Depression THE NICE GUIDELINE ON THE TREATMENT AND MANAGEMENT OF DEPRESSION IN ADULTS UPDATED EDITION DEPRESSION THE TREATMENT AND MANAGEMENT OF DEPRESSION IN ADULTS (UPDATED EDITION) National Clinical Practice Guideline 90 National Collaborating Centre for Mental Health commissioned by the National Institute for Health & Clinical Excellence published by The British Psychological Society and The Royal College of Psychiatrists © The British Psychological Society & The Royal College of Psychiatrists, 2010 The views presented in this book do not necessarily reflect those of the British Psychological Society, and the publishers are not responsible for any error of omission or fact. The British Psychological Society is a registered charity (no. 229642). All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN: 978-1-904671-85-5 Printed in Great Britain by Stanley Hunt. Additional material: data CD-Rom created by Pix18 (www.pix18.co.uk) developed by National Collaborating Centre for Mental Health The Royal College of Psychiatrists 4th Floor, Standon House 21 Mansell Street London E1 8AA www.nccmh.org.uk commissioned by National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn London WCIV 6NA www.nice.org.uk published by The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpsych.ac.uk CONTENTS GUIDELINE DEVELOPMENT GROUP MEMBERS 7 ACKNOWLEDGEMENTS 10 1 PREFACE 11 1.1 National guidelines 11 1.2 The national depression guideline 14 2 DEPRESSION 17 2.1 The disorder 17 2.2 Aetiology 25 2.3 Economic costs of depression 26 2.4 Treatment and management in the National Health Service 28 3 METHODS USED TO DEVELOP THIS GUIDELINE 34 3.1 Overview 34 3.2 The scope 34 3.3 The Guideline Development Group 35 3.4 Clinical questions 37 3.5 Systematic clinical literature review 38 3.6 Health economics methods 47 3.7 Methods for reviewing experience of care 49 3.8 Stakeholder contributions 51 3.9 Validation of the guideline 51 4 EXPERIENCE OF CARE 52 4.1 Introduction 52 4.2 Personal accounts – people with depression 52 4.3 Personal accounts – carers 68 4.4 Qualitative analysis 71 4.5 Review of the qualitative literature 83 4.6 From evidence to recommendations 86 4.7 Recommendations 94 5 CASE IDENTIFICATION AND SERVICE DELIVERY 97 5.1 Introduction 97 5.2 The identification of depression in primary care and community settings 98 5.3 Service delivery systems in the treatment and management of depression 121 5.4 Stepped care 124 5.5 Collaborative care 129 Contents 3 5.6 Medication management 141 5.7 Crisis resolution and home treatment teams 146 5.8 Acute day hospital care 149 5.9 Non-acute day hospital care 151 5.10 Non-statutory support 153 5.11 Research recommendation 155 6 INTRODUCTION TO PSYCHOLOGICAL AND PSYCHOSOCIAL INTERVENTIONS 157 6.1 Introduction 157 6.2 Recommending psychological and psychosocial treatments 157 6.3 How do psychological and psychosocial interventions become evidence based? 158 6.4 Contextual factors that impact on clinical practice 164 6.5 Databases searched and inclusion/exclusion criteria 168 6.6 Studies considered 168 7 LOW-INTENSITY PSYCHOSOCIAL INTERVENTIONS 170 7.1 Computerised cognitive behavioural therapy 170 7.2 Guided self-help 181 7.3 Physical activity programmes 190 7.4 From evidence to recommendations – low-intensity psychosocial interventions 212 7.5 Recommendations 213 8 HIGH-INTENSITY PSYCHOLOGICAL INTERVENTIONS 215 8.1 Cognitive behavioural therapies 215 8.2 Behavioural activation 238 8.3 Problem solving 242 8.4 Couples therapy 246 8.5 Interpersonal therapy 249 8.6 Counselling 261 8.7 Short-term psychodynamic psychotherapy 267 8.8 Rational emotive behavioural therapy 272 8.9 Economic modelling 274 8.10 From evidence to recommendations 291 8.11 Recommendations 296 8.12 Research recommendations 300 9 INTRODUCTION TO PHARMACOLOGICAL AND PHYSICAL INTERVENTIONS 304 9.1 Introduction 304 9.2 Dose and duration of antidepressant treatment: evidence from clinical practice 306 9.3 Limitations of the literature: problems with randomised controlled trials in pharmacology 308 9.4 Studies considered for review – additional inclusion criteria 309 Contents 4 9.5 Issues and topics covered by this review 311 9.6 Placebo-controlled randomised controlled trials of antidepressants 313 9.7 Selective serotonin reuptake inhibitors versus placebo 315 9.8 Tricyclic antidepressants versus placebo 319 9.9 From evidence to recommendations 326 9.10 Recommendation 327 10 PHARMACOLOGICAL INTERVENTIONS 328 10.1 Introduction 328 10.2 Use of individual drugs in the treatment of depression 329 10.3 Tricyclic antidepressants 330 10.4 Selective serotonin reuptake inhibitors 336 10.5 Escitalopram 341 10.6 The thread study 354 10.7 Monoamine oxidase inhibitors 354 10.8 Third-generation antidepressants 360 10.9 St John’s wort 387 10.10 Health economics evidence 391 10.11 Network meta-analysis of newer antidepressants 398 10.12 Economic model for the cost-effectiveness of pharmacological interventions for people with depression 399 10.13 From evidence to recommendations 411 10.14 Clinical practice recommendations 412 10.15 When to change antidepressant treatment when symptoms of depression are not improving 413 11 FACTORS INFLUENCING CHOICE OF ANTIDEPRESSANTS 418 11.1 Introduction 418 11.2 The pharmacological management of depression in older adults 418 11.3 The effect of sex on antidepressant choice 424 11.4 The pharmacological management of depression with psychotic symptoms 425 11.5 The pharmacological management of atypical depression 427 11.6 The physical and pharmacological management of depression with a seasonal pattern 430 11.7 Dosage issues for tricyclic antidepressants 451 11.8 Antidepressant discontinuation symptoms 453 11.9 The cardiotoxicity of antidepressants 457 11.10 Depression, antidepressants and suicide 462 12 THE PHARMACOLOGICAL AND PHYSICAL MANAGEMENT OF DEPRESSION THAT HAS NOT ADEQUATELY RESPONDED TO TREATMENT, AND RELAPSE PREVENTION 466 12.1 Introduction 466 12.2 Approach to the reviews 467 12.3 Pharmacological ‘next-step’ treatment for depression that has not adequately responded to treatment 469 Contents 5 12.4 Electroconvulsive therapy 508 12.5 Other non-pharmacological physical treatments 528 12.6 The pharmacological management of relapse prevention 530 13 THE MANAGEMENT OF SUBTHRESHOLD DEPRESSIVE SYMPTOMS 536 13.1 Introduction 536 13.2 Pharmacological interventions for subthreshold depressive symptoms and persistent subthreshold depressive symptoms (dysthymia) 537 13.3 Psychological and other strategies for the treatment of persistent subthreshold depressive symptoms (dysthymia) 555 13.4 From evidence to recommendations 563 13.5 Recommendations 564 13.6 Research recommendation 564 14 SUMMARY OF RECOMMENDATIONS 565 14.1 Care of all people with depression 565 14.2 Stepped care 567 14.3 Step 1: recognition, assessment and initial management 568 14.4 Step 2: recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression 569 14.5 Step 3: persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression 571 14.6 Treatment choice based on depression subtypes and personal characteristics 576 14.7 Enhanced care for depression 576 14.8 Sequencing treatments after initial inadequate response 577 14.9 Continuation and relapse prevention 579 14.10 Step 4: complex and severe depression 582 14.11 Research recommendations 585 15 APPENDICES 591 16 REFERENCES 647 17 ABBREVIATIONS 696 Contents 6 GUIDELINE DEVELOPMENT GROUP MEMBERS Professor Ian Anderson (Chair, Guideline Development Group) Professor of Psychiatry, University of Manchester Professor Stephen Pilling Director, National Collaborating Centre for Mental Health Director, Centre for Outcomes Research and Effectiveness, University College London Ms Alison Barnes Service User Member Ms Linda Bayliss Research Assistant (May 2008 to August 2008), National Collaborating Centre for Mental Health Ms Victoria Bird Research Assistant, National Collaborating Centre for Mental Health Ms Rachel Burbeck Lead Systematic Reviewer, National Collaborating Centre for Mental Health Dr Carolyn Chew-Graham General Practitioner and Senior Lecturer in Primary Care, University of Manchester Mr Jeremy Clarke Psychological Therapist, Lambeth Primary Care Trust Mr Matthew Dyer Health Economist, National Collaborating Centre for Mental Health Ms Esther Flanagan Project Manager (2009), National Collaborating Centre for Mental Health Ms Catherine Harris Carer member and Local Councillor Ms Sarah Hopkins Project Manager (until 2008), National Collaborating Centre for Mental Health Guideline Development Group members 7 Dr Mark Kenwright Consultant Cognitive Behavioural Psychotherapist, Ealing Cognitive Behavioural Therapy Service Professor Willem Kuyken Professor of Clinical Psychology and Co-Director, Mood Disorders Centre, School of Psychology, University of Exeter Ms Angela Lewis Research Assistant, National Collaborating Centre for Mental Health Professor Glyn Lewis Professor of Psychiatric Epidemiology, University of Bristol Mr Ryan Li Project Manager (2008), National Collaborating Centre for Mental Health Mr Brendan Masterson Clinical Nurse Leader, Affective Disorders Unit, Bethlem Royal Hospital Dr Nick Meader Systematic Reviewer, National Collaborating Centre for Mental Health Mr Alan Meudell Service User Member, Healthy Minds at Work Dr Alex Mitchell Consultant Psychiatrist and Honorary Lecturer in Liaison Psychiatry, University of Leicester Dr Richard Moore Clinical Psychologist, Cambridge and Peterborough NHS Foundation Trust Dr Suffiya Omarjee Health Economist, National Collaborating Centre for Mental Health Ms Carol Paton Chief Pharmacist, Oxleas NHS Foundation Trust Dr Alejandra Perez Systematic Reviewer, National Collaborating Centre for Mental Health Ms Peny Retsa Health Economist (until 2008), National Collaborating Centre for Mental Health Guideline Development Group members 8 Ms Maria Rizzo Research Assistant, National Collaborating Centre for Mental Health Ms Jennie Robertson Research Assistant (from September 2008), National Collaborating Centre for Mental Health Mr Rob Saunders Research Assistant (2008), National Collaborating Centre for Mental Health Ms Christine Sealey Centre Manager, National Collaborating Centre for Mental Health Ms Beth Shackleton Project Manager (until 2008), National Collaborating Centre for Mental Health Dr Thomas Shackleton General Practitioner, Suffolk Ms Sarah Stockton Senior Information Scientist, National Collaborating Centre for Mental Health Dr Clare Taylor Editor, National Collaborating Centre for Mental Health Ms Jane Wood Nurse, Strategic Development Manager, Mental Health, Leeds Primary Care Trust Guideline Development Group members 9 [...]... responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with depression or their carer In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations in clinical guidelines While national guidelines are concerned with clinical and. .. guideline The guideline makes recommendations for the treatment and management of depression It aims to: ● improve access and engagement with treatment and services for people with depression ● evaluate the role of specific psychological and psychosocial interventions in the treatment of depression ● evaluate the role of specific pharmacological interventions in the treatment of depression ● evaluate the. .. focus, the concerns of people with depression and their carers regarding health and social care have been highlighted and addressed by recommendations agreed by the whole GDG 3.2 THE SCOPE NICE commissioned the NCCMH to review recent evidence on the management of depression and to update the existing guideline Depression: Treatment and Management of Depression in Primary and Secondary Care (NICE, 2004a;... 17 Depression degrees of depression (for example, major depression) and those occurring ‘normally’ remains problematic and it is best to consider the symptoms of depression as occurring on a continuum of severity (Lewinsohn et al., 2000) The identification of major depression is based not only on its severity but also on persistence, the presence of other symptoms, and the degree of functional and. .. recommendations for the management of conditions and disorders by healthcare professionals ● be used as the basis to set standards to assess the practice of healthcare professionals ● form the basis for education and training of healthcare professionals ● assist people with depression and their carers in making informed decisions about their treatment and care ● improve communication between healthcare professionals,... (**_**) The previous guideline and this update have been developed to advise on the treatment and management of depression The guideline recommendations in the update have been developed by a multidisciplinary team of healthcare professionals, people with depression, a carer and guideline methodologists after careful consideration of the best available evidence It is intended that the guideline will... role of specific service-level interventions for people with depression ● integrate the above to provide best-practice advice on the care of people with depression and their family and carers ● promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales 1.2.4 The structure of this guideline The guideline. .. production of national clinical practice guidelines focused upon the overall treatment and management of a specific condition To enable this latter development, NICE originally established seven National Collaborating Centres in conjunction with a range of professional organisations involved in healthcare 1.1.4 The National Collaborating Centre for Mental Health This guideline has been commissioned by NICE. .. GDG received training in the process of guideline development from NCCMH staff, and the people with depression and the carer received training and support from the NICE Patient and Public Involvement Programme The NICE Guidelines Technical Adviser provided advice and assistance regarding aspects of the guideline development process All GDG members made formal declarations of interest at the outset, which... assessment and 29 Depression the subsequent co-ordination of their care (through the use of the Care Programme Approach [CPA] in secondary care services), is highly likely to improve outcomes and should, therefore, be comprehensive 2.4.3 Aim, and non-specific effects, of treatment and the placebo The aim of intervention is to restore health through the relief of symptoms and restoration of function and, in the . Depression THE NICE GUIDELINE ON THE TREATMENT AND MANAGEMENT OF DEPRESSION IN ADULTS UPDATED EDITION DEPRESSION THE TREATMENT AND MANAGEMENT OF DEPRESSION IN ADULTS (UPDATED EDITION) National. The guideline recognises the role of both in the treatment and support of people with depression. 1.2.3 Specific aims of this guideline The guideline makes recommendations for the treatment and. interventions in the treatment of depression ● evaluate the role of specific pharmacological interventions in the treatment of depression ● evaluate the role of specific service-level interventions