Depression

Short Text

Identification, treatment and management of depression in children (from age 5 years), young people and adults, including adults with a chronic physical health problem

Introduction

This pathway covers the identification, treatment and management of depression in children (from age 5 years), young people and adults, including adults with a chronic physical health problem.
Depression is a broad and heterogeneous diagnostic grouping, central to which is depressed mood or loss of pleasure in most activities. It often has a remitting and relapsing course, and symptoms may persist between episodes. Its severity is determined by both the number and severity of symptoms and the degree of functional impairment. A wide range of biological, psychological and social factors impact on the course of depression and a person's response to treatment, and these factors may not be captured well by current diagnostic systems. Therefore it is also important to consider personal past history and family history of depression as part of a diagnostic assessment.
Depression is two to three times more common in people with a chronic physical health problem; for these people, functional impairment is likely to be greater than if a person has depression or the physical health problem alone.
Note that NICE clinical guideline 28 on depression in children and young people uses ICD-10 criteria to define depression, whereas the 2009 update of NICE clinical guideline 23 on depression in adults changed from using ICD-10 criteria to DSM-IV criteria. It also uses the term subthreshold depressive symptoms to describe symptoms that are below the threshold for DSM-IV but which can be distressing and disabling if they persist. For more information about DSM-IV, see appendix C of NICE clinical guideline 90.

Source guidance

The NICE guidance that was used to create the pathway.
Depression with a chronic physical health problem. NICE clinical guideline 91 (2009)
Depression in adults (update). NICE clinical guideline 90 (2009)
Depression in children and young. NICE clinical guideline 28 (2005)
Vagus nerve stimulation for treatment-resistant depression. NICE interventional procedures guidance 330 (2009)
Transcranial magnetic stimulation for severe depression. NICE interventional procedures guidance 242 (2007)

Quality standards

Depression in adults quality standard

These quality statements are taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.
1Assessment
2Practitioner competence
3Recording health outcomes
4Low-intensity interventions for persistent subthreshold depressive symptoms or mild to moderate depression
5Antidepressants for persistent subthreshold depressive symptoms or mild depression
6Moderate to severe depression and no existing chronic physical health problem
7Moderate depression and a chronic physical health problem
8Severe depression and a chronic physical health problem
9Collaborative care
10Continuing antidepressants
11Reassessing people prescribed antidepressants
12Lack of response to initial treatment within 6 to 8 weeks
13Residual symptoms or risk of relapse

Quality statements

Assessment

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.

Quality measure

Structure
Evidence of an assessment process for people who may have depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Process
Proportion of people who receive an assessment for depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Numerator – the number of people in the denominator receiving an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Denominator – the number of people receiving an assessment for depression.

Description of what the quality statement means for each audience

Service providers ensure that a process is in place for assessing people who may have depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Healthcare professionals ensure that people who may have depression are assessed using a process that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Commissioners ensure they commission services that have an assessment process in place that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
People who may have depression receive an assessment to find out how severe their symptoms are, how much they are affected by the depression and how long it has lasted for.

Definitions

The term 'people who may have depression' includes all people with a chronic physical health problem who may have depression.
For details of the assessment see appendix C of NICE clinical guideline 90 and 91. This should be supported by use of a formal rating scale for symptom severity (for example, Patient Health Questionnaire [PHQ-9], Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI]).
The assessment of functional impairment should include social perspectives of impairment as defined by the World Health Organisation International Classification of Functioning, Disability and Health.

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.1.4.1 and NICE clinical guideline 91 recommendation 1.1.3.1.

Data source

Structure
Local data collection.
Process
Local data collection. Information on assessment of severity is collected by Quality and Outcomes Framework (QOF) indicator Depression 2: In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care.

Equality and diversity consideration

Quality statement 1 should be supplemented with recommendation 1.3.1.5 (which is the same in NICE clinical guideline 90 and 91) in cases where the person with depression has significant language or communication difficulties.
Recommendation 1.3.1.5 states: 'For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer and/or asking a family member or carer about the person's symptoms to identify possible depression. If a significant level of distress is identified, investigate further.'

Practitioner competence

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.

Quality measure

Structure
a) Evidence of local arrangements for the regular supervision of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression.
b) Evidence of local arrangements for regular monitoring of compliance with applicable competencies for practitioners delivering pharmacological, psychological or psychosocial interventions.
c) Evidence that services are commissioned to provide pharmacological, psychological or psychosocial interventions of content and duration in accordance with NICE guidance for people with depression.
Process:
a) Proportion of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression who receive regular supervision.
Numerator – the number of practitioners in the denominator receiving regular supervision.
Denominator – the number of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression.
b) Proportion of people with depression receiving interventions who receive interventions of appropriate content in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving interventions of appropriate content in accordance with NICE guidance.
Denominator – the number of people with depression receiving psychological, psychosocial or pharmacological interventions.
c) Proportion of people with depression receiving interventions who receive interventions of appropriate duration in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving interventions of appropriate duration in accordance with NICE guidance.
Denominator – the number of people with depression receiving psychological, psychosocial or pharmacological interventions.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to regularly supervise practitioners to ensure they are competent in delivering interventions of appropriate content and duration for people with depression in accordance with NICE guidance.
Healthcare professionals ensure they are competent to deliver interventions of appropriate content and duration for people with depression in accordance with NICE guidance.
Commissioners ensure they commission services that supervise practitioners and provide programmes of appropriate content and duration for people with depression in accordance with NICE guidance.
People with depression receive suitable treatment for the right length of time from competent staff.

Definitions

The term 'people with depression' includes all people with depression and a chronic physical health problem.
NICE clinical guideline 90 and 91 provide information on the correct content and duration of interventions.
Competencies for practitioners delivering psychological therapies are provided by the Improving Access to Psychological Therapies (IAPT) programme.
A competency based curriculum for specialist training in psychiatry is provided by the Royal College of Psychiatrists.
Regular supervision involves a review and reflection on practice and should be in a format appropriate to the setting, type of practitioner and type of intervention being delivered.

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Recording health outcomes

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust delivery of interventions.

Quality measure

Structure
Evidence of systems in place to monitor health outcomes for people with depression at each appointment and use the findings to adjust delivery of interventions.
Process
Proportion of people with depression receiving pharmacological, psychological or psychosocial interventions who have their health outcomes recorded at initial contact and subsequent review.
Numerator – the number of people in the denominator whose health outcomes are recorded at initial contact and subsequent review.
Denominator – the number of people with depression receiving pharmacological, psychological or psychosocial interventions.
(Suggested audit standard derived from Improving Access to Psychological Therapies [IAPT] performance indicators: Achievement of 90% data completion of health outcomes at initial contact and subsequent review).

Description of what the quality statement means for each audience

Service providers ensure systems are in place to record patient health outcomes.
Healthcare professionals ensure they record patient health outcomes and use findings to adjust delivery of interventions.
Commissioners ensure they commission services that record patient health outcomes at each appointment and use findings to adjust delivery of interventions.
People with depression have their progress checked at each appointment to help decide on how best to continue with treatments.

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1.
Structure
Local data collection
Process
Local data collection. The IAPT dataset will contain data-fields on the first and last patient outcome scores.

Low-intensity interventions for persistent subthreshold depressive symptoms or mild to moderate depression

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.

Quality measure

Structure
Evidence of local arrangements to provide appropriate low-intensity psychosocial interventions to people with persistent subthreshold depressive symptoms or mild to moderate depression.
Process
Proportion of people with persistent subthreshold symptoms or mild to moderate depression who receive appropriate low-intensity psychosocial interventions.
Numerator – the number of people in the denominator receiving appropriate low-intensity psychosocial interventions.
Denominator – the number of people with persistent subthreshold depressive symptoms or mild to moderate depression.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with persistent subthreshold depressive symptoms or mild to moderate depression to access appropriate low-intensity psychosocial interventions.
Healthcare professionals ensure people with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.
Commissioners ensure they commission services that provide appropriate low-intensity psychosocial interventions to people with persistent subthreshold depressive symptoms or mild to moderate depression.
People with some mild but long-lasting symptoms of depression or with mild or moderate depression receive appropriate psychological treatment, for example a self-help programme (undertaken alone or, if the person has a long-term physical health problem, in a group), a group exercise programme, or a treatment using a computer called 'computerised cognitive behavioural therapy' (or CCBT for short).

Definitions

The term 'people with persistent subthreshold depressive symptoms or mild to moderate depression' includes all people with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem.
NICE clinical guideline 90 and 91 define appropriate low-intensity interventions as:
  • individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
  • a structured group physical activity programme
  • computerised CBT
  • group-based CBT for people with persistent subthreshold depressive symptoms or mild to moderate depression and no existing chronic physical health problem who decline low-intensity psychosocial intervention
  • a group-based peer support (self-help) programme (for people with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem only).

Source clinical guideline references

NICE clinical guideline 90 recommendations 1.4.2.1 and 1.4.3.1, and NICE clinical guideline 91 recommendation 1.4.2.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Equality and diversity consideration

NICE clinical guideline 90 recommendation 1.4.2.1 and NICE clinical guideline 91 recommendation 1.4.2.1 include computerised cognitive behavioural therapy as a recommended intervention, which has been identified as a possible issue for people with learning disabilities and acquired cognitive impairment (although it may improve access for some people with mobility problems). A number of alternative interventions are offered in the recommendations (guided self-help, physical activity, peer support) in order to take this into account.
In addition, people with physical disabilities may experience access issues relating to participation in physical activity interventions. Therefore alternative interventions are provided in recommendation 1.4.2.1. In addition, recommendation 1.4.2.2 (NICE clinical guideline 91) recommends that physical activity programmes are modified to take into account participants' physical disability.

Antidepressants for persistent subthreshold depressive symptoms or mild depression

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.

Quality measure

Structure
Evidence of local arrangements to support the correct prescribing of antidepressants to people with persistent subthreshold depressive symptoms or mild depression in accordance with the NICE guidance.
Process
Proportion of people with persistent subthreshold depressive symptoms or mild depression prescribed antidepressant medication who meet specific clinical criteria for the prescription of antidepressants in accordance with NICE guidance.
Numerator – the number of people in the denominator meeting the specific clinical criteria for the prescription of antidepressants in accordance with NICE guidance.
Denominator – the number of people with persistent subthreshold depressive symptoms or mild depression prescribed antidepressants.

Description of what the quality statement means for each audience

Service providers ensure policies are in place for the prescription of antidepressants to people with subthreshold depressive symptoms or mild depression only when specific clinical criteria are met in accordance with NICE guidance.
Healthcare professionals ensure they prescribe antidepressants to people with subthreshold depressive symptoms or mild depression only when the person meets the specific clinical criteria in accordance with NICE guidance.
Commissioners ensure they commission services that monitor whether the prescription of antidepressants to people with subthreshold depressive symptoms or mild depression is being carried out in accordance with NICE guidance.
People with some mild but long-lasting symptoms of depression or mild depression are not usually prescribed antidepressants except in particular circumstances (for example, if they have had moderate or severe depression in the past; have depression which has lasted for a long time – usually at least 2 years; still have depression after other treatments; or if treatment of a physical health problem is made more difficult because of mild depression).

Definitions

The term 'people with persistent subthreshold depressive symptoms or mild depression' includes all people with persistent subthreshold depressive symptoms or mild depression and a chronic physical health problem.
NICE clinical guideline 90 recommendation 1.4.4.1 and NICE clinical guideline 91 recommendation 1.4.3.1 state that antidepressants should not be used routinely for people with persistent subthreshold depressive symptoms or mild depression, but may be considered in cases where there is:
  • 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 or
  • mild depression that complicates the care of a physical health problem (for people with depression and a chronic physical health problem only).

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.4.4.1 and NICE clinical guideline 91 recommendation 1.4.3.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Moderate to severe depression and no existing chronic physical health problem

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity CBT or IPT.

Quality measure

Structure
Evidence of coordination and cooperation between services delivering pharmacological and psychological interventions.
Process
Proportion of people with moderate or severe depression (and no existing chronic physical health problem) who receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Numerator – the number of people in the denominator receiving a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Denominator – the number of people with moderate or severe depression (and no existing chronic physical health problem).

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the delivery of a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy for people with moderate or severe depression (and no existing chronic physical health problem).
Healthcare professionals ensure people with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Commissioners ensure coordination and cooperation between services to enable effective delivery of combined psychological and pharmacological therapy for people with moderate or severe depression and no existing chronic physical health problem.
People with moderate or severe depression and no long-term physical health problems receive antidepressants along with psychological treatments (either a treatment called 'cognitive behavioural therapy', or CBT for short, or a treatment called 'interpersonal therapy', or IPT for short).

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.5.1.2.

Data source

Structure
Local data collection.
Process
Local data collection.

Moderate depression and a chronic physical health problem

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with moderate depression and a chronic physical health problem receive an appropriate high-intensity psychological intervention.

Quality measure

Structure
Evidence of local arrangements to provide appropriate high-intensity psychological interventions for people with moderate depression and a chronic physical health problem.
Process
Proportion of people with moderate depression and a chronic physical health problem who receive an appropriate high-intensity psychological intervention.
Numerator – the number of people in the denominator receiving an appropriate high-intensity psychological intervention.
Denominator – the number of people with moderate depression and a chronic physical health problem.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the delivery of appropriate high-intensity psychological interventions for people with moderate depression and a chronic physical health problem.
Healthcare professionals ensure people with moderate depression and a chronic physical health problem receive appropriate high-intensity psychological interventions.
Commissioners ensure they commission services to provide appropriate high-intensity psychological interventions to people with moderate depression and a chronic physical health problem.
People with moderate depression and a long-term physical health problem receive appropriate psychological treatment (for example, group or one-to-one CBT, or a treatment for people with a regular partner called behavioural couples therapy, if appropriate).

Definitions

NICE clinical guideline 91 defines appropriate high-intensity interventions for people with moderate depression and a chronic physical health problem as:
  • group-based cognitive behavioural therapy (CBT) or
  • individual CBT for people 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.

Source clinical guideline references

NICE clinical guideline 91 recommendation 1.5.1.2.

Data source

Structure
Local data collection.
Process
Local data collection.

Severe depression and a chronic physical health problem

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual CBT.

Quality measure

Structure
Evidence of local arrangements to provide a combination of antidepressant medication and individual cognitive behavioural therapy (CBT) to people with severe depression and a chronic physical health problem.
Process
Proportion of people with severe depression and a chronic physical health problem who receive a combination of antidepressant medication and individual CBT.
Numerator – the number of people in the denominator receiving a combination of antidepressant medication and individual CBT.
Denominator – the number of people with severe depression and a chronic physical health problem.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide people with severe depression and a chronic physical health problem with a combination of antidepressant medication and individual CBT.
Healthcare professionals ensure people with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual CBT.
Commissioners ensure they commission services to provide a combination of antidepressant medication and individual CBT to people with severe depression and a chronic physical health problem.
People with severe depression and a long-term physical health problem receive antidepressants along with one-to-one CBT.

Source clinical guideline references

NICE clinical guideline 91 recommendation 1.5.1.3

Data source

Structure
Local data collection.
Process
Local data collection.

Collaborative care

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.

Quality measure

Structure
Evidence of local arrangements to provide collaborative care to people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Process
Proportion of people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, who receive collaborative care.
Numerator – the number of people in the denominator receiving collaborative care.
Denominator – the number of people with a chronic physical health problem and moderate to severe depression with associated functional impairment whose symptoms are not responding to initial interventions.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for providing collaborative care to people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Healthcare professionals ensure collaborative care is provided to all people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Commissioners ensure they commission services that provide collaborative care for people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
People with moderate to severe depression and a long-term physical health problem affecting their everyday life, whose symptoms have not improved after early treatments, receive 'collaborative care', which means that a dedicated team of healthcare professionals work together to treat the depression and the physical health problem.

Definitions

NICE clinical guideline 91 states that collaborative care should form part of a well-developed stepped-care programme. In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.
Collaborative care requires that the patient and healthcare professional jointly identify problems and agree goals for interventions, and normally comprises:
  • case management which is supervised and supported by a senior mental health professional
  • close collaboration between primary and secondary physical health services and specialist mental health services in the delivery of services
  • the provision of a range of evidence-based interventions
  • the long term coordination of care and follow-up.

Source clinical guideline references

NICE clinical guideline 91 recommendation 1.5.4.1 and 1.5.4.2.

Data source

Structure
Local data collection.
Process
Local data collection.

Continuing antidepressants

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for people at risk of relapse.

Quality measure

Structure
Evidence of local arrangements for monitoring and reviewing people prescribed antidepressants.
Process
a) Proportion of people with depression benefiting from antidepressants who remain on them at least 6 months after remission.
Numerator – the number of people in the denominator remaining on antidepressants at least 6 months after remission.
Denominator – the number of people with depression benefiting from antidepressants.
b) Proportion of people with depression benefiting from antidepressants and at risk of relapse who remain on them 2 years after remission.
Numerator – the number of people in the denominator remaining on antidepressants 2 years after remission.
Denominator – the number of people with depression benefiting from antidepressants and at risk of relapse.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for monitoring and reviewing all people with depression prescribed antidepressants.
Healthcare professionals ensure people with depression benefiting from antidepressants are advised to continue with treatment for at least 6 months, extending to at least 2 years for people at risk of relapse.
Commissioners ensure they commission services that monitor compliance with antidepressant medication.
People with depression who are feeling better after taking antidepressants are advised to keep taking them for at least 6 months, and for up to at least 2 years if their symptoms are likely to return.

Definitions

The term 'people with depression' includes all people with depression and a chronic physical health problem.
The level of medication at which acute treatment was effective should be maintained for at least 2 years (unless there is good reason to reduce the dose, such as unacceptable adverse effects) if:
  • they have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
  • they have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
  • the consequences of relapse are likely to be severe (for example, suicide attempts, loss of functioning, severe life disruption and inability to work).

Source clinical guideline references

NICE clinical guideline 90 recommendations 1.9.1.1 and 1.9.1.4.

Data source

Structure
Local data collection.
Process
Local data collection.

Reassessing people prescribed antidepressants

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first 3 months of treatment.

Quality measure

Structure
Evidence of procedures to regularly reassess people with depression whose treatment consists solely of antidepressants.
Process
Proportion of people with depression treated solely with antidepressants who are reassessed at least every 4 weeks for the first 3 months of treatment.
Numerator – the number of people in the denominator reassessed at least every 4 weeks for the first 3 months of treatment.
Denominator – the number of people with depression treated solely with antidepressants.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to ensure people treated solely with antidepressants are reassessed at least every 2 to 4 weeks for at least the first 3 months of treatment.
Healthcare professionals ensure they reassess people treated solely with antidepressants at least every 2 to 4 weeks for at least the first 3 months of treatment.
Commissioners ensure they commission services that reassess people treated solely with antidepressants at least every 2 to 4 weeks for at least the first 3 months of treatment.
People with depression treated only with antidepressants are checked at least every 2 to 4 weeks for the first 3 months of treatment or longer.

Definitions

The term 'people with depression' includes all people with depression and a chronic physical health problem.

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.5.2.6 and NICE clinical guideline 91 recommendation 1.5.2.19.

Data source

Structure
Local data collection.
Process
Local data collection.

Lack of response to initial treatment within 6 to 8 weeks

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.

Quality measure

Structure
Evidence of local arrangements to identify people with depression that has not responded adequately to initial treatment within 6 to 8 weeks and to review treatment plans.
Process
Proportion of people with depression that has not responded adequately to initial treatment within 8 weeks who have their treatment plan reviewed.
Numerator – the number of people in the denominator receiving a review of their treatment plan.
Denominator – the number of people with depression that has not responded adequately to initial treatment within 8 weeks.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for reviewing treatment plans for people with depression that has not responded adequately to initial treatment within 6 to 8 weeks.
Healthcare professionals ensure people with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.
Commissioners ensure they commission services that review the treatment plans for people with depression that has not responded adequately to initial treatment within 6 to 8 weeks.
People with depression whose symptoms have not much improved 6 to 8 weeks after starting treatment have their treatment plan reviewed.

Definition

The term 'people with depression' includes all people with depression and a chronic physical health problem.

Source clinical guideline references

Recommendations on sequencing of treatments after initial inadequate response are contained within section 1.8 of NICE clinical guideline 90.

Data source

Structure
Local data collection.
Process
Local data collection.

Residual symptoms or risk of relapse

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice in depression care and should be read in full.

Quality statement

People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.

Quality measure

Structure
Evidence of local arrangements to provide appropriate psychological interventions to people who have been treated for depression who have residual symptoms or are at significant risk of relapse.
Process
Proportion of people who have been treated for depression who have residual symptoms or are at significant risk of relapse who receive appropriate psychological interventions.
Numerator – the number of people in the denominator receiving appropriate psychological interventions.
Denominator – the number of people who have been treated for depression who have residual symptoms or are at significant risk of relapse.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide appropriate psychological interventions for people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse.
Healthcare professionals ensure people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.
Commissioners ensure they commission services that provide appropriate psychological interventions for people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse.
People who have been treated for depression who have remaining symptoms or whose symptoms are likely to return receive further suitable psychological treatment.

Definitions

The term 'people who have been treated for depression' includes all people with a chronic physical health problem who have been treated for depression.
The term 'at significant risk of relapse' includes those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment.
People with depression are at risk of relapse if:
  • they have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
  • they have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response.
Appropriate psychological interventions for people at significant risk of relapse are:
  • individual cognitive behavioural therapy 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.

Source clinical guideline references

NICE clinical guideline 90 recommendation 1.9.1.8.

Data source

Structure
Local data collection.
Process
Local data collection.

Effective interventions library

Successful effective interventions library details

Implementation

Support for commissioners

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Commissioning stepped care for people with common mental health disorders: commissioning guide
Depression in adults with a chronic physical health problem: costing statement
Depression in adults: costing statement
Depression in children and young people: costing report
Depression in children and young people: costing template
Depression in adults quality standard: cost impact tool

Support for education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Depression in adults with a chronic physical health problem: education tool
Depression in adults: education tool
Depression in adults with a chronic physical health problem: slide set
Depression in adults: slide set
Depression in children and young people: slide set

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Depression in adults with a long-term physical health problem
Depression in adults
Depression in children and young people
Vagus nerve stimulation for treatment-resistant depression
Transcranial magnetic stimulation for severe depression
Depression in adults quality standard

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.

Updates to this pathway

18 January 2013 Minor maintenance updates
16 January 2012 A new commissioning guide: 'Commissioning stepped care for people with common mental health disorders' has been added to the implementation tool list, replacing the previous CBT commissioning guide.
4 November 2011 Minor maintenance updates
25 October 2011 Minor maintenance updates

Supporting information

Providing psychological therapies for children and young people

Ensure psychological therapies are provided by:
  • therapists who are also trained child and adolescent mental healthcare professionals
  • healthcare professionals who have been trained to an appropriate level of competence in the therapy being offered.
Develop a joint treatment alliance with the family. If this proves difficult consider providing the family with an alternative therapist.

Glossary

Child and adolescent mental health services
Child and adolescent psychiatric assessment
Cognitive behavioural therapy
Computerised cognitive behavioural therapy
Diagnostic and Statistical Manual of Mental Disorders
Electroconvulsive therapy
Health of the Nation Outcome Scales for Children and Adolescents
International Statistical Classification of Diseases and Related Health Problems (tenth edition)
Interpersonal therapy
Schedule for affective disorders and schizophrenia for school-age children
Monoamine oxidase inhibitor
Mood and feelings questionnaire
Few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment, according to DSM-IV.
Symptoms of depression or functional impairment are between mild and severe.
Non-steroidal anti-inflammatory drug
Primary care trust
Strengths and difficulties questionnaire
Most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.
Selective serotonin reuptake inhibitor
Fewer than 5 symptoms according to DSM-IV
Tricyclic antidepressant
Primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services.
Child and adolescent mental health services relating to workers in primary care including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists.
Specialised child and adolescent mental health services for more severe, complex or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community or inpatient), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists.
Tertiary-level child and adolescent mental health services such as day units, highly specialised outpatient teams and inpatient units.

Person with suspected depression

Person with suspected depression

Children and young people aged 5–17

Children and young people aged 5–17

Principles of care – children and young people

Principles of care

Principles of care

Good information, informed consent and support

Provide the child/young person and parent(s)/carer(s) with age-appropriate information at a suitable time. It should cover the nature, course and treatment of depression, and the likely side-effect profile of medication should this be offered.
Build a supportive and collaborative relationship with both the child/young person and family/carers.
Engage the child/young person and the parent(s)/carer(s) in treatment decisions so that they can give meaningful and properly informed consent before treatment starts.
Inform families and carers of self-help groups and support groups and encourage participation where appropriate.

Language and ethnic minorities

Provide the following in the language of the patient and their family/carers where possible:
  • written information (including information about medication and local services)
  • audiotaped material
  • psychological therapies.
Seek professional interpreters for those whose preferred language is not English.

Source guidance

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CG28

Care for children and young people

View the 'Care for children and young people with depression' path

Service organisation and training

Service organisation and training

Service organisation and training

Organisation and planning of services

CAMHS and PCTs should:
  • consider introducing a primary mental health worker (or CAMHS link worker) into each secondary school and secondary pupil referral unit as part of tier 2 provision within the locality
  • routinely monitor detection, referral and treatment rates of children/young people with mental health problems from all ethnic groups in local schools and primary care
  • use information about these rates to plan services, and make it available for local, regional and national comparison.
Primary mental health workers (or CAMHS link workers) should:
  • establish clear lines of communication between CAMHS and tier 1 and tier 2, with named contact people in each tier/service
  • develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2.
All healthcare professionals should:
  • routinely use, and record in the notes, appropriate outcome measures (e.g. HoNOSCA or SDQ), for assessing and treating depression in children/young people
  • use this information from outcome measures to plan services, and make it available for local, regional and national comparison.
Commissioners and strategic health authorities should ensure that:
  • inpatient treatment is available within reasonable travelling distance to enable family involvement and maintain social links
  • inpatient admission occurs within an appropriate time scale
  • immediate inpatient admission can be offered if necessary
  • inpatient services have a range of interventions available including:
    • medication
    • individual and group psychological therapies
    • family support
  • inpatient facilities are age appropriate and culturally enriching and can provide suitable educational and recreational activities.

Training and development

Managers of services need to ensure that training and development for healthcare professionals who are involved in the detection, recognition, assessment and treatment of children and young people with depression is available in the areas below. In particular, healthcare professionals specialising in depression in children and young people should work with local CAMHS to enhance specialist knowledge and skills. This work should include providing training and help with guideline implementation.

Detection and risk profiling – tier 1

Healthcare professionals in primary care, schools and other relevant community settings should be trained in:
  • detection of depressive symptoms and assessment of children/young people who may be at risk of depression. Training should include:
    • the evaluation of recent and past psychosocial risk factors, such as:
      • age
      • gender
      • family discord
      • bullying
      • physical, sexual or emotional abuse
      • history of parental depression
    • the natural history of single loss events
    • the importance of multiple risk factors
    • ethnic and cultural factors
    • factors known to be associated with a high risk of depression and other health problems such as:
      • homelessness
      • refugee status
      • living in institutional settings
  • developing ethnically and culturally sensitive systems for detecting, assessing, supporting and referring children and young people who are either depressed or at significant risk of depression
  • communications skills such as 'active listening' and 'conversational technique'.
In the provision of training by CAMHS professionals, give priority to the training of pastoral support staff in schools (particularly secondary schools), community paediatricians and GPs.
Healthcare professionals in primary care should be familiar with screening for mood disorders. They should have regular access to specialist supervision and consultation.

Recognition – tiers 2–4

Tier 2–4 CAMHS professionals should be trained in improving accuracy in diagnosing depressive conditions. Interviewer-based instruments (such as K-SADS and CAPA) could be used but will require modification for regular use in busy routine CAMHS settings.
Tier 3 CAMHS professionals who specialise in the treatment of depression should be trained in interviewer-based assessment instruments (such as K-SADS and CAPA) and have skills in nonverbal assessments of mood in younger children.

Inpatient care – tier 4

Tier 4 CAMHS professionals involved in assessing children/young people for possible inpatient admission should be specifically trained in:
  • issues of consent and capacity
  • use of current mental health legislation
  • use of childcare laws
as they apply to this group of patients.

Language and ethnic minorities – all tiers

Healthcare professionals in primary, secondary and relevant community settings should be trained in cultural competence to aid in the diagnosis and treatment of depression in children and young people from black and minority ethnic groups. (Training should consider the impact of the patient's and healthcare professional's racial identity status on the patient's depression.)
Healthcare professionals working with interpreters should be provided with joint training opportunities to ensure that both understand the specific requirements within a mental health setting.
Stakeholders (involving patients and their families and carers, including members of black and minority ethnic groups) should be involved in development and evaluation of services.

Source guidance

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Adults

Adults

Principles of care – adults

Principles of care

Principles of care

Information, support and consent

When working with people with depression and their families and carers:
  • build a trusting relationship and explore treatment options with hope and optimism, explaining the different courses of depression and that recovery is possible
  • be aware of possible stigma and discrimination associated with depression
  • ensure that confidentiality, privacy and dignity are respected
  • provide information about depression and its treatment, and about self-help groups, support groups and other resources
  • ensure that comprehensive written information is available in the appropriate language and in audio format if possible
  • provide independent interpreters if needed.
Be sensitive to diverse cultural, ethnic and religious backgrounds, and aware of possible variations in the presentation of depression. Ensure competence in:
  • culturally sensitive assessment
  • using different explanatory models of depression
  • addressing cultural and ethnic differences when developing and implementing treatment plans
  • working with families from diverse ethnic and cultural backgrounds.
Provide all interventions in the person's preferred language where possible.
Ensure that the person can give meaningful and informed consent before treatment starts, especially if they have severe depression or are subject to the Mental Health Act. Consent should be based on the provision of clear information (also provided in writing) covering:
  • what the intervention comprises
  • what is expected of the person while having it
  • likely outcomes (including side effects).

Supporting families and carers

When families or carers are involved in supporting a person with severe or chronicDepression is described as 'chronic' if symptoms have been present more or less continuously for 2 years or more. depression, consider:
  • providing written and verbal information on depression and how they can support the person
  • providing information about local family or carer support groups and voluntary organisations, and helping families or carers to access these
  • offering a carer's assessment
  • negotiating confidentiality and the sharing of information between the person and their family or carers.

Effective delivery of care

All interventions should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide their structure and duration. 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 treatment
  • monitor and evaluate treatment adherence and practitioner competence.

Additional considerations for people with a chronic physical health problem

If a person's care is shared between primary and secondary care, there should be clear agreement between practitioners (especially the person's GP) on the responsibility for monitoring and treating that person. Share the treatment plan with the person and (if appropriate) with their family or carer.
If a person's chronic physical health problem restricts their ability to engage with a psychosocial or psychological intervention for depression, discuss alternatives with the person, such as antidepressants or delivering the interventions by telephone if mobility or other difficulties prevent face-to-face contact.

Treatment based on depression subtype and personal characteristics

  • Do not routinely vary treatment strategies by depression subtype (for example, atypical depression or seasonal depression) or personal characteristics (for example, sex or ethnicity).
  • Advise people with winter depression who wish to try light therapy that the evidence for the efficacy of light therapy is uncertain.

Quality standards

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2Practitioner competence
3Recording health outcomes

Source guidance

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CG90
CG91

Care for adults

View the 'Care for adults with depression' path

Paths in this pathway

Pathway created: May 2011 Last updated: January 2013

Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.

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