Are clear for severe depression, but uncertain for mild or moderate depression

Guidelines from the National Institute for Clinical Excellence (NICE) focus on clinical conditions that have a substantial impact on public health and aim to improve standards of care and reduce variations in provision. Depression is a common condition, contributing 12% of the total burden of nonfatal global disease.1 Variations in its treatment within the NHS are striking and perplexing.2 3 We welcome these guidelines and recent advice from the Medicines and Healthcare products Regulatory Agency (MHRA) concerning the prescription of antidepressants.4 5

The methods underpinning the guidelines were rigorous and produced a definitive summary of current evidence. However, the uncertainty of many recommendations is disappointing. The guidelines advocate a stepped care approach, but the weakness of evidence supporting structured interventions for mild to moderate depression limits the value of recommendations referring to initial steps.

The review of the evidence highlights associations between the severity of depression and response to antidepressant …