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Step 4: Complex and severe depression in adults

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Depression

About

What is covered

This interactive flowchart 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.

Updates

Updates to this interactive flowchart

15 December 2015 Repetitive transcranial magnetic stimulation for depression (NICE interventional procedures guidance 542) added to treatment of severe or resistant depression, including inpatient care.
24 November 2015 Vortioxetine for treating major depressive episodes (NICE technology appraisal guidance 367) added to sequencing treatments after an inadequate response.
25 August 2015 Transcranial direct current stimulation (tDCS) for depression (NICE interventional procedures guidance 530) added to treatment of severe or resistant depression, including inpatient care.
5 March 2014 Agomelatine for the treatment of major depressive episodes (terminated appraisal) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on identifying, treating and managing depression in children, young people and adults in an interactive flowchart

What is covered

This interactive flowchart 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.

Updates

Updates to this interactive flowchart

15 December 2015 Repetitive transcranial magnetic stimulation for depression (NICE interventional procedures guidance 542) added to treatment of severe or resistant depression, including inpatient care.
24 November 2015 Vortioxetine for treating major depressive episodes (NICE technology appraisal guidance 367) added to sequencing treatments after an inadequate response.
25 August 2015 Transcranial direct current stimulation (tDCS) for depression (NICE interventional procedures guidance 530) added to treatment of severe or resistant depression, including inpatient care.
5 March 2014 Agomelatine for the treatment of major depressive episodes (terminated appraisal) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Depression in adults: recognition and management (2009 updated 2016) NICE guideline CG90
Vortioxetine for treating major depressive episodes (2015) NICE technology appraisal guidance 367
Repetitive transcranial magnetic stimulation for depression (2015) NICE interventional procedures guidance 542
Transcranial direct current stimulation (tDCS) for depression (2015) NICE interventional procedures guidance 530
Vagus nerve stimulation for treatment-resistant depression (2009) NICE interventional procedures guidance 330
Depression in adults (2011) NICE quality standard 8

Quality standards

Quality statements

Assessment

This quality statement is taken from the depression in adults quality standard. The quality standard defines clinical best practice for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendation 1.1.4.1 and NICE clinical guideline 91 recommendation 1.1.3.1 (key priorities for implementation).

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 considerations

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 for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1 (key priorities for implementation).

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 for depression in adults 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).

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 guidance

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

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 for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendations 1.4.2.1 and 1.4.3.1, and NICE clinical guideline 91 recommendation 1.4.2.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Equality and diversity considerations

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 for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendation 1.4.4.1 and NICE clinical guideline 91 recommendation 1.4.3.1 (key priorities for implementation).

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 for depression in adults 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 cognitive behavioural therapy or interpersonal therapy.

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).

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 guidance

NICE clinical guideline 90 recommendation 1.5.1.2 (key priority for implementation).

Data sources

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 for depression in adults 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.

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 guidance

NICE clinical guideline 91 recommendation 1.5.1.2 (key priority for implementation).

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 for depression in adults 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 cognitive behavioural therapy.

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.

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 guidance

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 for depression in adults 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.

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 guidance

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 for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendations 1.9.1.1 (key priority for implementation) 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 for depression in adults 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.

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 guidance

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 for depression in adults 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.

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.

Definitions

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

Source guidance

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 for depression in adults 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.

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 guidance

NICE clinical guideline 90 recommendation 1.9.1.8 (key priority for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

MHRA advice on valproate

Valproate treatment must not be used in girls and women including in young girls below the age of puberty, unless alternative treatments are not suitable and unless the conditions of the pregnancy prevention programme are met. Valproate must not be used in pregnant women. See also the MHRA toolkit to ensure female patients are better informed about the risks of taking valproate during pregnancy. Medicines containing valproate taken in pregnancy can cause malformations in 11% of babies and developmental disorders in 30–40% of children after birth.

Glossary

cognitive behavioural therapy
computerised cognitive behavioural therapy
diagnostic and Statistical Manual of Mental Disorders
electroconvulsive therapy
International Statistical Classification of Diseases and Related Health Problems (tenth edition)
interpersonal therapy
monoamine oxidase inhibitor
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
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

Paths in this pathway

Pathway created: May 2011 Last updated: June 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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