Step 2 - NICE guidance - recognised depression - persistent subthreshold depressive symptoms or mild to moderate depression

Last edited 08/2018 and last reviewed 06/2022

Step 2: Recognised depression - persistent subthreshold depressive symptoms or mild to moderate depression

• General measures
  • depression with anxiety
    • when depression is accompanied by symptoms of anxiety, usually treat the depression first. But if the person has an anxiety disorder and comorbid depression or depressive symptoms, consider treating the anxiety disorder first
      
      
  • sleep hygiene
    • offer advice on sleep hygiene, including:
      • establishing regular sleep and wake times
      • avoiding excess eating, smoking or drinking alcohol before sleep
      • creating a proper environment for sleep
      • taking regular physical exercise if possible
        
        
  • active monitoring
    • for people who may recover with no formal intervention, people with mild depression who do not want an intervention, or people with subthreshold depressive symptoms who request an intervention:
      • discuss the presenting problem(s) and any concerns the person has
      • arrange a further assessment, normally within 2 weeks
      • provide information about depression
      • make contact if the person does not attend appointments
        
        
  • drug treatment
    • do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression, but consider them for people with:
      • a past history of moderate or severe depression or
      • initial presentation of subthreshold depressive symptoms present for at least 2 years or
      • subthreshold depressive symptoms or mild depression persisting after other interventions
        
        
  • for people with depression and a chronic physical health problem
    • do not use antidepressants routinely to treat subthreshold depressive symptoms (less than five symptoms on DSM-IV criteria) or mild depression, but consider them for people with:
      • mild depression that complicates the care of the physical health problem or
      • a past history of moderate or severe depression or
      • initial presentation of subthreshold depressive symptoms present for at least 2 years or
      • subthreshold depressive symptoms or mild depression persisting after other interventions
  • NICE advise not to prescribe or advise use of St John's wort for depression - there are different potencies of the preparations available and potential serious interactions of St John's wort with other drugs (including oral contraceptives, anticoagulants and anticonvulsants)

Psychosocial and psychological interventions

• people with persistent subthreshold depressive symptoms or mild to moderate depression without a chronic physical health problem.
  • for people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the low-intensity psychosocial interventions in the first table on this page, guided by the person’s preference
    • individual guided self-help based on CBT principles
    • CCBT
    • a structured group physical activity programme
      • be delivered in groups supported by a competent practitioner typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10-14 weeks
  • for people who decline a low-intensity psychosocial intervention, consider group-based cognitive behavioural therapy (CBT)

• for people with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for people with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering one or more of the low-intensity psychosocial interventions in the table below, guided by the person’s preference
  • a structured group physical activity programme
  • a group-based peer support (self-help) programme
  • individual guided self-help based on CBT principles
  • computerised CBT

For more detailed guidance then refer to full NICE guideline (1).

Reference:

1. NICE (April 2018). Depression