Depression_NICE_Guidelines_Flashcards
How does NICE classify depression severity as of the 2022 guidelines?
NICE classifies depression severity as ‘less severe’ and ‘more severe’. ‘Less severe’ encompasses subthreshold and mild depression, while ‘more severe’ encompasses moderate and severe depression.
What PHQ-9 score corresponds to ‘less severe’ depression?
A PHQ-9 score of < 16 corresponds to ‘less severe’ depression.
What PHQ-9 score corresponds to ‘more severe’ depression?
A PHQ-9 score of ≥ 16 corresponds to ‘more severe’ depression.
What is the recommended approach for managing less severe depression according to NICE?
NICE recommends discussing treatment options with patients to reach a shared decision and considering the least intrusive and least resource intensive treatment first for managing less severe depression.
What does NICE recommend regarding the use of antidepressant medication for less severe depression?
NICE recommends not routinely offering antidepressant medication as first-line treatment for less severe depression, unless it is the person’s preference.
What are the treatment options for less severe depression listed in order of preference by NICE?
The treatment options for less severe depression listed in order of preference by NICE are: guided self-help, group cognitive behavioural therapy (CBT), group behavioural activation (BA), individual CBT, individual BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRIs), counselling, and short-term psychodynamic psychotherapy (STPP).
What is the recommended approach for managing more severe depression according to NICE?
NICE recommends making a shared decision for managing more severe depression.
What are the treatment options for more severe depression listed in order of preference by NICE?
The treatment options for more severe depression listed in order of preference by NICE are: a combination of individual cognitive behavioural therapy (CBT) and an antidepressant, individual CBT, individual behavioural activation (BA), antidepressant medication (SSRI, SNRI, or another antidepressant based on previous clinical and treatment history), individual problem-solving, counselling, short-term psychodynamic psychotherapy (STPP), interpersonal psychotherapy (IPT), guided self-help, and group exercise.
SUMMARISE DEPRESSION NICE GUIDELINES
Depression: NICE guidelines on management
NICE updated its depression guidelines in 2022. It now favours a simple classification of depression severity
‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression
a PHQ-9 score of < 16
‘more severe’ depression: encompasses what was previously termed moderate and severe depression
a PHQ-9 score of ≥ 16
The NICE guidelines are long and contain many important principles about dealing with patients who have depression. The following is a very brief section highlighting key points.
Management of less severe depression
NICE lists a large number of interventions that may be used first-line. It encourages us to discuss treatment options with patients to reach a shared decision. They recommend considering ‘the least intrusive and least resource intensive treatment first’. It also recommends not routinely offering ‘antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference’.
Treatment options, listed in order of preference by NICE
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
Management of more severe depression
Again, NICE recommend a shared decision should be made.
Treatment options, listed in order of preference by NICE
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
A 30-year-old woman presents to the GP with mental health concerns that she has been struggling with for the past six months. She says she has a lot going on and has persistent low mood, insomnia, decreased appetite, and social withdrawal. She denies any self-harm, suicidal ideation or plans.
Despite understanding the various treatment options, she expresses a clear preference for medication and says she does not want to talk to anybody or have any talking therapies. She is deemed to have the capacity to make this decision.
What is the most appropriate next step?
Do not offer pharmacological intervention and ask her to think about talking therapies and book another appointment
Offer her an SSRI
Offer her an SSRI and refer her for talking therapies
Refer her for talking therapies and tell her she has to engage with this prior to starting medication
Urgent same day mental health specialist assessment
Offer her an SSRI
Antidepressant medication should not routinely be offered as first-line treatment for less severe depression, unless that is the person’s preference
Offer her an SSRI is the correct choice. The patient in question exhibits symptoms of depression and, although she has decided against engaging with talking therapies, she has expressed a desire to pursue pharmacological treatment. While not typically the first-line recommendation, her strong preference for medication should be respected as she possesses the necessary capacity to make this decision.
Do not offer pharmacological intervention and ask her to think about talking therapies and book another appointment is incorrect. Having presented at the GP surgery seeking assistance, the patient remains interested in trying medication following a discussion of her options. Given that she has the capacity and presents with depressive symptoms, initiating treatment with an SSRI is appropriate. Asking her to reconsider could result in disengagement from medical care, posing additional risks.
Offer her an SSRI and refer her for talking therapies is incorrect because the patient has declined referral for talking therapies. Proceeding with such a referral without consent would be inappropriate.
Refer her for talking therapies and tell her she must engage with this before starting medication is incorrect as it goes against the patient’s wishes not to participate in talking therapy at this time. NICE guidelines do not mandate engagement with talking therapies before commencing SSRIs.
Urgent same-day mental health specialist assessment is incorrect based on available information indicating that the patient does not present as high risk; there are no signs of self-harm or suicidal ideation or plans. Consequently, an urgent same-day mental health assessment does not appear warranted. Nonetheless, it remains imperative to provide the patient with emergency contact details and clear safety netting instructions should they experience suicidal thoughts or require urgent support.
A 42-year-old man, who lived alone, booked a follow-up appointment to see his GP. Due to the COVID-19 pandemic, he had been self-isolating at home for several months. After the easing of the lockdown, he still preferred to stay at home and was afraid to go out.
Prior to the pandemic, he went through a difficult divorce with ongoing issues with respect to the custody of his children. Unfortunately, he lost his job as his workplace were unable to offer him a position going forward.
He had received a telephone consultation 4 weeks prior with his GP and was diagnosed with moderate depression. He was referred for computerised cognitive behavioural therapy and advised to increase his levels of exercise.
Unfortunately, his mental health was deteriorating and he started to have difficulty sleeping and early morning awakening, and fleeting thoughts that he would be ‘better off gone’ but with no active suicidal plans. He stated he did not wish to be referred for psychological treatments such as one-to-one cognitive behavioural therapy, as he found them difficult to engage with.
His GP discussed the next step in managing his depression.
What treatment should he be offered?
Commence citalopram
Commence mirtazapine
Commence venlafaxine
Refer to a structured exercise programme
Refer to the local crisis resolution team
Commence citalopram
SSRIs are the first-line antidepressant for ‘less severe’ depression
This patient is suffering from moderate depression with deteriorating mental health despite low-level therapy. He has already been prescribed CBT and he has refused psychological treatments. He should now be offered an anti-depressant.
Although mirtazapine and venlafaxine may be valid choices, they are not considered to be first-line. NICE suggests that practitioners consider the increased likelihood of patients stopping treatment with venlafaxine because of side effects, and its higher cost, compared with selective serotonin reuptake inhibitors (SSRIs) which are equally as effective. Both mirtazapine and venlafaxine are generally reserved as second-line agents when the response has been poor with an SSRI.
NICE states you should offer an SSRI first-line because they typically have fewer side effects than other types of antidepressants and are just as effective.
In this patient, he has not expressed any true suicidal plans or intent so referral to a crisis team would unlikely be needed.
