Guidance update: NICE guidelines on depression in adults

Dr Toni Hazell explains NICE guidance on depression in adults.

This article was first published on MIMS Learning in November 2016.

1. What is the latest evidence?
2. What's new in the latest guidance?
3. What to do differently in your practice?
4. Anything uncertain/controversial?
5. New/upcoming treatments
6. Multimorbidity
7. Case study
8. Audit ideas
9. Quality improvement activities
10. Key points
11. Useful resources
12. References


1. What is the latest evidence?

The NICE guidance on depression in adults, originally published in 2009 was updated in April 2016.1 There was only a small change to the guidance at this time, so this module provides a useful reminder of the current guidance as well as detailing the new update.


2. What's new in the latest guidance?

As GPs we often make diagnoses based on our clinical experience rather than sticking closely to diagnostic criteria, but in this guidance NICE has slightly raised the threshold for diagnosing depression by suggesting use of the DSM-IV instead of the ICD-10 criteria.

The key difference is that patients need to have at least five symptoms of depression (instead of four) to be diagnosed with mild depression and that we should be doing a functional assessment – in other words, assessing how much the depression impacts on the patient’s day-to-day life and ability to carry out their normal daily activities – rather than just a simple symptom count. Boxes 1 and 2 give more details about the diagnostic criteria for depression.

Box 1. Symptoms of depression

Symptoms that can fluctuate should be present on most days and should not be due to substance abuse or a physical condition2

  • Depressed mood most of the day
  • Reduced interest or pleasure in all or almost all activities
  • Significant weight loss or gain (e.g. more than 5% of body weight) which is not due to dieting
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation which is observable by others
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Reduced ability to concentrate or make decisions
  • Recurrent thoughts of death, with or without a plan, or a suicide attempt or plan
Box 2. Diagnostic criteria for depression1

Mild: Five of the above symptoms and not many more. Any functional impairment is only mild
Moderate: Symptoms or functional impairment between mild and severe
Severe: Most of the symptoms above and a marked impairment of functioning, with or without psychotic symptoms


3. What to do differently in your practice?

The most challenging patients to manage are often those who don’t fit the criteria for depression, but are clearly low in mood. This guidance introduces the concept of ‘subthreshold depressive symptoms’ – patients who have at least one symptom of depression that persists for several months but do not meet the diagnostic criteria for major depression.

NICE tells us that there is little evidence for antidepressants in this group but that cognitive behavioural therapy (CBT) – in person or computerised – or a group physical activity programme may be helpful. Many areas now have exercise on referral and this is worth considering for patients who would previously have been coded as ‘low mood’ and just given general advice. The same principle should apply to treating those with mild depression, as it is only at the threshold for moderate or severe depression that initial treatment with antidepressants is recommended.

Exercise
Exercise referral is a useful option for patients with subthreshold depressive symptoms

Antidepressants should be considered for patients with subthreshold symptoms or mild depression only when the treatments above have failed to work, if the symptoms persist for two years or if there is a past history of moderate or severe depression. They are first-line for patients with moderate to severe depression, an SSRI being recommended as the usual first-line treatment along with CBT or interpersonal therapy (IPT). IPT focuses on how a patient interacts with other people and guides changes of behaviours that are causing problems, whereas CBT focuses on internal thoughts and beliefs, and how these need to be changed for the patient to have better mental health.3

Important! Initial treatment with antidepressants is not recommended for patients with mild depression.


4. Anything uncertain/controversial?

NICE advises that patients started on antidepressants who aren’t at particular risk of suicide are seen after two weeks and then every two to four weeks for three months. Those at increased suicide risk should be seen after a week; this includes everyone under the age of 30 because of the increased prevalence of suicidal thoughts early in antidepressant treatment in this group.1

This seems quite a short interval for low-risk patients and I wonder whether general practice really has the resources for this intensity of follow-up. This is an area where I might remind myself that these are ‘guidelines not tramlines’ and tailor my follow-up to the patient. Some will prefer to speak on the phone, or to have a longer review period with an assurance that they can contact me if they want to be seen sooner. Conversely, if I really felt that someone was at high risk of suicidal ideation, I probably wouldn’t want to wait a week and might involve the crisis team to review them sooner.


5. New/upcoming treatments

This guidance links to information about a relatively new treatment – repetitive transcranial magnetic stimulation, which NICE reviewed in 2015.4 Unlike ECT, this can be done in outpatients with no need for anaesthesia. Repeated pulses of electromagnetic energy are delivered to the scalp in daily sessions for several weeks. NICE suggests that this is a safe and effective process – clearly, it isn’t something we will be doing in primary care, but we may start to see mentions of it in clinic letters or have patients come to ask us about it.

Another interesting new development was announced in October 2016 by a team from Cambridge, but does not feature in the NICE guidance. They suggest that depression may be associated with raised inflammatory markers and found that patients using anti-cytokine drugs such as adalimumab to treat inflammatory conditions had an improvement in their depression that was significant when compared with placebo. They call for randomised trials of these drugs in patients who only have depression, with no physical illness.5 This is not an entirely new concept as the idea of depression having an inflammatory cause was discussed in a review article earlier in 2016.6 Clearly, if clinical trials support this theory, the way we treat depression could fundamentally change.


6. Multimorbidity

When choosing an antidepressant, it is important to be aware of drug interactions if your patients have other medical conditions. For example, cardiac arrhythmias can be exacerbated with higher doses of venlafaxine, which can also exacerbate hypertension, as can duloxetine. Tricyclic antidepressants can cause postural hypotension and arrhythmias, and both tricyclics and SSRIs lower the seizure threshold for patients who have epilepsy.7

It may be worth a discussion with the patient’s neurologist before starting antidepressants in a patient who has epilepsy, particularly if it is not well controlled. Drugs should be started at a low dose with a gradual increase in dose. Dosulepin should no longer be used – this follows a 2007 MHRA drug safety update, which warned about its narrow therapeutic window and stated that it should only be prescribed by GPs with a particular interest in psychiatry or by specialists to reduce the risk of accidental overdose.8 Various CCGs have issued guidance as to how to change patients on dosulepin to another antidepressant.9

Important! Be aware of possible drug interactions with antidepressants in patients with other medical conditions.


7. Case study

Anita is a 35-year-old woman who is overweight and has high blood pressure. She comes to see you as she has been feeling low most days for the last three months. You take a full history and find that she has been suffering from insomnia and weight gain (due to comfort eating) but has no other symptoms of depression. You discuss with her that she may have subthreshold depressive symptoms, which aren’t likely to be helped by medication, but that CBT or exercise therapy may help.

She is keen to try exercise therapy as she wants to lose weight but doesn’t really know where to start. You fill in a form for your local exercise on referral scheme – three months later she sends you a thank you card, saying that she has lost a stone in weight, is now exercising regularly on her own and her low mood has disappeared.


8. Audit ideas

  • Carry out a search for dosulepin – do you have any patients taking it? Should they be switched to something else?
  • Audit the appropriate prescribing of venlafaxine in patients with a cardiac history.
  • Audit how appropriately patients with depression are followed up.

9. Quality improvement activities

  • Develop a system template to ensure all doctors use the NICE diagnostic guidelines.
  • Build a regular search to ensure patients with depression are not lost to follow-up.

10. Key points

  • At least five symptoms of depression are needed for a diagnosis to be made
  • Patients who don’t meet this threshold may benefit from CBT or exercise therapy
  • SSRIs are first-line for moderate or severe depression
  • Review sooner if your patient is under 30 or at risk of suicidal ideation – NICE recommends that these patients are reviewed one week after starting antidepressants

11. Useful resources

Patient information

  • Mind. Depression. Explains depression, causes, treatment and support for people with depression and their families/carers.
  • Royal College of Psychiatrists. Depression. A helpful animation and online leaflet exploring what it feels like to be depressed and what help you can get if you are depressed.

Take a test and add notes to your CPD Organiser on MIMS Learning

  • Dr Toni Hazell is a GP in London.

12. References

  1. NICE. Depression in adults: recognition and management. CG90. Updated April 2016
  2. Depression Today. DSM IV: Major depressive episode.
  3. National Institute of Mental Health. Psychotherapies.
  4. NICE. Repetitive transcranial magnetic stimulation for depression. IPG542. December 2015
  5. Kappelmann N, Lewis G, Dantzer R et al. Antidepressant activity of anti-cytokine treatment: a systematic review and meta-analysis of clinical trials of chronic inflammatory conditions. Mol Psychiatry 2016. DOI: 10.1038/mp.2016.167.
  6. Miller AH, Raison CL. The role of inflammation in depression: from evolutionary imperative to modern treatment target. Nat Rev Immunol 2016; 16: 22-34.
  7. NHS Specialist Pharmacy Service. Q&A: What is the most appropriate antidepressant to use in patients with epilepsy? February 2016
  8. MHRA. Drug safety update. Dosulepin: measures to reduce risk of fatal overdose. December 2007
  9. Dorset CCG. Safety bulletin: dosulepin prescribing. July 2016

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