Ep 87 – Depression in adults

NICE published its last guideline on depression in 2009. Since that time, the prevalence of depression has increased, especially among vulnerable adults during the COVID-19 pandemic. NICE published a new guideline in June 2022 to reflect this. In this episode, Dr Roger Henderson looks at the new recommendations on managing depression in primary care, along with services providing psychological therapies that update and replace the 2009 guideline. Among the topics covered are treatments for first depressive episodes, advice on preventing relapse and withdrawing from antidepressant treatment.

Key references

1. NICE. Depression in adults: treatment and management (NG222). 29 June 2022. 
2. Kendrick T, et al. BMJ. 2022;378:o1557. doi: 10.1136/bmj.o1557.
3. NHS Digital. Adult psychiatric morbidity survey: survey of mental health and wellbeing, England, 2014. 29 September 2016. 
4. Kronenberg G, et al. Lancet Psychiatry. 2019;6(7):560-561. doi: 10.1016/S2215-0366(19)30183-X. 
5. Patel K, et al. JAMA Netw Open. 2022;5(4):e227629. doi: 10.1001/jamanetworkopen.2022.7629. 

Key take home points

• This podcast summarises new recommendations on the management of depression that are most relevant to primary care and services providing psychological therapies from the NICE guideline published in June 2022, which updates and replaces the 2009 guideline.
• In the new guideline, depression is classified as “less severe” and “more severe,” because the NICE 2009 recommendations that used “mild to moderate” and “moderate to severe” classifications left ambiguity for moderate depression.
• Discuss treatment options to match the needs and preferences of a person with a new episode of depression.
• Consider the least intrusive and least resource-intensive available treatment first for less severe depression (e.g., guided self-help).
• Do not offer antidepressant medication routinely as first line treatment for less severe depression unless that is the person’s preference.
• Discuss with people that continuation of antidepressants or psychological therapies after full or partial remission may reduce their risk of relapse and help them to stay well.
• Allow adequate time for the initial discussion about treatment options, involving family members, carers, or other supporters if agreed by the person with depression.
• When stopping a person’s antidepressant: take into account the pharmacokinetic profile (antidepressants with a short half-life need to be tapered more slowly) and duration of treatment; slowly reduce the dose to zero, prescribing a proportion of the previous dose at each step (for example, 50%); consider using smaller reductions (for example, 25%) as the dose becomes lower.
• Ask explicitly about suicidal thoughts. There is no evidence that asking about suicide will prompt a person to act.
• If a person with depression presents considerable immediate risk to themselves or others, refer them urgently.
• For patients at high risk of relapse, continue antidepressant treatment for up to 2 years and maintain the same dose unless side effects preclude this.