NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, entions, and moderate and bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 20 September 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Person with inadequate response to initial interventions, or moderate or severe depression No additional information 2 Treatment options Choosing treatments Choice of intervention should be influenced by the: duration of the episode and trajectory of symptoms previous illness course and response to treatment likelihood of adherence and potential adverse effects person's preference course and treatment of any chronic physical health problem. Treatment options for people without a chronic physical health problem For people with persistent subthreshold depressive symptoms or mild depression to moderate depression who have not benefited from a low-intensity psychosocial intervention, discuss different interventions with the person and provide: an antidepressant (normally an SSRI) or a high-intensity psychological intervention, normally one of the following: CBT IPT behavioural activation (but note that the evidence is less robust than for CBT or IPT) behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit. For people who decline the options above, consider 1 : counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6 10 sessions over 8 12 weeks Page 3 of 13

4 1 Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression. Page 4 of 13

5 short-term psychodynamic psychotherapy for people with mild to moderate depression; offer sessions over 4 6 months. For people with moderate or severe depression, combine antidepressants with a high-intensity psychological intervention (CBT or IPT). Treatment options for people with a chronic physical health problem For people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, provide an antidepressant (normally an SSRI) or one of the following high-intensity psychological interventions: group-based CBT or individual CBT (if group-based CBT is declined, not appropriate or not available) or behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit. For people with initial presentation of moderate depression, offer group-based CBT, individual CBT or behavioural couples therapy. For people with severe depression, consider offering both individual CBT and an antidepressant. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Depression in adults quality standard 6. Moderate to severe depression and no existing chronic physical health problem 7. Moderate depression and a chronic physical health problem 8. Severe depression and a chronic physical health problem Page 5 of 13

6 3 Delivering high-intensity psychological interventions 1 Interventions for people without a chronic physical health problem Individual CBT Typically deliver sessions over 3 4 months. Consider 3 4 follow-up sessions over the next 3 6 months. For moderate or severe depression, consider 2 sessions per week for the first 2 3 weeks. IPT Typically deliver sessions over 3 4 months. For severe depression, consider 2 sessions per week for the first 2 3 weeks. Behavioural activation Typically deliver sessions over 3 4 months. Consider 3 4 follow-up sessions over the next 3 6 months. For moderate or severe depression, consider 2 sessions per week for the first 3 4 weeks. Behavioural couples therapy Typically deliver sessions over 5 6 months. Interventions for people with a chronic physical health problem Group-based CBT Typically deliver in groups of 6 8 people with a common physical health problem, over 6 8 weeks. 1 Duration of interventions can be tailored to individual circumstances. Page 6 of 13

7 Individual CBT Deliver until symptoms have remitted but typically: 6 8 weeks (no longer than weeks) for moderate depression plus 2 follow-up sessions in the next 6 months weeks for severe depression plus 2 or 3 follow-up sessions in the next 12 months; offer twice-weekly sessions for the first 2 3 weeks focusing on behavioural activation. Behavioural couples therapy Typically deliver sessions over 5 6 months. 4 Antidepressant treatment See Depression / Antidepressant treatment in adults 5 Combining psychological and drug treatment For people with moderate or severe depression without a chronic physical health problem, combine antidepressants with a high-intensity psychological intervention (CBT or IPT). For people with severe depression and a chronic physical health problem, consider offering both individual CBT and an antidepressant. If a person's depression has not responded to either pharmacological or psychological interventions, consider combining antidepressants with CBT. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Depression in adults quality standard 6. Moderate to severe depression and no existing chronic physical health problem Page 7 of 13

8 8. Severe depression and a chronic physical health problem 6 Is there a response to interventions? No additional information 7 Continuation and relapse prevention See Depression / Continuation and relapse prevention for adults with depression 8 Considering referral and/or enhanced care If a person's depression has not responded to various augmentation and combination treatments, consider referral to a specialist practitioner or service. Enhanced care Do not routinely provide medication management as a separate intervention for people with depression. For people with severe depression, or with moderate depression and complex problems, consider referring to specialist mental health services for a programme of coordinated multiprofessional care. If a person with long-standing moderate or severe depression would benefit from additional social or vocational support, consider: befriending as an adjunct to pharmacological or psychological treatments; trained volunteers should provide at least weekly contact for 2 6 months a rehabilitation programme if depression has resulted in long-term loss of work or disengagement from social activities. 9 Collaborative care for people with a chronic physical health problem Consider collaborative care for people with moderate to severe depression and a chronic physical health problem with associated functional impairment whose depression has not Page 8 of 13

9 responded to initial high-intensity psychological interventions, pharmacological treatment or a combination of these. Collaborative care should normally include: case management which is supervised by a senior mental health professional close collaboration between primary and secondary physical health services and specialist mental health services a range of interventions consistent with those recommended in this guideline long-term coordination of care and follow-up. Quality standards The following quality statement is relevant to this part of the interactive flowchart. Depression in adults quality standard 9. Collaborative care 10 Step 4: Complex and severe depression See Depression / Step 4: Complex and severe depression in adults Page 9 of 13

10 Glossary CAMHS child and adolescent mental health services CAPA child and adolescent psychiatric assessment CBT cognitive behavioural therapy CCBT computerised cognitive behavioural therapy DSM-IV diagnostic and Statistical Manual of Mental Disorders ECT electroconvulsive therapy HoNOSCA Health of the Nation Outcome Scales for Children and Adolescents ICD-10 International Statistical Classification of Diseases and Related Health Problems (tenth edition) IPT interpersonal therapy K-SADS schedule for affective disorders and schizophrenia for school-age children Page 10 of 13

11 MAOI monoamine oxidase inhibitor MFQ mood and feelings questionnaire Mild depression few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment, according to DSM-IV Moderate depression symptoms of depression or functional impairment are between mild and severe NSAID non-steroidal anti-inflammatory drug PCT primary care trust SDQ strengths and difficulties questionnaire Severe depression most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms SSRI selective serotonin reuptake inhibitor Subthreshold depressive symptoms fewer than 5 symptoms according to DSM-IV Page 11 of 13

12 TCA tricyclic antidepressant Tier 1 primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services Tier 2 child and adolescent mental health services relating to workers in primary care including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists Tier 3 specialised child and adolescent mental health services for more severe, complex or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community or inpatient), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists Tier 4 tertiary-level child and adolescent mental health services such as day units, highly specialised outpatient teams and inpatient units Sources Depression with a chronic physical health problem (2009) NICE guideline CG91 Depression in adults (update) (2009) NICE guideline CG90 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when Page 12 of 13

13 carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 13 of 13