NICE: avoid antidepressants as first treatment for less-severe depression

Updated NICE guidance on depression includes new recommendations on antidepressants for less-severe depression, further-line treatment and relapse prevention, and advice on stopping the drugs.

A group of people sit in a circle at a group counselling session.
Group and individual talking therapies can be effective for less-severe depression. | GETTY IMAGES

NICE has published a new guideline on the treatment and management of depression in adults, updating and replacing its 2009 guideline.

Less-severe depression

The 2022 guideline reclassifies depression as 'less severe' and 'more severe', to avoid the ambiguity of the overlapping previous categories 'mild to moderate' and 'moderate to severe'. Less-severe depression covers mild and sub-threshold depression and more-severe depression includes moderate and severe cases.

For less-severe depression, NICE emphasises that psychological treatments - rather than antidepressant medication - should usually be offered first, unless the patient prefers medication. Psychological treatment options suggested by NICE are: guided self-help, group or individual cognitive behavioural therapy (CBT), group or individual behavioural activation, group exercise, group mindfulness and meditation, interpersonal psychotherapy, counselling, and short-term psychodynamic psychotherapy.

For more-severe depression, NICE suggests: CBT combined with an antidepressant, individual CBT, individual behavioural activation, an antidepressant alone, individual problem-solving, counselling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

Further-line treatment

If there is no response to 4 weeks of antidepressant treatment or 4–6 weeks of psychological therapy (or combined medication and psychological therapy), NICE says the prescriber should discuss with the patient whether there are any factors that might explain why the treatment is not working, and ask whether they are finding it difficult to adhere to the treatment plan.

If no obvious issue can be found and resolved, options suggested by the guideline for patients started on psychological therapy alone are: switching to an alternative psychological therapy, adding an SSRI to psychological therapy, or switching to an SSRI alone. For patients started on antidepressants alone, options suggested are: adding a group exercise intervention, switching to a psychological therapy, switching or increasing the dose of antidepressant, or combining psychological therapy with antidepressant treatment.

For patients started on combined antidepressant and psychological therapy, the options are either switching or increasing the dose of antidepressant or an switching to a different psychological therapy.

Combination treatment with a second antidepressant can be considered if the patient is willing to accept the possibility of an increased side-effect burden. Referral to a specialist is recommended.

Preventing relapse

Antidepressants should usually be continued for at least 6 months after remission of symptoms. For people at higher risk of relapse, such as those with a history of recurrent or severe depression, an incomplete response to previous treatment, or ongoing contributing factors (such as other chronic illness, poverty or isolation), NICE says prescribers can consider continuing antidepressants, switching to psychological therapy, or prescribing a course of psychological therapy in addition to antidepressants. Antidepressant treatment should be reviewed at least every 6 months.

The choice to continue antidepressant medication should be made as a shared decision with the patient, based on discussion of the risk of relapse, possible side-effects of the drugs (such as an increased bleeding risk or long-term effects on sexual function) and the risk of difficulty stopping antidepressants.

Stopping antidepressants

The guideline says prescribers should explain to patients that it is usually necessary to reduce the dose of their antidepressant gradually but that most people stop treatment successfully. Patients should be warned about withdrawal symptoms (such as dizziness, altered feelings, agitation and insomnia), which can be mild and tend to disappear within 1–2 weeks, but can in some cases be more severe or long-lasting.

When stopping an antidepressant, prescribers should take into account the drug's pharmacokinetic profile (antidepressants with a short half-life need to be tapered more slowly) and duration of treatment. The dose should be slowly reduced to zero, by prescribing a proportion of the previous dose (eg, 50%) at each step, and considering smaller reductions (eg, 25%) as the dose becomes lower. If slow tapering cannot be achieved using tablets or capsules, liquid preparations can be considered.

If mild withdrawal symptoms occur, the patient should be reassured that these are common and do not reflect a relapse of their depression. If symptoms are severe, it may be necessary to restart the drug at the previous dose, and re-attempt tapering at a slower rate after symptoms have resolved.

The guideline recommends particular care is taken when stopping antidepressants such as paroxetine and venlafaxine, which are more likely to be associated with withdrawal symptoms. It notes that rapid tapering may be possible when switching to a different antidepressant. MIMS provides a table of guidance on switching and withdrawing antidepressants, summarised from the 14th edition of the Maudsley Prescribing Guidelines in Psychiatry.

Serotonin theory

Following publication of the NICE guidance, an umbrella 'review of reviews' has thrown further doubt on the serotonin or 'chemical imbalance' theory of depression, which the authors argue has  provided a justification for the use of antidepressants. 

However, other researchers pointed out that the serotonin theory of depression is no longer current thinking, and that use of antidepressants is based on their efficacy in clinical trials. 

Responding to the review, a spokeperson for the Royal College of Psychiatrists said: 'Antidepressants are an effective, NICE-recommended treatment for depression that can also be prescribed for a range of physical and mental health conditions.

'Treatment options such as medication and talking therapy play an important role in helping many people with depression and can significantly improve people’s lives. Antidepressants will vary in effectiveness for different people, and the reasons for this are complex, which is why it’s important that patient care is based on each individual’s needs and reviewed regularly.

'Continued research into treatments for depression is important to help us better understand how medications work as well as their effectiveness. Medication should be available for anyone who needs it. We would not recommend for anyone to stop taking their antidepressants based on this review, and encourage anyone with concerns about their medication to contact their GP.'

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