The National Institute for Health and Care Excellence (NICE), a non-departmental public body of England’s Department of Health, provides evidence-based guidance on the treatment of medical conditions. Every so often, they update their guidelines, and new depression guidelines are expected to be released in May 2022. This post will take a look at the draft guideline and what it could mean for people experiencing depression.
Details on the draft guidelines for depression in adults are available on the NICE website. The consultation period ends on January 12. There’s extensive documentation on the evidence reviews conducted by NICE, but my interest is the recommendations themselves more so than the hundreds of pages of evidence reviews.
Some preliminaries
In the principles of care for depression, this statement is added: “Be aware that the symptoms of depression itself, and the impact of stigma, can make it difficult for people to access mental health services or take up offers of treatment. Ensure steps are taken to reduce stigma and barriers for individuals seeking help for depression.” I don’t think this will change anything for anyone, but it’s still a nice thought.
The draft guidelines recommend ensuring that people with depression can see the same health care provider whenever possible to support a trusting relationship. They also recommend providing “the option to express a preference for the gender of the healthcare professional, to see a professional they already have a good relationship with, or to change professional if the relationship is not working.”
I don’t know if the UK is anything like Canada, but here, professionals can get all kinds of worked up if a patient wants a say in who’s treating them. While there are probably some instances when concerns are better addressed within the treatment relationship than by provider-hopping, a therapeutic relationship is a 2-way street. If the health professional is being an asshat, that’s not the patient’s fault, nor is it anything the patient can fix.
The cycle of options
NICE has developed two cycles of treatment options; one for less severe and one for more severe depression. The idea is to move clockwise around the cycles until a shared decision (i.e. agreed to by the provider and patient) is arrived at regarding which treatment to try first.
Less severe depression guidelines
This is the order in which treatments are presented in the cycle for less severe depression:
- Group cognitive behavioural therapy (CBT): 8 weekly 90-minute sessions with 2 therapists and 8 participants per group
- Group behavioural activation (a specific type of intervention in CBT – the University of Michigan has a BA workbook here): same delivery as group CBT
- Individual CBT: 8 weekly or bi-weekly 60-minute sessions
- Individual behavioural activation: same delivery as individual CBT
- Self-help with support: CBT-based, with 8 structured 15-minute sessions with a therapist
- Group exercise: 60-minute sessions, 3 times per week for 10 weeks
- Group mindfulness or meditation: 8 weekly 2-hour sessions, with 2 therapists and 8 group members, using an approach like mindfulness-based cognitive therapy (MBCT) – PositivePsychology.com has info on MBCT here
- Interpersonal therapy: 16 weekly 60-minute sessions (CAMH has info on IPT here)
- SSRI antidepressant: according to the draft guidelines, antidepressants shouldn’t be routinely offered as first-line treatment unless that’s the patient’s preference; SSRIs are recommended based on being the most likely to be well-tolerated
- Counselling: 8 weekly 60-minute sessions
- Short-term psychodynamic psychotherapy: up to 16 weekly 50-60 minute sessions
More severe depression guidelines
The “more severe” depression includes moderate and severe depression.
- Combination of individual CBT + antidepressant
- Individual CBT: 12-16 weekly/bi-weekly 60-minute sessions
- Individual behavioural activation: same delivery as CBT
- Antidepressant medication: usually taken for at least 6 months
- Individual problem-solving: 1-hour first session then 8 30-minute sessions (the American Psychological Association provides has a one-page overview of problem-solving therapy here)
- Counselling: 12-16 60-minute sessions
- Short-term psychodynamic psychotherapy: 16 weekly 50-60 minute sessions
- Interpersonal therapy: 16 60-minute sessions
- Self-help with support: 16 weeks, CBT-based
- Group exercise: 60-minute sessions, 3 times per week for 10 weeks
Antidepressant discontinuation
There is a section of the draft guidelines devoted to stopping antidepressants. The section instructs providers: “Explain that withdrawal symptoms can be mild, appear within a few days of reducing or stopping antidepressant medication, and go away within 1 to 2 weeks. However, they can last longer (in some cases, several weeks, occasionally several months) and can sometimes be severe, particularly if the antidepressant medication is stopped suddenly.”
The draft guidelines also say that the patient should have control over the speed and duration of tapering off antidepressants, and prescribers should wait until withdrawal symptoms resolve before making the next drop in dose.
Other recommendations
For people with chronic depressive symptoms (at least 2 years of depressive symptoms, either at or below the level of a major depressive episode), the recommendation is starting with CBT and/or an SSRI or tricyclic antidepressant, and then switching to an SNRI or MAOI as needed.
There are recommendations for various switches or add-ons for people who haven’t responded at all after 4 weeks at a therapeutic dose of medication or 6 weeks of psychotherapy.
For people with co-occurring depression and a personality disorder, the recommendation is a combination of medication and psychotherapy for up to a year. I’m not sure what’s supposed to happen after that year has gone by. Does the patient turn into a pumpkin?
Electroconvulsive therapy (ECT) is recommended for severe depression when it’s the patient preference, a rapid response is required (e.g. if suicidal, not eating/drinking), or other treatments have been unsuccessful. When consent can’t be given, ECT should only be given if it doesn’t conflict with an advanced directive.
The draft guidelines also address collaborative care, specialist care, and crisis resolution and home treatment (CRHT).
My thoughts
I don’t really have any major issues with the recommendations per se, although when it comes to “more severe” depression, I think an antidepressant alone might be fine for the #4 spot for moderate depression, but someone who is severely depressed probably needs a head start with meds before they’re well enough to really benefit from therapy.
My concern with these guidelines is in a practical sense, as I think they’re living in la-la land if they think these guidelines are implementable as the NHS currently exists. Granted, these guidelines are supposed to be based on evidence rather than what’s doable under the status quo, but how is all of this psychotherapy supposed to be magicked into existence? From what I’ve heard from blogging friends in the UK, psychotherapy is not currently easy to access, and it’s certainly not speedy to access.
Are the folks at the NHS going to decide oh wow, we need to create all of these new therapy spots? Do enough therapists even exist in the public system for all of that CBT? If waitlists are bad now, how gargantuan are they going to be if everyone with mild depression is suddenly supposed to get therapy rather than meds?
If the picture painted by these guidelines is so very different from the reality that actually exists, is there even any point? Or is NICE out to lunch about the fact that their guidelines live in fairytale world?
Guidelines released June 19/22
NICE released the final guidelines in June 2022. They include the following PDF flowcharts:
- Cycle of treatment options for less severe depression and more severe depression
- Further-line treatment
- Preventing relapse
- The matched care model
- Treatment options for depression with personality disorder, psychotic depression, and chronic depression
What are your thoughts on the NICE depression guidelines?
Managing the Depression Puzzle takes a holistic look at the different potential pieces that might fit into your unique depression puzzle.
I don’t have an issue with the NICE guidelines. What occurs to me is the need for a user or patient guide — for the mildly depressed, how to assess whether a treatment is working and when to think about changing therapists, for example. For someone severely affected, this guide might serve a caregiver or court-appointed trustee. Does one exist?
In terms of a guide as in a third-party advocate, I haven’t heard of anywhere that happens routinely, although I know patient navigator services exist in health care more generally.
If someone was too unwell to be capable of giving consent, then it would depend on what’s stipulated in local mental health legislation and adult guardianship legislation.
That sounds like a lot of therapy. Personally, I wouldn’t mind that, probably…but I don’t think that would work for the majority of people. And like you said, it’s already so hard to actually find a therapist. Let alone one that you actually connect with.
They mentioned that patient preference was key in making individual decisions, but I’m also not convinced that the options are going to be workable for the majority of people.
Based on my experience of the system under the old rules, if it gets to the end of a year and you’re not getting better, they pretty much give up on you.
I suspect the focus on group therapy is to provide more therapy per therapist. It’s not so hard to get CBT on the NHS at the moment, but it is a lot harder to get psychodynamic therapy.
That whole giving up on people thing is really not okay. I would imagine that could produce pretty substantial costs in terms of disability burden.
It isn’t OK, but I suppose the reasoning is, beyond a certain point, you have to triage and say, “By not treating this person, I can treat three mildly depressed people,” and so on.
“By not treating this gunshot wound, I can treat three people with skin conditions.” They’d never do it.
It really sucks to need help when you have mental illness.
And, just like that…she was angry. I suppose they mean well. The timelines, however, are stupid. The push to get off medication is stupid. And, as you mentioned, it’s doubtful the resources exist. Continuity of care would be nice: it’s not a thing that happens here for sure. And expressing a desire for someone else here is a good way to get labelled difficult or to get kicked out.
Continuity of care would definitely be nice.
In terms of medications, I think it’s good to make therapy more available so that doctors don’t have to prescribe meds because they’re more available even in cases where therapy would likely be more effective. But I don’t think trying to get people off medications that are working for them is helpful at all.
It’s a hot button for me, I suppose, since doctors who aren’t psychiatrists and have no or limited mental health experience like to suggest it 🙄
Yeah, there seem to be a lot of GPs who are completely out to lunch when it comes to anything but the most mild cases of mental illness.
I completely feel you and, as someone with co-occuring depressive symptoms and a personality disorder, I can attest to not having turned into a pumpkin. What happens most likely, at least here in the Netherlands, is that after a year of psychotherapy (if that at all, I hardly got any psychotherapy), these patients are relegated to the care of community psychiatric nurses and case managers to do just support. And in the UK, they’re more likely to be left to their own resources, because mental health care there is a joke.
That makes sense that at some point there would be a shift in approach from treating an acute condition to managing a chronic one.
This would make such an amazing valuable resource for patients in the UK. Your passion for mental health is quite inspiring. Do you often look at different countries regarding mental health care? Sadly, I know the system completely fails many in Australia, and know (by 2 degrees separation) disastrous outcomes in the last few months alone.
I find it’s hard to get a grasp of what mental health care looks like in a particular country. I’ve done a fair bit of reading about the systems in the UK and US and heard the experiences of quite a few bloggers in those countries, but I still feel like I’ve only got part of the picture.
I guess it’s like travel, you can’t really know unless you’ve experienced it first hand. This is still a great post.
Thanks!
Interesting. I understand the appeal of starting with group therapy from a public health perspective – it allows more patients to be treated with less resource.
But I keep reading “less severe depression” as “newly diagnosed and new to treatment” (I am aware these terms are not synonymous and that this is a reflection of my own bias) and started with group therapy sounds somewhat terrifying. I have a pretty high tolerance for embarrassing myself by saying highly personal and incriminating shit about myself in public (Exhibit A: my public blog) and I would still find the idea of group therapy kind of terrifying.
Yeah, it’s definitely not everyone’s cup of tea, and it wouldn’t be my choice either.
I must say I have little faith in the ability of medical professionals to make honest, caring, and suitable recommendations for patient care.
There are definitely good ones out there, and I’ve worked with some of them, but they do seem to be in the minority.
Electroconvulsive therapy (ECT) is recommended for severe depression when it’s the patient preference, a rapid response is required (e.g. if suicidal, stopping eating/drinking), or other treatments have been unsuccessful.Â
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Dang, ECT could have helped me… I was very depressed, suicidal and completely stopped eating and drinking.
But it wasn’t offered to me and my current living situation is now bad, because my landlady C and friends had to help me. C now a freaking difficult landlady and I have enough on my plate.
Thanks for the post. It was very interesting. My opinion is it seems like the emphasis here is on the short-term – year one or two of the therapy – and there is not an emphasis on long-term care and on-going therapy or meds. This upfront care seems to me to assume that mental health can be “cured” in a year or two with the right combination of therapy and meds. My experience is that 27 years after diagnosis, it is still extremely important for me to take meds on a regular basis and see a therapist every 4 to 8 weeks. It is all about management of the mental illness not about a silver bullet “cure.” Hope this is not a downer position just reality-based.
I agree.
Thank you for a great but depressing read. I believe a pumpkin is a fantastic description. And, it was almost expected that the new guidelines would fit well into the checkbox health system the nhs has grown into.
The NHS sure sounds like a weird beast.