NICE guidance - management of depression in primary and secondary care

Last edited 08/2018 and last reviewed 07/2022

NICE have made recommendations for the identification, treatment and management of depression for adults aged 18 years and over, in primary and secondary care.

• depression is a broad and heterogeneous diagnostic grouping, central to which is depressed mood or loss of pleasure in most activities
  • depressive symptoms are frequently accompanied by symptoms of anxiety, but may also occur on their own
  • increasingly, it is recognised that depressive symptoms below the DSM IV and ICD 10 threshold criteria can be distressing and disabling if persistent
    • the most recent NICE guideline covers 'subthreshold depressive symptoms', which fall below the criteria for major depression, and are defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet the criteria for full diagnosis
      • symptoms are considered persistent if they continue despite active monitoring and/or low-intensity intervention, or have been present for a considerable time, typically several months. (For a diagnosis of dysthymia, symptoms should be present for at least 2 years .)
      • assessment of depression is based on the criteria in DSM-IV. Assessment should include the number and severity of symptoms, duration of the current episode, and course of illness:
      • Key symptoms:
        • persistent sadness or low mood; and/or
        • marked loss of interests or pleasure
        • at least one of these, most days, most of the time for at least 2 weeks
          
          
        • if any of above present, ask about associated symptoms:
          • disturbed sleep (decreased or increased compared to usual)
          • decreased or increased appetite and/or weight
          • fatigue or loss of energy
          • agitation or slowing of movements
          • poor concentration or indecisiveness
          • feelings of worthlessness or excessive or inappropriate guilt
          • suicidal thoughts or acts

      • DSM-IV severities of depression

        • subthreshold depressive symptoms: Fewer than 5 symptoms
        • Mild depression: few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
        • Moderate depression: symptoms or functional impairment are between 'mild' and 'severe'
        • Severe depression: most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.

The NICE guideline is based on a stepped care management of depression:

Step 1: All known and suspected presentations of depression

• assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions

Step 2: Persistent subthreshold depressive symptoms; mild to moderate depression

• low-intensity psychological and psychosocial interventions, medication and referral for further assessment and interventions

Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

• medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions

Step 4: severe and complex depression; risk to life; severe self-neglect

• medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Notes:

1. when depressive symptoms are accompanied by anxious symptoms, the first priority should usually be to treat the depression

Reference:

1. NICE (April 2018). Depression.