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Give people choice of treatment options for depression, says NICE

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2877 (Published 23 November 2021) Cite this as: BMJ 2021;375:n2877
  1. Gareth Iacobucci
  1. The BMJ

People with depression should choose what treatment option is right for them, in discussion with their healthcare professional, the National Institute for Health and Care Excellence has recommended in draft guidance.1

In the first guideline for 12 years to focus on identifying, treating, and managing depression in adults, NICE advises that antidepressant drugs should not be offered as the first line treatment for less severe depression “unless that is the person’s preference.”

Patients with less severe depression should be able to choose from cognitive behavioural therapy (CBT), exercise, counselling, or psychotherapy as their first line treatment, it says.

The draft guidance puts much emphasis on shared decision making, with NICE creating a menu of treatment options to allow patients to pick the one that is right for them, in discussion with their healthcare practitioner. It advises that patients with more severe depression could choose from similar psychological interventions, as well as being able to choose an antidepressant as the first line treatment.

Nav Kapur, professor of psychiatry and population health at the University of Manchester and chair of the guideline committee, said, “As a committee we have drawn up recommendations that we hope will have a real impact on people who are suffering from depression and their carers.

“In particular we’ve emphasised the role of patient choice—suggesting that practitioners should offer people a choice of evidence based treatments and understanding that not every treatment will suit every person.”

NICE highlighted data from the Office of National Statistics showing that 17% of adults aged 16 years or over in Great Britain experienced some form of depression in summer 2021, nearly double the 10% before the covid pandemic.2

Paul Chrisp, director of NICE’s centre for guidelines, said, “People with depression need these evidence based guideline recommendations available to the NHS, without delay.”

The draft guideline also has new recommendations for people stopping antidepressant treatment. People who are considering taking or stopping antidepressant drugs should discuss the benefits and risks with their healthcare professional, who should explain that withdrawal may take weeks or months to complete successfully, that it is usually necessary to reduce the dose in stages over time, and that most people stop antidepressants successfully, it says.

NICE said that the recommendations reflected current practice but may require additional psychological services to be commissioned in some areas. It said that initial consultations with patients may need to be longer to support informed choice but added that a “positive choice may improve engagement and outcomes.”

The Royal College of Psychiatrists, which plans to respond to the consultation, said it supported making different treatment options available for people with depression, depending on the severity of their symptoms. A spokesperson said, “Depression is different for everyone: some people might experience mild symptoms for a limited time while others might become severely unwell for longer periods. Shared decision making with healthcare professionals is key in ensuring patients are fully informed about the benefits and understand the risks of each treatment option in relation to their own personal experience.”

Matt Smith-Lilley, lead on policy and engagement for mental health at the British Association for Counselling and Psychotherapy, said, “We’ve long campaigned for significant changes to these guidelines, including calling on NICE to recognise the substantial evidence base showing the effectiveness of counselling and psychotherapy for the treatment of depression.

“We know that our membership of highly skilled and qualified counsellors and psychotherapists have the capacity to take on more work. But they are currently underused and undervalued by commissioners, including the NHS. The update to these guidelines must be backed by further investment in employment opportunities for counsellors and psychotherapists to ensure people receive the mental health support they so crucially need.”

The consultation is open until Wednesday 12 January 2022.

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