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Depression
Short Text
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.
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.
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.
Support for service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
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.
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 referred to specialist mental health services
Person referred to specialist mental health services
Principles of care
Principles of care
Principles of care
Assess a person referred to specialist mental health services, including:
- symptom profile, suicide risk, treatment history and comorbidities
- psychosocial stressors, personality factors and significant relationship difficulties, particularly if the depression is chronic or recurrent.
Consider reintroducing treatments that have been inadequately delivered or adhered to.
Use crisis resolution and home treatment teams to manage crises for people with severe depression who present significant risk, and to deliver high-quality acute care. Monitor risk in a way that allows people to continue their lives without disruption.
Medication in secondary care mental health services should be started under the supervision of a consultant psychiatrist.
Develop a multidisciplinary care plan with the person (and their family or carer if the person agrees) which:
- identifies the roles of all professionals involved
- includes a crisis plan that identifies potential crisis triggers and strategies to manage them
- is shared with the person, their GP and other relevant people.
For people with recurrent severe depression or depression with psychotic symptoms and for those who have been treated under the Mental Health Act, consider developing advance decisions and advance statements with the person. Include copies in the person's care plan in primary and secondary care. Give copies to the person and to their family or carer, if the person agrees.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAdditional consideration
Additional consideration for people with a chronic physical health problem
Additional consideration for people with a chronic physical health problem
When treating people with complex and severe depression and a chronic physical health problem in specialist mental health services, work closely with physical health services and be aware of possible additional drug interactions.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInpatient care
Treatment of severe or resistant depression, including inpatient care
Treatment of severe or resistant depression, including inpatient care
Consider inpatient treatment for people who are at significant risk of suicide, self-harm or self-neglect.
The full range of high-intensity psychological interventions should normally be offered in inpatient settings. However, consider increasing the intensity and duration of the interventions and ensure that they can be provided effectively and efficiently on discharge.
Electroconvulsive therapyThe recommendations on ECT update the depression aspects only of 'Guidance on the use of electroconvulsive therapy' (NICE technology appraisal guidance 59)
Consider ECT for severe, life-threatening depression and when a rapid response is required, or when other treatments have failed.
Do not use ECT routinely for people with moderate depression but consider it if their depression has not responded to multiple treatments.
Ensure the person is fully informed of the risks and benefits associated with having ECTThe risks may be greater in older people; consider ECT with caution in this group.. Document the assessment and consider:
- the risks associated with a general anaesthetic
- medical comorbidities
- potential adverse events, notably cognitive impairment
- the risks associated with not receiving ECT.
Make the decision to use ECT jointly with the person if possible, taking into account the Mental Health Act 2007. Also:
- obtain valid informed consent without pressure or coercion
- remind the person of their right to withdraw consent at any point
- adhere to recognised guidelines about consent and involve advocates or carers
- if informed consent is not possible, give ECT only if it does not conflict with a valid advance directive, and consult the person's advocate or carer.
For people whose depression has not responded well to a previous course of ECT, consider a repeat trial of ECT only after:
- reviewing the adequacy of the previous treatment course and
- considering all other options and
- discussing the risks and benefits with the person and/or, where appropriate, their advocate or carer.
The choice of electrode placement and stimulus dose related to seizure threshold should balance efficacy against the risk of cognitive impairment. Take into account that:
- bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment
- with unilateral ECT, a higher stimulus dose is associated with greater efficacy, but also increased cognitive impairment compared with a lower stimulus dose.
Assess clinical status after each ECT treatment using a formal valid outcome measure, and stop treatment when remission has been achieved, or sooner if side effects outweigh the potential benefits.
Assess cognitive function before the first ECT treatment and monitor at least every three to four treatments, and at the end of a course of treatment.
Assessment of cognitive function should include:
- orientation and time to reorientation after each treatment
- measures of new learning, retrograde amnesia and subjective memory impairment carried out at least 24 hours after a treatment.
If there is evidence of significant cognitive impairment at any stage consider, in discussion with the person with depression, changing from bilateral to unilateral electrode placement, reducing the stimulus dose or stopping treatment depending on the balance of risks and benefits.
If a person's depression has responded to a course of ECT, antidepressant medication should be started or continued to prevent relapse. Consider lithium augmentation of antidepressants.
NICE interventional procedures guidance
NICE interventional procedures guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use.
Transcranial magnetic stimulation for severe depression
Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure's clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors.
Future research should aim to address patient selection criteria, the optimal use of this procedure in relation to other treatments, and the duration of any treatment effect. Clinicians should collaborate to ensure that studies are sufficiently large to be adequately powered. The Institute may review the procedure upon publication of further evidence.
These recommendations are from Transcranial magnetic stimulation for severe depression (NICE interventional procedure guidance 242).
NICE has produced a booklet for patients and carers explaining this guidance.
Vagus nerve stimulation for treatment-resistant depression
Current evidence on the safety and efficacy of vagus nerve stimulation (VNS) for treatment-resistant depression is inadequate in quantity and quality. Therefore this procedure should be used only with special arrangements for clinical governance, consent and audit or research. It should be used only in patients with treatment-resistant depression.
Clinicians wishing to undertake VNS for treatment-resistant depression should take the following actions.
- Inform the clinical governance leads in their Trusts.
- Ensure that patients and/or their parents/carers understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. In addition, the use of NICE's information for the public is recommended.
- Audit and review clinical outcomes of all patients having VNS for treatment-resistant depression (see audit support tool).
- Patient selection and management should be carried out by a multidisciplinary team including a psychiatrist and a surgeon (usually a neurosurgeon), with other relevant specialists (for example, a clinical psychologist and an appropriately trained technician).
NICE encourages further research into VNS for treatment-resistant depression. Research outcomes should include depression rating scales, objective measures of depressive symptoms and patient-reported quality of life. NICE may review the procedure on publication of further evidence.
These recommendations are from Vagus nerve stimulation for treatment-resistant depression (NICE interventional procedures guidance 330).
Implementation tools
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Using crisis resolution and home treatment on discharge
Using crisis resolution and home treatment on discharge
Consider crisis resolution and home treatment teams for people who might benefit from early discharge from hospital.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePharmacological management of depression with psychotic symptoms
Pharmacological management of depression with psychotic symptoms
Pharmacological management of depression with psychotic symptoms
For people who have depression with psychotic symptoms, consider augmenting their treatment plan with antipsychotic medication.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Care for children and young people with depression
- Depression in children and young people: recognition, detection, risk profiling and referral
- Management of mild depression in children and young people – tiers 1 and 2
- Management of moderate to severe (including psychotic) depression in children and young people – tiers 2–4
- Using antidepressants in children and young people
- Transfer to adult services from CAMHS
- Care for adults with depression
- Step 1: Recognition, assessment and initial management of depression in adults
- Step 2: Recognised depression in adults – persistent subthreshold depressive symptoms or mild to moderate depression
- Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression in adults
- Antidepressant treatment in adults
- Continuation and relapse prevention for adults with depression
- Step 4: Complex and severe depression in adults
Pathway created: May 2011 Last updated: January 2013
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