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National Collaborating Centre for Mental Health (UK). Depression: The Treatment and Management of Depression in Adults (Updated Edition). Leicester (UK): British Psychological Society; 2010. (NICE Clinical Guidelines, No. 90.)

Cover of Depression

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

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This guideline was first published in December 2004 (NICE, 2004a; NCCMH, 2004) (referred to as the ‘previous guideline’). The present guideline (referred to as the ‘update’) updates many areas of the previous guideline. There are also new chapters on the experience of depression for people with depression and their carers (Chapter 4), and on the treatment and management of subthreshold depressive symptoms (including dysthymia symptoms) (Chapter 13), which were not part of the scope of the previous guideline. Recommendations categorised as ‘good practice points’ in the previous guideline were reviewed for their current relevance (including issues around consent and advance directives). Further details of what has been updated and what is left unchanged can be found at the beginning of each evidence chapter. The scope for the update also included updating two National Institute for Health and Clinical Excellence (NICE) technology appraisals (TAs) on the use of electroconvulsive therapy (ECT) (TA59) and on computerised cognitive behaviour therapy (TA51) (NICE, 2003, 2002)1. See Appendix 1 for more details on the scope of this update. Sections of the guideline where the evidence has not been updated are marked by asterisks (**_**).

The previous guideline and this update have been developed to advise on the treatment and management of depression. The guideline recommendations in the update have been developed by a multidisciplinary team of healthcare professionals, people with depression, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with depression while also emphasising the importance of the experience of care for them and their carers.

Although the evidence base is rapidly expanding there are a number of major gaps, and further revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, people with depression and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists.


1.1.1. What are clinical practice guidelines?

Clinical practice guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate the evidence relating to the specific condition in question. Where evidence is lacking, the guidelines incorporate statements and recommendations based upon the consensus statements developed by the Guideline Development Group (GDG).

Clinical guidelines are intended to improve the process and outcomes of health-care in a number of different ways. They can:

  • provide up-to-date evidence-based recommendations for the management of conditions and disorders by healthcare professionals
  • be used as the basis to set standards to assess the practice of healthcare professionals
  • form the basis for education and training of healthcare professionals
  • assist people with depression and their carers in making informed decisions about their treatment and care
  • improve communication between healthcare professionals, people with depression and their carers
  • help identify priority areas for further research.

1.1.2. Uses and limitations of clinical guidelines

Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high-quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals with depression.

Although the quality of research in this field is variable, the methodology used here reflects current international understanding on the appropriate practice for guideline development (AGREE: Appraisal of Guidelines for Research and Evaluation Instrument;; AGREE Collaboration [2003]), ensuring the collection and selection of the best research evidence available and the systematic generation of treatment recommendations applicable to the majority of people with depression. However, there will always be some people and situations for which clinical guideline recommendations are not readily applicable. This guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with depression or their carer.

In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations in clinical guidelines. While national guidelines are concerned with clinical and cost effectiveness, issues of affordability and implementation costs are to be determined by the National Health Service (NHS).

In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In addition, of particular relevance in mental health, evidence-based treatments are often delivered within the context of an overall treatment programme including a range of activities, the purpose of which may be to help engage the person and to provide an appropriate context for the delivery of specific interventions. It is important to maintain and enhance the service context in which these interventions are delivered; otherwise the specific benefits of effective interventions will be lost. Indeed, the importance of organising care in order to support and encourage a good therapeutic relationship is at times as important as the specific treatments offered.

1.1.3. Why develop national guidelines?

NICE was established as a Special Health Authority for England and Wales in 1999, with a remit to provide a single source of authoritative and reliable guidance for patients, professionals and the public. NICE guidance aims to improve standards of care, diminish unacceptable variations in the provision and quality of care across the NHS and ensure that the health service is patient centred. All guidance is developed in a transparent and collaborative manner using the best available evidence and involving all relevant stakeholders.

NICE generates guidance in a number of different ways, three of which are relevant here. First, national guidance is produced by the Technology Appraisal Committee to give robust advice about a particular treatment, intervention, procedure or other health technology. Second, NICE commissions public health intervention guidance focused on types of activity (interventions) that help to reduce people’s risk of developing a disease or condition or help to promote or maintain a healthy lifestyle. Third, NICE commissions the production of national clinical practice guidelines focused upon the overall treatment and management of a specific condition. To enable this latter development, NICE originally established seven National Collaborating Centres in conjunction with a range of professional organisations involved in healthcare.

1.1.4. The National Collaborating Centre for Mental Health

This guideline has been commissioned by NICE and developed within the National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration of the professional organisations involved in the field of mental health, national patient and carer organisations, and a number of academic institutions and NICE. The NCCMH is funded by NICE and is led by a partnership between the Royal College of Psychiatrists and the British Psychological Society’s Centre for Outcomes Research and Effectiveness.

1.1.5. From national guidelines to local implementation

Once a national guideline has been published and disseminated, local healthcare groups will be expected to produce a plan and identify resources for implementation, along with appropriate timetables. Subsequently, a multidisciplinary group involving commissioners of healthcare, primary care, specialist mental health professionals, and people with depression and their carers should undertake the translation of the implementation plan locally, taking into account both the recommendations set out in this guideline and the priorities set in the National Service Framework for Mental Health (Department of Health, 1999) and related documentation. The nature and pace of the local plan will reflect local healthcare needs and the nature of existing services; full implementation may take considerable time, especially where substantial training needs are identified.

1.1.6. Auditing the implementation of guidelines

This guideline identifies key areas of clinical practice and service delivery for local and national audit. Although the generation of audit standards is an important and necessary step in the implementation of this guidance, a more broadly based implementation strategy will be developed. Nevertheless, it should be noted that the Healthcare Commission will monitor the extent to which Primary Care Trusts, trusts responsible for mental health and social care and Health Authorities have implemented these guidelines.


1.2.1. Who has developed this guideline?

The GDG was convened by the NCCMH and supported by funding from NICE. The GDG included two people with depression and a carer, and professionals from psychiatry, clinical psychology, general practice, nursing and psychiatric pharmacy.

Staff from the NCCMH provided leadership and support throughout the process of guideline development, undertaking systematic searches, information retrieval, appraisal and systematic review of the evidence. Members of the GDG received training in the process of guideline development from NCCMH staff, and the people with depression and the carer received training and support from the NICE Patient and Public Involvement Programme. The NICE Guidelines Technical Adviser provided advice and assistance regarding aspects of the guideline development process.

All GDG members made formal declarations of interest at the outset, which were updated at every GDG meeting. The GDG met a total of 14 times throughout the process of guideline development. It met as a whole, but key topics were led by a national expert in the relevant topic. The GDG was supported by the NCCMH technical team, with additional expert advice from special advisers where needed. The group oversaw the production and synthesis of research evidence before presentation. All statements and recommendations in this guideline have been generated and agreed by the whole GDG.

1.2.2. For whom is this guideline intended?

This guideline is relevant for adults with depression as the primary diagnosis and covers the care provided by primary, community, secondary, tertiary and other health-care professionals who have direct contact with, and make decisions concerning the care of, adults with depression.

The guideline will also be relevant to the work, but will not cover the practice, of those in:

  • occupational health services
  • social services
  • forensic services
  • the independent sector.

The experience of depression can affect the whole family and often the community. The guideline recognises the role of both in the treatment and support of people with depression.

1.2.3. Specific aims of this guideline

The guideline makes recommendations for the treatment and management of depression. It aims to:

  • improve access and engagement with treatment and services for people with depression
  • evaluate the role of specific psychological and psychosocial interventions in the treatment of depression
  • evaluate the role of specific pharmacological interventions in the treatment of depression
  • evaluate the role of specific service-level interventions for people with depression
  • integrate the above to provide best-practice advice on the care of people with depression and their family and carers
  • promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales.

1.2.4. The structure of this guideline

The guideline is divided into chapters, each covering a set of related topics. The first three chapters provide an introduction to guidelines, the topic of depression and the methods used to update this guideline. Chapters 5 to 13 provide the evidence that underpins the recommendations about the treatment and management of depression, with Chapter 4 providing personal accounts from people with depression and carers that offer an insight into their experience of depression.

Each evidence chapter begins with a general introduction to the topic that sets the recommendations in context. Depending on the nature of the evidence, narrative reviews or meta-analyses were conducted, and the structure of the chapters varies accordingly. Where appropriate, details about current practice, the evidence base and any research limitations are provided. Where meta-analyses were conducted, information is given about the review protocol and studies included in the review. Clinical evidence summaries are used to summarise the data presented. Health economic evidence is then presented (where appropriate), followed by a section (from evidence to recommendations) that draws together the clinical and health economic evidence and provides a rationale for the recommendations. On the CD-ROM, further details are provided about included/excluded studies, the evidence, and the previous guideline methodology (see Table 1 for details).

Table 1. Appendices on CD-ROM.

Table 1

Appendices on CD-ROM.



Recommendations from TA59 and TA97 were incorporated into the previous depression guideline according to NICE protocol.

Copyright © The British Psychological Society & The Royal College of Psychiatrists, 2010.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK63774


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