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This summary only covers the key priorities for implementation. Please refer to the full guideline for the complete set of recommendations

Key priorities for implementation

Principles for assessment

  • When assessing a patient with a chronic physical health problem who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode.

Effective delivery of interventions for depression

  • All interventions for depression should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:
    • receive regular high-quality supervision
    • use routine outcome measures and ensure that the patient with depression is involved in reviewing the efficacy of the treatment
    • engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny where appropriate.

Case identification and recognition

  • Be alert to possible depression (particularly in patients with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking patients who may have depression two questions, specifically:
    • During the last month, have you often been bothered by feeling down, depressed or hopeless?
    • During the last month, have you often been bothered by having little interest or pleasure in doing things?

Low-intensity psychosocial interventions

  • For patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering one or more of the following interventions, guided by the patient’s preference:

    • a structured group physical activity programme
    • a group-based peer support (self-help) programme
    • individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
    • computerised cognitive behavioural therapy (CCBT)[A]

Treatment for moderate depression

  • For patients with initial presentation of moderate depression and a chronic physical health problem, offer the following choice of high-intensity psychological interventions:

    • group-based CBT or

    • individual CBT for patients who decline group-based CBT or for whom it is not appropriate, or where a group is not available or 

    • behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.

Antidepressant drugs

  • Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild depression in patients with a chronic physical health problem (because the risk–benefit ratio is poor), but consider them for patients with:

    • a past history of moderate or severe depression or

    • mild depression that complicates the care of the physical health problem or

    • initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or

    • subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

  • When an antidepressant is to be prescribed for a patient with depression and a chronic physical health problem, take into account the following:
    • the presence of additional physical health disorders
    • the side effects of antidepressants, which may impact on the underlying physical disease (in particular, SSRIs may result in or exacerbate hyponatraemia, especially in older people)
    • that there is no evidence as yet supporting the use of specific antidepressants for patients with particular chronic physical health problems
    • interactions with other medications.

Collaborative care

  • Consider collaborative care for patients with moderate to severe depression and a chronic physical health problem with associated functional impairment whose depression has not responded to initial high-intensity psychological interventions, pharmacological treatment or a combination of psychological and pharmacological interventions.

[A] This recommendation (and recommendation in CG90) updates the recommendations on depression only in ‘Computerised cognitive behaviour therapy for depression and anxiety (review)’ (NICE technology appraisal guidance 97).

© NICE 2009. Depression in adults with a chronic physical health problem: recognition and management. Available from: https://www.nice.org.uk/guidance/cg91. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: First included: 28 October 2009.