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covid free office

BY Jessica Culnane


NICE Depression Guidelines Updated After 12 Years

Will the new NICE depression guidelines empower patients or add to an already strained mental healthcare service?

DECEMBER 07  2021


The National Institute for Clinical Excellence (NICE) has released an updated draft on guidance about how to identify, treat, and manage depression in adults. The updated depression guidelines focus on patient-led treatments and emphasises shared decision making between patients and healthcare practitioners.

The update comes as the UK faces a mental health epidemic as we emerge from the COVID-19 pandemic. ONS figures estimate that roughly one in 10 adults in England suffered from moderate to severe depression before the pandemic started in March 2020 – this doubled to almost one in five by June 2020.

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

A ‘menu’ of treatment options

The new depression guidelines propose a more focused and bespoke approach to depression treatment. It distinguishes between two categories: less severe depression (meaning mild), and more severe depression (meaning moderate or severe). For both categories, there is a ‘menu’ of treatment options, listed in order of recommended use.

If a patient falls into the less severely depressed category the treatment options recommended take a holistic lifestyle approach. This means that non-pharmaceutical interventions such as Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA), along with group exercise, mindfulness, and meditation are recommended before medicated treatment such as antidepressants. Furthermore, it specifically states that antidepressants should not be routinely offered as the first line of treatment for less severe depression – unless it is the patient’s personal preference. With antidepressants being one of the most commonly used drugs in the UK, it is arguably a step in the right direction to recognise and be transparent to patients about the efficacy of lifestyle interventions.

Another significant change to the guidance focuses on increasing transparency about the process of discontinuing antidepressant treatment, or ‘tapering’. It emphasises transparency and awareness of the impact that tapering antidepressants can have, particularly on symptoms. This is important because discontinuing antidepressants is a largely under-researched area, with little good-quality evidence available informing how to do it effectively and safely. As a result, prior UK guidelines have underestimated and overlooked the duration and severity of antidepressant withdrawal. Making the potential side effects of discontinuing antidepressants transparent for the patient may be able to preclude an inappropriate continuation of antidepressants if symptoms are interpreted to be a relapse of depression.


A perfect storm?

The emphasis on patient empowerment and non-pharmaceutical treatment of depression is very welcomed. However, it is no secret that the UK currently has a ‘chronic’ shortage of GPs. Similarly, psychiatric departments are severely understaffed – with just one consultant psychiatrist for every 12,6000 people in England.

This may make the guidelines difficult to implement in practice because it takes a more resource-intensive approach. For example, the guidelines recommended extending initial consultations to ensure treatment plans are bespoke and transparent for patients. Similarly, prescribing CBT, BA, and other non-pharmaceutical interventions will mean the supply of these already saturated treatments will need to significantly increase.

Without the supply available to meet increased demand, the new guidelines have the potential to backfire. For example, long waiting lists and referrals may exacerbate the severity of a patient’s depression. A study by the Royal College of Psychiatrists found that in 2020 around one in four patients waited more than three months between their referral and second appointment, with one in nine waiting over six months. This meant that two-fifths of patients waiting for mental health treatment were forced to contact emergency services before receiving treatment, with one in ten ending up in the emergency department.

‘It simply isn’t good enough that so many people are waiting for mental health treatment and ending up in crisis’ said Dr Kate Lovett, Dean of the Royal College of Psychiatrists. ‘Even before the pandemic hit, mental health services were not keeping up with demand. But the looming mental health crisis fuelled by the pandemic and the economic recession means waiting times could get a lot worse’.

The mental healthcare infrastructure desperately needs attention and funding by the Government – it was severely damaged through the pandemic and the new guidelines may only burden the sector further.


A fine line

The updated guidelines are long overdue. An emphasis on holistic and non-pharmaceutical interventions reflects a wider shift in the mood in society and medicine to move away from the traditional concept of mental health as an isolated and insular issue and towards a concept that understands mental health as a concatenation of many different physical things within the body.

However, it is also important that the new guidelines find the right balance between empowering the patient to make changes to their overall lifestyle and potentially validating feelings of helplessness. This is because encouraging exercise and meditation have the potential to make patients feel their issues are misunderstood or overlooked, and could only lead to an internalisation of the public stigma surrounding depression.

Overall, the guidelines are a step in the right direction however it also acts as a reminder that further research is required into how non-pharmaceutical interventions can be effectively prescribed, accessed, funded, and monitored.




About the author: Jessica Culnane is a contributing Features Writer with in-depth knowledge of policy, politics, and economics. She’s interested in technological advancements, business developments, data, and culture.

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