Step 2: Recognised depression in adults persistent subthreshold depressive symptoms or mild to moderate depression A NICE pathway brings together all NICE guidance, quality standards and materials to support implementation on a specific topic area. The pathways are interactive and designed to be used online. This pdf version gives you a single pathway diagram and uses numbering to link the boxes in the diagram to the associated recommendations. To view the online version of this pathway visit: http://pathways.nice.org.uk/pathways/depression Pathway last updated: 25 August 2015. To see details of any updates to this pathway since its launch, visit: About this Pathway. For information on the NICE guidance used to create this path, see: Sources. All rights reserved NICEPathways
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1 Person with persistent subthreshold depressive symptoms or mild to moderate depression No additional information 2 Initial management and advice Depression with anxiety When depression is accompanied by symptoms of anxiety, usually treat the depression first. But if the person has an anxiety disorder and comorbid depression or depressive symptoms, consider treating the anxiety disorder first (refer to the NICE pathway on anxiety). Sleep hygiene Offer advice on sleep hygiene, including: establishing regular sleep and wake times avoiding excess eating, smoking or drinking alcohol before sleep creating a proper environment for sleep taking regular physical exercise if possible. Active monitoring For people who may recover with no formal intervention, people with mild depression who do not want an intervention, or people with subthreshold depressive symptoms who request an intervention: discuss the presenting problem(s) and any concerns the person has arrange a further assessment, normally within 2 weeks provide information about depression make contact if the person does not attend appointments. 3 Does person have a chronic physical health problem? No additional information Page 3 of 14
4 Low-intensity psychosocial interventions or group-based CBT for people without a chronic physical health problem For people with persistent subthreshold, consider offering one or more of the low-intensity psychosocial interventions described below, guided by the person's preference. Individual guided self-help based on CBT principles (and including behavioural activation and problem-solving techniques) CCBT 1 include written materials (or alternative media) be supported by a trained practitioner who reviews progress and outcome consist of up to 6 8 sessions (face-to-face and by telephone) over 9 12 weeks, including follow-up. be provided via a stand-alone computer-based or web-based programme explain the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes be supported by a trained practitioner who reviews progress and outcome typically take place over 9 12 weeks, including follow-up. A structured group physical activity programme be delivered in groups supported by a competent practitioner typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10 14 weeks. Group-based CBT For people who decline a low-intensity psychosocial intervention, consider group-based CBT. be based on a model such as 'Coping with depression' Page 4 of 14
1 This recommendation updates the recommendations on depression only in 'Computerised cognitive behaviour therapy for depression and anxiety (review)' (NICE technology appraisal guidance 97). Page 5 of 14
be delivered by two trained and competent practitioners consist of 10 12 meetings of 8 10 participants typically take place over 12 16 weeks, including follow-up. Quality standards The following quality statement is relevant to this part of the pathway. Depression in adults quality standard 4. Low-intensity interventions for persistent subthreshold depressive symptoms or mild to moderate depression 5 Low-intensity psychosocial interventions for people with a chronic physical health problem For people with persistent subthreshold and a chronic physical health problem, and for people with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering one or more of the low-intensity psychosocial interventions described below, guided by the person's preference. A structured group physical activity programme be modified for different abilities according to the physical health problem, in liaison with the team treating the physical health problem be delivered in groups supported by a competent practitioner typically consist of 2 3 sessions per week (lasting 45 minutes to 1 hour) over 10 14 weeks be coordinated with any rehabilitation programme for the physical health problem. A group-based peer support (self-help) programme be delivered to groups of people with a shared chronic physical health problem focus on sharing experiences and feelings associated with having a chronic physical health problem Page 6 of 14
be supported by practitioners who should facilitate attendance, understand the chronic physical health problem and its relationship to depression, and review outcomes consist typically of 1 session per week over 8 12 weeks. Individual guided self-help based on CBT principles (and including behavioural activation and problem-solving techniques) CCBT 1 include written materials (or alternative media) be supported by a trained practitioner who reviews progress and outcome consist of up to 6 8 sessions (face-to-face and by telephone) over 9 12 weeks, including follow-up. be provided via a stand-alone computer-based or web-based programme explain the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes be supported by a trained practitioner who reviews progress and outcome typically take place over 9 12 weeks, including follow-up. Quality standards The following quality statement is relevant to this part of the pathway. Depression in adults quality standard 4. Low-intensity interventions for persistent subthreshold depressive symptoms or mild to moderate depression 6 When to consider drug treatment For people with depression without a chronic physical health problem Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression, but consider them for people with: Page 7 of 14
1 This recommendation updates the recommendations on depression only in 'Computerised cognitive behaviour therapy for depression and anxiety (review)' (NICE technology appraisal guidance 97). Page 8 of 14
a past history of moderate or severe depression or initial presentation of subthreshold depressive symptoms present for at least 2 years or subthreshold depressive symptoms or mild depression persisting after other interventions. For people with depression and a chronic physical health problem Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild depression, but consider them for people with: mild depression that complicates the care of the physical health problem or a past history of moderate or severe depression or initial presentation of subthreshold depressive symptoms present for at least 2 years or subthreshold depressive symptoms or mild depression persisting after other interventions. St John's Wort Do not prescribe or advise use of St John's wort for depression. Explain the different potencies of the preparations available and the potential serious interactions of St John's wort with other drugs (including oral contraceptives, anticoagulants and anticonvulsants). For more information about antidepressants, see the antidepressant treatment section of this pathway. Quality standards The following quality statement is relevant to this part of the pathway. Depression in adults quality standard 5. Antidepressants for persistent subthreshold depressive symptoms or mild depression 7 Inadequate response to initial interventions No additional information 8 Page 9 of 14
Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression See Depression / Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression in adults Page 10 of 14
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 11 of 14
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 12 of 14
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 13 of 14
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 2015. 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 www.nice.org.uk nice@nice.org.uk 0845 003 7781 Page 14 of 14