goodmedicine

NICE - the UK National Institute for Health and Clinical Excellence - recently published guidance on "Depression in adults (update)" and on "Depression with a chronic physical health problem".  The "Depression in adults (update)"  replaces guidance originally published in 2004 and amended in 2007.  The 28 page Quick reference guide provides a helpful overview.  Interestingly NICE here use the DSM-IV diagnostic criteria for depression rather than the ICD-10 criteria (used in their earlier publications).  A four step approach is charted - each step is described both by who the intervention is for (e.g. by what severity of depression they are suffering) and by the nature of the treatment interventions being recommended.  It makes interesting reading.  Titbits include recommendations for how health practitioners should be monitoring their own practice (regular supervision, routine assessment questionnaires, and use of session tapes), approaches for milder symptoms (guided self-help, computerised CBT, and group physical exercise), the use of combined antidepressant medication and a high-intensity course of CBT (cognitive behavioural therapy) or IPT (interpersonal psychotherapy) for those suffering with moderate or severe depression (classified as such primarily by the degree of functional impairment), the use of continuation antidepressant treatment for at least 6 months after remission (not just after initiating treatment), and recommendations on considering relapse prevention with individual CBT or training in MBCT (mindfulness based cognitive therapy - for those with 3 or more previous depressive episodes).  The full guidance is book length - 585 pages - and is also freely viewable and downloadable. 

The guidance on "Depression with a chronic physical health problem" is new and particularly relevant for health professionals in general hospital settings.  The 10 page quick reference guide starts by pointing out:  "Depression is approximately two to three times more common in patients with a chronic physical health problem (such as cancer, heart disease or diabetes) than in people who have good physical health. A chronic physical health problem can both cause and exacerbate depression, and treating depression in these patients has the potential to increase their quality of life and life expectancy.  The presence of a physical illness can complicate the recognition and assessment of depression, because some symptoms are common to both mental and physical disorders. Symptoms below the threshold for a diagnosis of depression can be distressing and disabling, especially in patients with a physical health problem. Therefore this guideline also covers subthreshold depressive symptoms".  The guide then goes on to make a whole series of helpful and interesting points including the importance of "having little interest or pleasure in doing things" as an alerting feature suggesting the need to explore the possibility of depression further, the potential value of computerised CBT, the good sense in considering possible use of behavioural couples therapy, and the importance of carefully considering potential drug interactions (e.g. SSRI's and NSAID's or triptans).  For fuller details of drug interactions refer to Appendix 1 of the British National Formulary (BNF) and Appendix 16 of this guideline on "Depression with a chronic physical illness".  The 10 page quick reference guide is simply a very abbreviated key point overview of the much longer 397 page full guidance.