Quality statement 3: Preventing relapse | Depression in adults | Quality standards

Quality statement

Adults with depression who are at a higher risk of relapse have relapse prevention interventions. [2011, updated 2023]

Rationale

All adults who achieve full or partial remission and have 1 or more risk factor for relapse should discuss with their healthcare professional whether they need to continue treatment. They should, after discussion, be offered interventions that focus on relapse prevention, which will help reduce the likelihood of further episodes of depression.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

The proportion of adults with depression who are at a higher risk of relapse who received relapse prevention interventions.

Numerator – the number in the denominator who received relapse prevention interventions.

Denominator – the number of adults with depression who are at a higher risk of relapse.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

a) Rates of relapse within 2 years of their last session among adults who have been treated for depression with psychological therapy.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

NHS England's Improving Access to Psychological Therapies (IAPT) data set includes therapy-based outcomes for courses of therapy using mean Patient Health Questionnaire (PHQ-9) scores at the start and end of a course of therapy.

b) Rates of relapse within 2 years of a review at 9 to 12 months after starting antidepressants among adults who have been treated for a first episode of depression.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

c) Rates of relapse within 2 years of a review 2 years after starting antidepressants among adults who have been treated for a second or subsequent episode of depression.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (GP practices and mental health services, including NHS talking therapy services) ensure that systems and protocols are in place for adults with depression who are at a higher risk of relapse to be offered relapse prevention interventions based on their clinical needs and preferences.

Healthcare professionals (such as GPs, specialist nurses and mental health professionals) discuss treatment options with adults with depression who are at a higher risk of relapse. They offer relapse prevention interventions, based on the adult's clinical needs and preferences, after reaching a joint decision about the treatment.

Commissioners ensure that they commission services that offer relapse prevention interventions to adults with depression who are at a higher risk of relapse. They commission psychological therapy services that offer psychological therapies with a relapse prevention component.

Adults with depression whose symptoms are likely to return talk to their healthcare professional about treatment options to prevent new episodes of depression. These may include continuing with their existing treatment (psychological therapy, adapted for relapse prevention or antidepressants, or both), or switching to or adding psychological therapy if they are on antidepressants alone. They make decisions with their healthcare professional and are offered treatment based on their needs and preferences.

Source guidance

Depression in adults: treatment and management. NICE guideline NG222 (2022), recommendations 1.8.1 and 1.8.2

Definitions of terms used in this quality statement

Adults with depression at a higher risk of relapse

Adults who have achieved full or partial response following acute treatment (using criteria such as the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases) are at a higher risk of relapse if they have:

a history of recurrent episodes of depression, particularly if these have occurred frequently or within the last 2 years
a history of incomplete response to previous treatment, including residual symptoms (such as fatigue, poor sleep, poor concentration and impaired motivation)
a history of severe depression (including adults with severe functional impairment)
coexisting physical or mental health problems
unhelpful coping styles (such as avoidance or rumination)
personal, social or environmental factors that contributed to depression and that are still present (for example, relationship problems, ongoing stress, poverty, isolation and unemployment).

[Adapted from NICE's guideline on depression in adults, recommendation 1.8.2 and the visual summary on preventing relapse after completing a course of treatment for depression]

Relapse prevention interventions

Options for relapse prevention include:

continuing with the same psychological therapy, adapted by the therapist for relapse prevention, or
continuing with antidepressant medication to prevent relapse, maintaining the dose that led to full or partial remission, unless there is good reason to reduce it (such as side effects), or
a course of psychological therapy for relapse prevention (group cognitive behavioural therapy [CBT] or mindfulness-based cognitive therapy [MBCT]) for adults who do not wish to continue on antidepressants, or
continuing with antidepressant medication and a course of psychological therapy for relapse prevention (group CBT or MBCT).

Relapse prevention components of psychological interventions focus on the development of relapse prevention skills and what is needed to stay well. These may include:

reviewing lessons and insights learnt in therapy and what was helpful in therapy
making concrete plans to maintain progress beyond the end of therapy, including plans to consolidate any changes made to stay well and to continue to practice useful strategies
identifying stressful circumstances, triggering events, warning signs (such as anxiety or poor sleep), or unhelpful behaviours (such as avoidance or rumination) that have preceded worsening of symptoms and personal or social functioning, and making detailed contingency plans of what to do if any of these reoccur
making plans for any anticipated challenging events over the next 12 months, including life changes and anniversaries of difficult events.

[Adapted from NICE's guideline on depression in adults, recommendations 1.8.5 to 1.8.10, and expert opinion]

Equality and diversity considerations

Commissioners and providers should consider their local population and any unwarranted variation in provision of treatment between adults with depression in groups such as:

adults from minority ethnic backgrounds
lesbian, gay, bisexual and trans adults
adults experiencing homelessness, refugees and asylum seekers.

[Adapted from NICE's guideline on depression in adults, recommendation 1.16.6, and NICE's guideline on depression in adults with a chronic physical health problem, recommendation 1.1.3.3]