Avoid routinely offering antidepressants for 'less severe' depression, says NICE in draft guidance

Reviewing its depression guidance for the first time since 2009, NICE recommends that people with 'less severe' depression should be offered a non-pharmacological therapy as first-line treatment.

Moderate intensity aerobic exercise has been shown to have beneficial effects on mental health as well as physical health. | GETTY IMAGES
Moderate intensity aerobic exercise has been shown to have beneficial effects on mental health as well as physical health. | GETTY IMAGES

The draft guidance, out for consultation until January 12, 2022, covers the identification, treatment and management of depression in adults. Expected to be published in May 2022, it will update and replace the current NICE guideline (CG90, October 2009).

As part of the review process the guidelines committee considered the available evidence on the treatment of new depressive episodes, further-line treatment, treatment of chronic or psychotic depression, or depression with a co-existing diagnosis of personality disorder, as well as prevention of relapse, patient choice and the organisation of and access to services.

Non-pharmacological options first-line

The draft guidance recommends that people with a new episode of 'less severe' depression (covering the traditional categories of sub-threshold symptoms and mild depression) should be offered non-pharmacological treatments such as cognitive behavioural therapy (CBT), exercise, psychotherapy or counselling as first-line options. Antidepressants should not be routinely offered as first-line treatment unless the person expresses a preference for drug therapy.

Combined treatment

NICE states that people suffering with 'more severe' depression (covering the traditional moderate to severe categories) could also be offered these non-pharmacological treatments with the added option of antidepressant therapy. It adds that there is 'good evidence' for the effectiveness and cost-effectiveness of antidepressants (SSRIs, SNRIs, TCADs and mirtazapine) and for the cost-effectiveness of combining CBT with antidepressants.

Data from the Office of National Statistics cited by NICE shows that the incidence of depression in Great Britain has increased since before the COVID-19 pandemic with 17% of people aged 16 and over having experienced some form of depression during summer 2021 compared with 10% during the nine-month period preceding the pandemic.

NICE centre for guidelines director Dr Paul Chrisp said: 'The COVID-19 pandemic has shown us the impact depression has had on the nation’s mental health. People with depression need these evidence-based guideline recommendations available to the NHS, without delay.'

Withdrawing antidepressants

The draft guidance also provides advice for healthcare professionals on stopping antidepressant medication, saying that they should discuss the benefits and risks of stopping medication with patients, and warn that 'withdrawal may take weeks or months to complete successfully' and will likely need to be tapered down gradually but that 'most people stop antidepressants successfully'.

Commenting on the draft guidance, Nav Kapur, professor of psychiatry and population health at the University of Manchester and chair of the guideline committee said: 'As a committee, we have drawn up recommendations that we hope will have a real impact on people who are suffering from depression, and their carers.'

'In particular, we’ve emphasised the role of patient choice — suggesting that practitioners should offer people a choice of evidence-based treatments and understanding that not every treatment will suit every person.'

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