Depression in adults: campaigners and doctors demand full revision of NICE guidance

A coalition of mental health organisations and individual clinicians has described the latest draft guidelines on adult depression by the National Institute for Health and Care Excellence (NICE) as misleading, invalid, and not fit for purpose, saying that they could harm patients.

Fourteen organisations including the Royal College of Psychiatrists and six leading doctors including Simon Wessely, former president of the college, and Clare Gerada, former president of the Royal College of General Practitioners, have signed a position statement sent to NICE.1

It says that the draft revision of NICE’s guideline on depression in adults2 is based on wide ranging and fundamental methodological flaws for establishing effective treatment and falls short of acceptable scientific standards. The guideline development group favours medical trials over psychological trials and particular psychological treatments over others, the statement says, adding that it relies too much on randomised controlled trials that have limitations in the field of mental health.

The group is demanding a full revision of the guideline.

The coalition was formed after a number of stakeholders to the NICE review process expressed concerns about the draft guideline, published in July 2017. The subsequent consultation comments ran to 898 pages.

The issue was taken up by the Liberal Democrat MP Norman Lamb and others, and in February 2018 an early day motion3 was tabled and a number of MPs signed a cross party letter to NICE, asking it to respond to the stakeholders’ call for a second consultation.

After a meeting in April with stakeholders NICE agreed to an “exceptional” second four week consultation,4 which ended on 12 June.

But Felicitas Rost, who cowrote the position statement in her capacity as president of the Society for Psychotherapy Research UK, said that the resulting draft revision contained only “cosmetic” changes and remained not fit for purpose.

Each stakeholder has sent NICE an individual response in addition to the joint statement.

Rost, a psychotherapy research lead at the Tavistock and Portman NHS Foundation Trust, said, “The stakeholders were seriously concerned last summer, so I contacted other organisations to see if they had the same feeling. We started small, and it snowballed.

“The flaws are still there, and it still cannot be trusted. We would ask that the NICE executive take the necessary step of postponing publication of this guideline until a proper revision can be undertaken that will meet the high scientific standards expected of NICE, which is otherwise seen as a world leader in guideline development.”

The coalition’s statement reads: “The various methodological concerns we raised in our first response to the draft have not been addressed in the revised version. Thus, we maintain our position that this guideline is not fit for purpose and if published will seriously impede the care of millions of people in the UK suffering from depression, potentially even causing clinical harm.”

It spells out six amendments that it says must be undertaken before the draft is published, such as including 1-2 year follow-up data (as is required for physical conditions) and a systematic review of primary studies of service user experience.

Rost said that the group was unusual in that it contained scientists, clinicians, service users, and societies and that, while some of the organisations involved may have a particular leaning towards one therapeutic approach or another, they were united in their opposition to the methodology.

Wendy Burn, president of the Royal College of Psychiatrists and one of the position statement’s signatories, said, “We have major concerns about the new draft guidelines and have written to NICE to inform them of this. We hope that they will take our concerns seriously.”

Sarah Niblock, chief executive of the UK Council for Psychotherapy, said, “We urge NICE not to publish this guideline because it fails to meet the high scientific standards essential for ensuring public safety. With a least a quarter of the UK adult population suffering depression at any given moment, we must get this right or face a worsening of a crisis situation.”

Mark Baker, director of the NICE centre for guidelines, said, “Our guideline on the management of depression in the NHS has just been through its second public consultation. The committee will soon meet to review and discuss the comments received. We will respond in due course.”