This Guidelines summary covers NICE’s key priorities for implementation for primary care healthcare practitioners on the identification, treatment, and management of depression in adults aged 18 years and older. For the complete set of recommendations, including the Medicines and Healthcare Regulatory Agency’s advice on valproate, refer to the full guideline.
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 cognitive behavioural therapy (CCBT)
- a structured group physical activity programme.
- 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 IPT).
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
- 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.
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: 28 October 2009.
Last updated: April 2018 (amended May 2021).
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