NPC Archive Item: NICE updates depression guideline

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5 November 2009

NICE has issued a clinical guideline on the treatment and management of depression in adults. The guideline makes recommendations on the identification, treatment and management of depression in adults in both primary and secondary care, and partially updates and replaces previous NICE guidance (CG23) issued in 2004.

Healthcare professionals involved in the treatment and management of patients with depression should familiarise themselves with the new guideline and base their management on this. The quick reference guide provides a summary of the recommendations and the key priorities for implementation. NICE has also issued a costing statement that discusses areas of possible costs and savings that should be considered locally.

What does the guideline cover?

Recommendations include:

  • Case identification and recognition — Be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem). Note that NICE now recommends diagnosis according to DSM-IV criteria; this is different from previous guidance.
  • Low-intensity psychosocial interventions — For people with persistent sub threshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:
    • individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
    • computerised cognitive behavioural therapy
    • a structured group physical activity programme.
  • Drug treatment — Do not use antidepressants routinely to treat persistent sub threshold depressive symptoms or mild depression, but consider them for people with:
    • a past history of moderate or severe depression, or
    • initial presentation of sub threshold depressive symptoms that have been present for a long period (typically at least 2 years), or
    • sub threshold depressive symptoms or mild depression that persist(s) after other interventions.
  • Treatment for moderate or severe depression — For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention, such as CBT.
  • Continuation and relapse prevention — Support and encourage a person who has benefited from taking an antidepressant to continue medication for at least 6 months after remission of an episode of depression. Discuss with the person that this greatly reduces the risk of relapse and antidepressants are not associated with addiction.
  • Counselling — This is now only recommended for people with persistent sub threshold depressive symptoms or mild-to-moderate depression who decline an antidepressant, CBT, behavioural activation, interpersonal psychotherapy and behavioural couples therapy.

Which antidepressants are recommended?
The review carried out for the NICE guideline considered escitalopram and duloxetine▼ for the first time. However, the overall conclusion (unchanged from the previous guideline) was that antidepressants have largely equal efficacy. Choice should,therefore, largely depend on side-effect profile, patient preference and previous experience of treatments, propensity to cause discontinuation symptoms and safety in overdose, as well as cost. Potential interactions with concomitant medications or physical illness are also important to consider when choosing an antidepressant.

A generic SSRI should normally be chosen. It is necessary to take into account that:

  • Selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of bleeding. Consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs or aspirin.
  • fluoxetine, fluvoxamine and paroxetine have a higher propensity for drug interactions.
  • for people who also have a chronic physical health problem, consider using citalopram or sertraline as these have a lower propensity for interactions.
  • paroxetine is associated with a higher incidence of discontinuation symptoms.

Take into account toxicity in overdose for people at significant risk of suicide. Be aware that:

  • compared with other equally effective antidepressants recommended in primary care, venlafaxine is associated with a greater risk of death from overdose.
  • the greatest risk in overdose is with tricyclic antidepressants (TCAs), except for lofepramine.

When prescribing drugs other than SSRIs, take into account:

  • the increased likelihood of the person stopping treatment because of side effects, and the consequent need to increase the dose gradually, with venlafaxine, duloxetine▼  and TCAs
  • the specific cautions, contraindications and monitoring requirements for some drugs
  • that non-reversible monoamine oxidase inhibitors (MAOIs, such as phenelzine), combined antidepressants and lithium augmentation of antidepressants should normally be prescribed only by specialist mental health professionals
  • that dosulepin should not be prescribed.

When prescribing antidepressants for older adults prescribe at an age-appropriate dose, taking into account physical health and concomitant medication and monitor carefully for side effects.

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).

Switching of antidepressants. The evidence for the relative advantage of switching either within or between classes of antidepressants is weak. When this is considered appropriate, NICE recommends a different SSRI or a better tolerated newer-generation antidepressant. Subsequently, an antidepressant of a different pharmacological class that may be less well tolerated, should be considered, for example venlafaxine, a TCA (but not dosulepin) or an MAOI.

Other relevant guidance
Alongside this guidance, NICE has also published guidance on the treatment and management of depression in adults with chronic physical health problems.

Other relevant NICE guidelines should be consulted for depression occurring in the context of other disorders:

Details of how the recommendations were developed, and reviews of the evidence they were based on, can be found in the NICE Full Guideline.

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