Step 3 - NICE guidance for treatment of persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

Last edited 08/2018 and last reviewed 07/2022

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

• Choosing treatments
  • treatment options for people with depression without a chronic physical health problem
    • for people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, discuss different interventions with the person and provide:
      • an antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]) or
      • a high-intensity psychological intervention, normally one of the following:
        • cognitive behavioural therapy (CBT)
        • interpersonal therapy (IPT)
        • behavioural activation (but note that the evidence is less robust than for CBT or IPT)
        • behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit
      • NICE state that for people who decline the options above, consider
        • counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression
        • short-term psychodynamic psychotherapy for people with mild to moderate depression
    • NICE suggest that, for people with moderate or severe depression, clinicians combine antidepressants with a high-intensity psychological intervention (CBT or IPT)
      
      
  • treatment options for people with depression and a chronic physical health problem
    • for people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, provide an antidepressant (normally an SSRI) or one of the following high-intensity psychological interventions:
      • group-based CBT or
      • individual CBT (if group-based CBT is declined, not appropriate or not available) or
      • behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit
    • treatment options for people with depression and a chronic physical health problem
      • NICE suggest that an antidepressant (normally an SSRI) is an option (and not mandatory) for patients with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, provide an antidepressant (normally an SSRI):
    • for people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, provide an antidepressant (normally an SSRI) or one of the following high-intensity psychological interventions:
    • group-based CBT or
    • individual CBT (if group-based CBT is declined, not appropriate or not available) or
    • behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.
    • for people with initial presentation of moderate depression, offer group-based CBT, individual CBT or behavioural couples therapy
    • for people with severe depression, consider offering both individual CBT and an antidepressant

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

Reference:

1. NICE (April 2018).Depression