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Persistent
ersistent subthreshold depressiv
depressive e
symptoms or mild to moder
moderate
ate depression with
inadequate response to initial interv
interventions,
entions, and
moder
moderate
ate and sesevvere depression in adults
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/depression
NICE Pathway last updated: 24 April 2018
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
Depression Page 1 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Depression Page 2 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
No additional information
2 Treatment options
Choosing treatments
For people with persistent subthreshold depressive symptoms or mild depression to moderate
depression who have not benefited from a low-intensity psychosocial intervention, discuss
different interventions with the person and provide:
IPT
behavioural activation (but note that the evidence is less robust than for CBT or
IPT)
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.
Depression Page 3 of 14
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1
Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in
treating depression.
Depression Page 4 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
For people with moderate or severe depression, combine antidepressants with a high-intensity
psychological intervention (CBT or IPT).
For people with persistent subthreshold depressive symptoms or mild to moderate depression
who have not benefited from a low-intensity psychosocial intervention, provide an
antidepressant (normally an SSRI) or one of the following high-intensity psychological
interventions:
group-based CBT or
individual CBT (if group-based CBT is declined, not appropriate or 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.
For people with initial presentation of moderate depression, offer group-based CBT, individual
CBT or behavioural couples therapy.
For people with severe depression, consider offering both individual CBT and an
antidepressant.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Depression in adults
Depression Page 5 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Individual CBT
For moderate or severe depression, consider 2 sessions per week for the first 2–3 weeks.
IPT
For severe depression, consider 2 sessions per week for the first 2–3 weeks.
Behavioural activation
For moderate or severe depression, consider 2 sessions per week for the first 3–4 weeks.
Group-based CBT
Typically deliver in groups of 6–8 people with a common physical health problem, over 6–8
weeks.
1
Duration of interventions can be tailored to individual circumstances.
Depression Page 6 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Individual CBT
6–8 weeks (no longer than 16–18 weeks) for moderate depression plus 2 follow-up
sessions in the next 6 months
16–18 weeks for severe depression plus 2 or 3 follow-up sessions in the next 12 months;
offer twice-weekly sessions for the first 2–3 weeks focusing on behavioural activation.
4 Antidepressant treatment
For people with moderate or severe depression without a chronic physical health problem,
combine antidepressants with a high-intensity psychological intervention (CBT or IPT).
For people with severe depression and a chronic physical health problem, consider offering both
individual CBT and an antidepressant.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Depression in adults
Depression Page 7 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
No additional information
See Depression / Continuation and relapse prevention for adults with depression
Enhanced care
Do not routinely provide medication management as a separate intervention for people with
depression.
For people with severe depression, or with moderate depression and complex problems,
consider referring to specialist mental health services for a programme of coordinated
multiprofessional care.
If a person with long-standing moderate or severe depression would benefit from additional
social or vocational support, consider:
Consider collaborative care for people with moderate to severe depression and a chronic
physical health problem with associated functional impairment whose depression has not
Depression Page 8 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Depression in adults
9. Collaborative care
Depression Page 9 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Glossary
CAMHS
CAPA
CBT
CCBT
DSM-IV
ECT
electroconvulsive therapy
HoNOSCA
ICD-10
International Statistical Classification of Diseases and Related Health Problems (tenth edition)
IPT
interpersonal therapy
K-SADS
Depression Page 10 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
MAOI
MFQ
Mild depression
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
Moderate depression
NSAID
SDQ
Severe depression
most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms
SSRI
TCA
tricyclic antidepressant
Depression Page 11 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
Tier 1
primary care services including GPs, paediatricians, health visitors, school nurses, social
workers, teachers, juvenile justice workers, voluntary agencies and social services
Tier 2
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
Tier 3
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
Tier 4
tertiary-level child and adolescent mental health services such as day units, highly specialised
outpatient teams and inpatient units
Sources
Depression in adults with a chronic physical health problem: recognition and management
(2009) NICE guideline CG91
Depression in adults: recognition and management (2009 updated 2016) NICE guideline CG90
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
Depression Page 12 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
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.
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.
Depression Page 13 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.
Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults
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.
Depression Page 14 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.