What is the new evidence?
NICE has recently published two new guidelines on depression developed by the National Collaborating Centre for Mental Health: Depression: the treatment and management of depression in adults (London: NICE, 2009; available at www.nice.org.uk/CG90) and Depression in adults with a chronic physical health problem: treatment and management (London: NICE, 2009; available at www.nice.org.uk/CG91). Both guidelines constitute an update of the 2004 NICE guideline on depression, which was amended in 2007 (available at www.nice.org.uk/CG23). It also updates recommendations for the treatment of depression included in the NICE technology appraisal of electroconvulsive therapy (www.nice.org.uk/TA59) and in a NICE review of its technology appraisal of computerised cognitive behavioural therapy (CCBT) for depression and anxiety (www.nice.org.uk/TA97).
A guideline on depression in people with a chronic physical health problem was developed because of the specific needs of that population, such as the challenges in identifying depression in people with long-term medical conditions, the uncertainties surrounding the use of antidepressants (in particular drug interactions) and engaging them in treatment. There were also some uncertainties concerning the application of evidence derived from studies of the non-physically ill to those with depression and a chronic health problem.
Why is this evidence significant?
The new guideline on depression in adults with a chronic physical health problem is significant because it seeks to improve recognition of depression, alleviate the increased burden of having both a chronic physical health problem comorbid with depression, and enhance care for this patient group by improving access to evidence-based treatments, including pharmacological and psychological interventions. This is important as depression is associated with both increased morbidity and mortality in people with chronic physical health problems.
Both guidelines cover the treatment and management of subthreshold depressive symptoms (including dysthymia), which were not part of the scope of the previous guideline. Such symptoms can be disabling if they are persistent and complicate the care of the physical health problem. For persistent subthreshold depressive symptoms and mild to moderate depression, and for subthreshold symptoms that complicate the care of the physical health problem, both guidelines promote low-intensity psychosocial interventions. Such interventions include structured group physical activity programmes, individual guided self-help, computerised cognitive behavioural therapy and group-based peer support programmes. These interventions are less intensive than formal psychological interventions and can be accessed more readily and in a more flexible manner.
For people with depression and a chronic physical health problem guideline there is important clarification about drug interactions for people taking an antidepressant and medication for their physical illness.
What does it add to knowledge we already have? What is current practice and how might this evidence change that?
Although the prevalence of depression is increased in people with a chronic physical health problem, it remains under-recognised in that patient group. The guideline provides the means to improve the detection of depression through use of a number of case identification questions. The guidelines also reinforce the value of a range of low intensity interventions, for mild to moderate depression, for people with depression including those with chronic physical health problems. The nature and flexibility of low intensity interventions make them suitable for use in a range of different settings including secondary care and by different modes of delivery (e.g. the telephone). The guidelines also provide helpful advice on drug interactions which should lead to more effective use of antidepressants (there has been concern about inadequate doses of drugs being used because of concerns about interactions)
The guidelines promote the use of high-quality, well-monitored high-intensity psychological interventions (CBT, IPT, behavioural activation and couples therapy; or CBT or couples therapy for people with a chronic physical health problem). Counselling and short-term psychodynamic psychotherapy are identified as limited options for people who decline an antidepressant or a high-intensity psychological intervention , but the guideline makes it clear that healthcare professionals should discuss with the patient the uncertainty of the effectiveness of counselling and short-term psychodynamic psychotherapy in treating depression. In the new guidelines there is a strong emphasis on the use of routine outcome monitoring and supervision to ensure interventions are delivered competently;, while this is important for both psychological and pharmacological interventions it is particularly important for the former.
The guidelines also carefully reviewed the evidence for collaborative care and recommended that its use should be reserved for chronic physical health problems and moderate to severe depression which has not responded to initial high intensity psychological interventions, pharmacological treatment, or a combination of both of these. Collaborative care typically involves case management supervised by a senior mental health professional, close collaboration between primary and secondary care services, a range of interventions consistent with those recommended in the guidelines (including patient education, psychological and pharmacological interventions, and medication management), and long term coordination of care and follow-up.
Is the new evidence likely to result in significant/minor/no change to clinical practice and current delivery of services?
The new guidelines present some implementation challenges, especially for healthcare professionals working in secondary care settings who treat people with depression and a chronic physical health problem. There is an emphasis on identifying depression, which if successful could lead to an increase in the delivery of some aspects of care in those settings. (This may also require additional training and supervision if the interventions are to be delivered effectively). Establishing collaborative care systems will inevitably require time and resources and will lead to changes in the way care is delivered for people with depression (e.g. the introduction of stepped care systems) with greater coordination between primary and secondary care services.
Are there any potential cost savings or efficiencies to be made as a result of implementing the new evidence?
The implementation of the previous NICE guideline was significantly limited by the absence of sufficient therapists to provide the psychological therapies. The development of the Improving Access to Psychological Therapies in England and a similar programme in Scotland has begun to address this problem. The more targeted and effective use of antidepressants (for moderate and severe depression in combination with psychological interventions) recommended in these guidelines will also improve care. Implementation of the guidelines will therefore reduce relapse rates which will lead to a decreased burden of disease and thereby reducing long-term costs of mental health care particularly in primary care.
