New NICE draft guidance has recommended that prescribers do not routinely offer patients with ‘less severe’ depression antidepressants as the first line of treatment.

It said this should only be the case if this is their ‘preference’ and that GPs could first offer alternatives such as cognitive behavioural therapy (CBT); counselling; group mindfulness or meditation; or group exercise.

The guidance, published today and currently out for consultation, said: ‘Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference.’

It added that those with ‘more severe’ depression should also be offered a range of different options of first-line treatments, depending on their ‘clinical needs and preference’.

The guidance said that GPs should ‘discuss treatment options with people who have a new episode of less severe depression’ – defined as ‘subthreshold symptoms and mild depression’ – and reach a ‘shared decision’ based on their ‘clinical needs and preferences’.

They should take into account that all treatments listed in the guidance ‘can be used as first-line treatments’, it added.

The options, listed ‘in order of recommended use’, are:

  • Group CBT
  • Group behavioural activation (BA) 
  • Individual CBT
  • Individual BA
  • Self-help ‘with support’
  • Group exercise
  • Group mindfulness or meditation
  • Interpersonal psychotherapy (IPT)
  • Selective serotonin reuptake inhibitors (SSRIs) 
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP)

GPs should not prescribe or advise the use of St John’s Wort to those with depression because of ‘uncertainty’ about appropriate doses and persistence of effect and ‘potential serious interactions’ with other drugs, it added.

Those with a new episode of ‘more severe’ depression – defined as ‘moderate and severe depression’ – should also be offered a range of potential first-line treatments with a shared decision reached based on their needs and preference, the guidance said.

Treatment options for ‘more severe’ depression in order of ‘recommended use’ are:

  • Combination of individual CBT and an antidepressant 
  • Individual CBT
  • Individual behavioural activation (BA) 
  • Antidepressant medication, which could be an SSRI, SNRI or ‘other antidepressant if indicated based on previous clinical and treatment history’
  • Individual ‘problem-solving’
  • Counselling
  • Short-term psychodynamic psychotherapy (STPP) 
  • Interpersonal psychotherapy (IPT)
  • Self-help ‘with support’
  • Group exercise

GPs should recognise that people with all severities of depression ‘have a right to decline treatment, the guidance added.

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘People with depression deserve and expect the best treatment from the NHS which is why this guideline is urgently required.

‘The Covid-19 pandemic has shown us the impact depression has had on the nation’s mental health. People with depression need these evidence-based guideline recommendations available to the NHS, without delay.’

Nav Kapur, professor of psychiatry and population health at the University of Manchester and chair of the guideline committee, added that the ‘broad-ranging’ was ‘an enormous challenge to produce’.

He said: “In particular we’ve emphasised the role of patient choice – suggesting that practitioners should offer people a choice of evidence-based treatments and understanding that not every treatment will suit every person. 

‘We now need stakeholders’ help to make the recommendations as good as they can possibly be.’

The consultation on the guideline, which is the first in 12 years on identifying, treating and managing depression in adults, will close on 12 January.

The final guideline is expected for publication on 12 May 2022.

It comes as an Office for National Statistics analysis last month revealed that around one in six (17%) of UK adults experienced ‘some form of depression’ in summer 2021 – almost double the levels observed before the Covid pandemic (10%).

Meanwhile, NICE last month recommended that pharmacists should provide regular reviews for patients on antidepressants and drugs for chronic pain that may be addictive in draft guidance on managing withdrawal.

A version of this story first appeared on our sister website, Pulse.