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Depression in adults with a chronic physical health problem: recognition and management

Introduction

  • Depression is a broad and heterogeneous diagnosis, characterised by depressed mood and/or loss of pleasure in most activities. Severity of the disorder is determined by both the number and severity of symptoms and the degree of functional impairment (see Severities of depression)
  • This updated guideline uses the DSM-IV criteria for major depression (referred to here as ‘depression’) instead of the ICD-10 criteria used in NICE clinical guideline 23. Using DSM-IV enables specific interventions to be better targeted for more severe degrees of depression; its definition of severity also makes it less likely that a diagnosis will be made solely on symptom counting
  • Symptoms below the threshold for diagnosis can be distressing and disabling; therefore this updated guideline also covers ‘subthreshold depressive symptoms’ (see Severities of depression)

Key priorities for implementation

The following key priorities are from Depression: the treatment and management of depression in adults (update)’ (NICE clinical guideline 90). Key priorities marked with an asterisk (*) are also key priorities for implementation in ‘Depression in adults with a chronic physical health problem: treatment and management’ (NICE clinical guideline 91)

Principles for assessment

  • *When assessing a person 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 person 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 people with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking people 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 people with persistent subthreshold 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 CBT (CCBT)
    • a structured group physical activity programme

Drug treatment

  • Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor, but consider them for people with:
    • a past history of moderate or severe depression 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

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 (CBT or interpersonal therapy [IPT])

Continuation and relapse prevention

  • Support and encourage a person who has benefited from taking an antidepressant to continue medication for at least 6months after remission of an episode of depression. Discuss with the person that:
    • this greatly reduces the risk of relapse
    • antidepressants are not associated with addiction

Psychological interventions for relapse prevention

  • People with depression who are considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, should be offered one of the following psychological interventions:
    • individual CBT for people who have relapsed despite antidepressant medication and for people with a significant history of depression and residual symptoms despite treatment
    • mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression

The following key priorities are from ‘Depression in adults with a chronic physical health problem: treatment and management’ (NICE clinical guideline 91)

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 CBT
    • CCBT

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

Severities of depression

  • Subthreshold depressive symptoms:
    Fewer than 5 symptoms
  • Mild depression:
    Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
  • Moderate depression:
    Symptoms or functional impairment are between ‘mild’ and ‘severe’
  • Severe depression:
    Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms

These recommendations update the recommendations on depression only in ‘Computerised cognitive behaviour therapy for depression and anxiety (review)’ (NICE technology appraisal guidance 97)

Taken from DSM-IV (see www.nice.org.uk/CG90niceguideline for further details)

© NICE 2009. Depression in adults with a chronic physical health problem: recognition and management. Available from: www.nice.org.uk/CG90. All rights reserved. Subject to Notice of rights.

© NICE 2009. Depression in adults: recognition and management. Available from: www.nice.org.uk/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. 

First included: June 2004.