressive symptoms
- Depression in people with a diagnosis of personality disorder
- Psychotic depression
- Access to services
- Collaborative care and specialist care
- Crisis care, home treatment and inpatient care
These sections briefly explain why the committee made the recommendations and how they might affect practice or services.
The evidence showed that both people with depression and healthcare professionals want time to engage in meaningful discussions and to build trusting relationships with healthcare professionals who they feel comfortable with, so that people with depression can be actively involved in decision making about treatment options and choices. There was evidence that people's involvement in making choices about their treatment may be impacted by preconceptions about different treatment options, the depression symptoms themselves, and the resources available.
Offering people choice of treatments and discussing treatment options may mean longer consultation times are needed, and this may have a resource impact for the NHS. However, providing information about choices is likely to lead to improved adherence with therapy and better outcomes for people with depression, offsetting any costs associated with longer consultations.
The committee reviewed the evidence on antidepressants identified as part of the development of the NICE guideline on safe prescribing, and used this together with their knowledge and experience to develop recommendations.
There was some limited evidence that people with depression wanted information about how and when they would be monitored when prescribed antidepressants, and that they appreciated being able to self-monitor their symptoms as this was empowering. There was also some limited evidence that, when planning to stop medication, tapering antidepressants may reduce withdrawal effects. The committee used their knowledge to add more detail to the recommendations on techniques for tapering, drugs that may be associated with more withdrawal symptoms, and those which could be tapered more quickly such as fluoxetine.
There was evidence on the range of adverse effects that people experienced when withdrawing from antidepressants, but the committee agreed that more detailed information on incidence and severity for specific interventions would be useful to inform patient choice and so they made a research recommendation on stopping antidepressants. There was evidence on the information needs and support needs of people with depression, that showed that people would like to receive realistic information about the potential benefits and harms of antidepressants, how long they will take to work, the length of treatment and the process of withdrawal. The evidence also showed they value support from healthcare professionals when withdrawing from medication, including a recognition of their fears and concerns about the withdrawal process.
The committee made the recommendations on the use of lithium by informal consensus and based on their knowledge and experience and in line with the monitoring requirements specified in the BNF.
The committee made the recommendations on the use of antipsychotics by informal consensus and based on their knowledge and experience and in line with the monitoring requirements for antipsychotics specified in the BNF and the NICE guideline on psychosis and schizophrenia.
The committee were aware, based on their knowledge and experience, that informal exercise, and particularly exercise outdoors, may lead to an improved sense of wellbeing. They were also aware that a healthy lifestyle may improve a sense of wellbeing. These views were confirmed by stakeholder comments
The recommendations may encourage conversations about the value of informal exercise and a healthy lifestyle, but as this is self-directed exercise and lifestyle changes there will not be resource implications for the NHS.
There was good evidence for the effectiveness of group cognitive behavioural therapy (CBT) and group behavioural activation (BA) and these treatments were found to likely be the most cost effective, on average, for adults with less severe depression. There was also good evidence for the effectiveness of individual BA, individual CBT and some evidence for the effectiveness of guided self-help, and these interventions were also likely to be cost effective. Therefore, these options were provided as alternatives for people who did not wish to participate in group therapy. The committee discussed that, in practice, it was logical to offer the least intrusive and least resource intensive treatments first, and then step up to other treatments if necessary. For this reason, the committee agreed that guided self-help should be considered first for most people with less severe depression.
There was some evidence for the effectiveness of group mindfulness and meditation, group exercise, interpersonal psychotherapy (IPT) and antidepressants and they were also cost effective so these were recommended as alternative treatments for people who did not wish to receive CBT or BA (in a group, individual or self-help format). The committee advised that selective serotonin reuptake inhibitors (SSRIs) would be the preferred antidepressants to use in people with less severe depression because of their safety and tolerability. The committee discussed that as the evidence suggested that some psychological therapies were more effective than antidepressants and due to the potential for side effects, medication should not be the default treatment for people with less severe depression, unless it was the person's preference to take antidepressants rather than engage in a psychological intervention.
There was some evidence that counselling and short-term psychodynamic psychotherapy (STPP) may be effective, but these treatments did not appear to be as cost effective, on average, at improving the symptoms of less severe depression. However, the committee recognised that these treatments may be helpful for some people and so included them as options as well.
The committee provided details of the treatments in a table to allow a discussion between healthcare professionals and people with depression about treatment options. Apart from the advice to use guided self-help first for pragmatic reasons, this table is arranged in order of the committee's consensus on the average effectiveness and cost effectiveness of the treatments in adults with less severe depression, with the most effective and cost effective listed at the top of the table, but to also take into account factors which may promote implementation, such as the use of least intrusive treatments first. However, the committee agreed that choice of therapy should be a personalised decision and that some people may prefer to use a treatment further down the table and that this is a valid choice.
As there was a lack of evidence on the effectiveness of peer support, the committee made a research recommendation on peer support. As there was considerable uncertainty in the evidence for the effectiveness and cost effectiveness of psychological interventions, the committee made a further research recommendation to find out if identifying the mode of action of psychological interventions would allow greater differentiation between the interventions and aid patient choice.
The recommendations reflect current practice, but may reduce variation in practice across the NHS. Commissioners and services will need to ensure that a meaningful choice of all NHS-recommended therapies is available, and depending on current availability, this may need an increase in resource use. Initial consultations and assessment may need longer because of the need for detailed discussions to support informed choice, but a positive choice may improve engagement and outcomes.
There was good evidence for the effectiveness of combination of CBT with antidepressants, individual CBT and individual behavioural therapies and these treatments also appeared to be cost effective, on average, for adults with more severe depression. There was good evidence for the effectiveness and cost effectiveness of antidepressants (SSRIs, SNRIs, tricyclic antidepressants [TCAs] and mirtazapine) and the committee agreed that SSRIs and SNRIs should be recommended as first line because of their tolerability, but for people whose symptoms had responded well to a TCA in the past and who had no contraindications, a TCA might be preferred. The committee agreed that mirtazapine should not be included as a first-line option, but the committee decided to reserve it for use for further-line treatment.
There was some evidence for the effectiveness of counselling and individual problem-solving therapy, both of which also appeared to be cost effective.
There was some evidence for the effectiveness of IPT and STPP but these treatments did not appear to be as cost effective, on average, at improving the symptoms of depression. However, the committee recognised that these treatments may be helpful for some people and so included them as options as well.
There was some evidence of effectiveness and cost effectiveness for the combination of acupuncture and antidepressants but the committee were aware this evidence was based on Chinese acupuncture which is different to Western acupuncture and so these results may not be applicable to the UK population, so the committee made a research recommendation on acupuncture and antidepressants.
Both guided self-help and group exercise were, on average, shown to be effective and appeared to be cost effective, but the committee were concerned that in clinical practice these interventions may be offered to people with severe depression in whom regular contact with a healthcare professional may be of benefit, and so advised that the potential advantages of providing other treatment choices with more therapist contact should be carefully considered first.
In addition to the evidence reviewed, the committee were aware of large-scale and pragmatic trials that were excluded from the network meta-analysis (because they involved patient populations that did not meet specific search criteria). However, the results of these studies were largely consistent with the evidence reviewed and supported the recommendations.
The committee provided details of the treatments in a table to allow a discussion between healthcare professionals and people with depression about treatment options. This table is arranged in order of the committee's consensus on the average effectiveness and cost effectiveness of the treatments (as well as consideration of implementation factors) with the most effective and cost effective listed at the top of the table, but the committee agreed that choice of therapy should be a personalised decision and that some people may prefer to use a treatment further down the table and that this is a valid choice.
The recommendation reflects current practice, but may reduce variation in practice across the NHS. Commissioners and services will need to ensure that a meaningful choice of all recommended therapies is available, and depending on current availability, this may need an increase in resource use. Initial consultations and assessment may need longer because of the need for detailed discussions to support informed choice, but a positive choice may improve engagement and outcomes.
There was some very limited evidence for the effectiveness of behavioural couples therapy for people with depression and who had problems in their relationship, but the committee agreed this was a treatment that was available through the Improving Access to Psychological Therapy (IAPT) services and should be included as an option in the guideline.
The recommendation reflects current practice, but may reduce variation in practice across the NHS.
The committee highlighted a number of risk factors, based on their knowledge of the wider literature and experience, which increase the likelihood of relapse. They agreed that people with a higher risk of relapse should be considered for continuation of treatment, but recognised that not all people would wish to take relapse prevention treatment. They also agreed those who wished to continue on antidepressant medication should be warned about the possible long-term effects.
There was good evidence that SSRIs, SNRIs and TCAs, group CBT and mindfulness-based cognitive therapy (MBCT) were effective for relapse prevention and were, on average, cost-effective treatments for people at a high risk of relapse, with data for treatment periods up to 2 years. The committee therefore recommended continuation antidepressant treatment or group CBT or MBCT, with their advice framed to take into account the therapy the person had already received. The committee agreed that psychological therapies used for relapse prevention should explicitly focus on relapse prevention skills.
The committee used their knowledge and experience to recommend follow-up arrangements for people on relapse prevention therapy, to ensure that people did not remain on therapy indefinitely.
As there was little evidence for the use of brief courses of psychotherapy or maintenance electroconvulsive therapy (ECT) in preventing relapse, the committee made a research recommendation on the effectiveness and cost effectiveness of brief courses of psychological treatment and a research recommendation on maintenance ECT.
The recommendations reflect current practice, but may reduce variation in practice across the NHS. Commissioners and services will need to provide therapies with an explicit relapse prevention component.
The committee made recommendations based on their knowledge and experience that people's symptoms may not respond to treatment for depression for a number of reasons, and that these reasons should be explored and addressed before considering further-line treatment.
No evidence was identified for people whose depression had not responded to the use of psychological therapies as first-line treatment, but the committee used their experience to recommend further-line treatment options for people whose depression had initially been treated with psychological therapies. As there was no evidence for people whose symptoms did not respond to initial psychological treatments, the committee made a research recommendation on further-line treatment.
For people whose depression had not responded to antidepressants, there was some evidence that augmenting antidepressant regimens with group exercise was effective. There was also some very limited evidence that switching to a different antidepressant or increasing the dose of the antidepressant may be effective. There was also some evidence that a combination of psychological therapy and antidepressants was effective so the committee also recommended the use of combination treatment. Based on the evidence from the review of first-line treatment for more severe depression, the committee agreed that the psychological interventions that had been effective and cost effective for first-line treatment of more severe depression could be used for people whose symptoms had not responded to antidepressants and wished to try a psychological therapy instead.
There was evidence that combinations of antidepressants, or combinations of an antidepressant with other treatments (ECT, antipsychotics, lithium, lamotrigine and triiodothyronine), were effective, but the committee agreed these combinations would need specialist advice.
There was some limited evidence for the use of ECT as further-line treatment, alone or in combination with exercise, so the committee agreed ECT should remain available as an option for the further-line treatment of depression in certain situations when there has been no or inadequate response to other treatment. Based on their knowledge, experience and awareness of the wider evidence base for ECT, the committee were aware that ECT leads to rapid effects and so they advised that it should also be considered in other circumstances (not just as further-line treatment), when a rapid response was needed, and provided some examples of situations where this might be appropriate. The committee were also aware that there may be people with depression who have had ECT in the past, know it is effective, and express a preference for it. Based on their knowledge and experience, and to ensure better patient experience, the committee reinforced the recommendations about taking into account patient preferences when considering ECT as a treatment option, in line with their recommendations for other treatment options.
The committee discussed the existing recommendations on the delivery of ECT and agreed these were still correct and so retained them. However, the committee agreed that there were now recognised up-to-date standards produced by the Royal College of Psychiatrists which covered the standards of service provision needed for a safe and effective ECT service, and a recognised ECT accreditation service (ECTAS), and so the committee recommended that clinics and trusts delivering ECT should be accredited and should adhere to these standards.
The recommendations for further-line treatment reflect current practice, but may reduce variation in practice across the NHS. The recommendations for ECT should ensure the availability of ECT for people if it is an appropriate treatment option for them, but reinforce that it is only a treatment option in certain circumstances.
There was some evidence for CBT, SSRIs, SNRIs and TCAs for the treatment of chronic depressive symptoms and some very limited evidence that combinations of psychological therapies and antidepressants may be more effective, on average, than either alone. As there was such limited evidence, particularly for older people who may be more susceptible to chronic depression, and for those whose chronic depression may be because of the impact of social determinants, the committee made a research recommendation on the effectiveness and cost effectiveness of psychological, pharmacological or a combination of these treatments.
There was some evidence for the effectiveness of other medications, including TCAs, phenelzine, amisulpride and moclobemide for people with chronic depression, so the committee considered these could be used as alternatives with specialist advice in people whose symptoms did not respond to SSRIs or SNRIs. However, this was an extrapolation of the evidence which was for the first-line treatment of chronic depression (not further-line). As there was no evidence for the use of monoamine oxidase inhibitors (MAOIs) for further-line treatment of chronic depression, the committee made a research recommendation on the effectiveness, acceptability and safety of MAOIs.
There was some limited evidence for the effectiveness of psychological therapies in combination with antidepressants for the treatment of depression in people with a personality disorder, and the committee were aware that extended duration of use and multidisciplinary support may be beneficial to improve uptake and adherence. However, the evidence base was very limited, with small studies of low to very low quality. As a result, the committee were not able to recommend a specific antidepressant or psychological therapy, but agreed that the choice should be guided by the person's preference. The committee were also limited by the available data when making recommendations for different types of personality disorders, as the evidence was for mixed or non-specified types of personality disorder.
Based on their knowledge and experience, and in accordance with existing NICE guidelines, the committee were aware that in people with depression and personality disorder, treatment of the personality disorder by specialist services may lead to an improvement in depression.
The recommendations may reduce variation in the treatment offered to people presenting with depression and personality disorder, and will reinforce current practice to treat people with personality disorder in a specialist programme.
There was some limited evidence that the combination of an antidepressant and an antipsychotic may provide some benefits in the treatment of psychotic depression. There was some evidence for olanzapine and quetiapine, and the committee knew that quetiapine has antidepressant actions as well as antipsychotic actions and is therefore widely used for psychotic depression. The committee discussed that combination therapy would not usually be started in primary care and therefore people who wished to start an antipsychotic, would need a referral to specialist mental health services. Based on their experience, the committee agreed the effectiveness of this combination should be monitored and that people should be reviewed regularly, not left on the combination longer than necessary, and that specialist advice would be needed to determine when the antipsychotic medication could be stopped. As there was limited evidence, the committee made a research recommendation on the most effective and cost-effective interventions for the treatment and management of psychotic depression.
For recommendations on access to services for all people with depression, the committee used their knowledge and experience of how access to services could be improved using a stepped care or matched care approach by, good integration between primary and secondary care, ensuring information on services was available and using a variety of different methods to deliver services.
There was some evidence that modifying the way interventions to treat depression were delivered, such as the co-location of physical and mental health services, use of telephone or online video interventions, collaborative care, and culturally adapted services, led to increased uptake and engagement with services for some men, older people and those from black, Asian and minority ethnic groups with depression. However, as there was limited evidence, the committee made a research recommendation on the most effective and cost-effective methods to promote increased access to, and uptake of, treatments for people with depression who are under-served and under-represented in current services.
Modifying the way treatments are delivered to improve access for certain groups may mean modifications to services are needed, and may have resource implications. However, prompt and effective treatment of depression may lead to reduced health and social care costs in the longer term.
There was good evidence that simple collaborative care improved outcomes in people with depression, and that overall, it was cost effective in people with depression, including older people with depression.
There was some evidence that certain components of collaborative care led to benefits, and this was supplemented by the committee's expertise.
The committee did not specifically review evidence for specialist care for people with severe depression with multiple complicating problems or significant coexisting conditions. However, based on their in-depth understanding of the evidence base, the committee were aware of studies suggesting benefits for this group of people, and together with their knowledge and expertise, the committee recommended specialist care.
The recommendations on collaborative care may increase resource use but there is evidence that this is cost effective. Specialist care is likely to increase resource use, but will only be necessary for a small number of people, and may offset future costs for long-term care and treatment.
There was some evidence that crisis resolution and home treatment (CHRT) teams improved symptoms in people with severe non-psychotic mental illness, and that this was a cost-effective option compared to standard inpatient care. However, based on their experience, the committee recognised that people with more severe depression may need inpatient care.
Based on their knowledge and experience, the committee agreed that psychological therapies should be available for people with depression in inpatient settings.
There may be some reduction in costs as CRHT is less costly than inpatient care, and it may prevent longer and more costly inpatient admissions. If used effectively it may also prevent readmission after inpatient stays.