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NICE: Give therapy and exercise before medication for ‘less severe’ depression



NICE draft guidance has recommended that clinicians do not routinely offer patients with ‘less severe’ depression antidepressants as the first line of treatment.

It said this should only be the case if this is their ‘preference’ and that clinicians could first offer alternatives such as cognitive behavioural therapy (CBT); counselling; group mindfulness or meditation; or group exercise.

The guidance, published this week and currently out for consultation, said: ‘Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference.’

It added that those with ‘more severe’ depression should also be offered a range of different options of first-line treatments, depending on their ‘clinical needs and preference’.

The guidance said that clinicians should ‘discuss treatment options with people who have a new episode of less severe depression’ – defined as ‘subthreshold symptoms and mild depression’ – and reach a ‘shared decision’ based on their ‘clinical needs and preferences’.

They should take into account that all treatments listed in the guidance ‘can be used as first-line treatments’, it added.

The options, listed ‘in order of recommended use’, are:

  • Group CBT
  • Group behavioural activation (BA) 
  • Individual CBT
  • Individual BA
  • Self-help ‘with support’
  • Group exercise
  • Group mindfulness or meditation
  • Interpersonal psychotherapy (IPT)
  • Selective serotonin reuptake inhibitors (SSRIs) 
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP)

Healthcare professionals should not prescribe or advise the use of St John’s Wort to those with depression because of ‘uncertainty’ about appropriate doses and persistence of effect and ‘potential serious interactions’ with other drugs, it added.

Those with a new episode of ‘more severe’ depression – defined as ‘moderate and severe depression’ – should also be offered a range of potential first-line treatments with a shared decision reached based on their needs and preference, the guidance said.

Treatment options for ‘more severe’ depression in order of ‘recommended use’ are:

  • Combination of individual CBT and an antidepressant 
  • Individual CBT
  • Individual behavioural activation (BA) 
  • Antidepressant medication, which could be an SSRI, SNRI or ‘other antidepressant if indicated based on previous clinical and treatment history’
  • Individual ‘problem-solving’
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP) 
  • Interpersonal psychotherapy (IPT)
  • Self-help ‘with support’
  • Group exercise

Healthcare professionals should recognise that people with all severities of depression ‘have a right to decline treatment, the guidance added.

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘People with depression deserve and expect the best treatment from the NHS which is why this guideline is urgently required.

‘The Covid-19 pandemic has shown us the impact depression has had on the nation’s mental health. People with depression need these evidence-based guideline recommendations available to the NHS, without delay.’

Nav Kapur, professor of psychiatry and population health at the University of Manchester and chair of the guideline committee, added that the ‘broad-ranging’ was ‘an enormous challenge to produce’.

He said: ‘In particular we’ve emphasised the role of patient choice – suggesting that practitioners should offer people a choice of evidence-based treatments and understanding that not every treatment will suit every person. 

‘We now need stakeholders’ help to make the recommendations as good as they can possibly be.’

The consultation on the guideline, which would be the first in 12 years on identifying, treating and managing depression in adults, will close on 12 January with final publication expected on 12 May 2022.

The guideline – which will update and replace NICE guideline CG90 published in 2009 – is now out for its third consultation.

A version of this article was originally published on Nursing in Practice‘s sister title Pulse.

To complete relevant mental health CPD modules on Nursing in Practice Learning, click here.