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Depression: The Treatment and Management of Depression in Adults (Updated Edition)

Depression: The Treatment and Management of Depression in Adults (Updated Edition)

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK)

Version: 2010

FACTORS INFLUENCING CHOICE OF ANTIDEPRESSANTS

This chapter updates the reviews on the effect of sex on antidepressant choice, antidepressant discontinuation symptoms, cardiotoxicity of antidepressants, and antidepressants and suicide. It includes a new review of treatments for depression with a seasonal pattern because this diagnosis was added to the scope of the updated guideline.

PHARMACOLOGICAL INTERVENTIONS

This chapter reviews the use of individual drugs in the treatment of depression. The GDG updated its reviews of drugs (including escitalopram and antipsychotic augmentation) where there were substantial new data likely to change the recommendations from the previous guideline, and where studies for newly licensed drugs (duloxetine) were available. It did not update most of the reviews of individual antidepressants undertaken for the previous guideline because most of these were large-scale reviews – a substantial amount of new evidence would have had to have been published to change the overall conclusion that there is little difference in efficacy between individual drugs. This includes SSRIs (apart from escitalopram) and venlafaxine. Although new RCT data on venlafaxine have become available and several meta-analyses (for example, Nemeroff et al., 2008; Weinmann et al., 2008) and systematic reviews (Gartlehner et al., 2008) have been published, these new data do not change the conclusion that if there is an efficacy advantage for venlafaxine over other antidepressants it is small and unlikely to be of clinical importance. Some of the recommendations were revised (NICE, 2007a) in light of the safety review of venlafaxine conducted by the Medicines and Healthcare products Regulatory Agency (MHRA 2006a, ), and further revised in this guideline update.

THE MANAGEMENT OF SUBTHRESHOLD DEPRESSIVE SYMPTOMS

The previous guideline made recommendations only for major depressive disorder. However, the scope for the update included the management of milder depressive disorders, including subthreshold depressive symptoms and persistent subthreshold depressive symptoms (including dysthymia). This chapter brings together the evidence for pharmacological and psychological interventions for this group.

HIGH-INTENSITY PSYCHOLOGICAL INTERVENTIONS

This section covers the high-intensity interventions that were identified in the searches for the guideline update and groups them according to the definitions developed for the previous guideline (NICE, 2004a). Although to some degree cognitive behavioural therapies, behavioural activation, problem solving therapy and couples therapy 54 Five out of six of the included studies of couples therapy were based on a behavioural model. share a common theoretical base, they are reviewed separately.

INTRODUCTION TO PHARMACOLOGICAL AND PHYSICAL INTERVENTIONS

For the guideline update the following reviews of pharmacological interventions are updated: escitalopram, relapse prevention and next-step treatments (treatments for treatment-resistant depression in the previous guideline), and the following narrative reviews have been updated with new data: effect of sex on antidepressant choice, dosage, discontinuation, cardiotoxicity, and antidepressants and suicide. There are also new reviews for TCAs, duloxetine and therapies for depression with a seasonal pattern, new narrative reviews of transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS), and new sections for chronic depression and residual symptoms. The scope for the update also includes updating the NICE technology appraisal on the use of ECT (for depression) (TA59; NICE, 2003) 74 Recommendations from TA59 were incorporated into the previous depression guideline according to NICE protocol. . Where reviews have not been updated, an explanation has been added to the relevant chapter introduction.

SUMMARY OF RECOMMENDATIONS

Inform people with depression about self-help groups, support groups and other local and national resources.

THE PHARMACOLOGICAL AND PHYSICAL MANAGEMENT OF DEPRESSION THAT HAS NOT ADEQUATELY RESPONDED TO TREATMENT, AND RELAPSE PREVENTION

In this chapter, sections marked by asterisks (**__**) are from the previous guideline and have not been updated except for style and minor clarification.

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