Since the National Institute for Health and Care Excellence (NICE) published its last guideline on depression in 2009,1 the prevalence of depression has increased,2 particularly among vulnerable adults during the covid-19 pandemic.3 Yet fewer than half of people affected receive treatment,2 despite increased provision of psychological therapies4 and antidepressants.5 Most people who are treated still receive antidepressants6 despite previous guideline recommendations to offer psychological therapies first,1 and Public Health England is concerned that long term antidepressant prescribing is increasing, with many people experiencing withdrawal symptoms and having difficulty stopping them when appropriate.7 In addition to cognitive behavioural therapy (CBT) as previously recommended,1 other psychological treatments that have shown promise in recent years include behavioural activation8 and mindfulness based therapies,9 and these could offer more alternatives to antidepressants in the future.
This article summarises new recommendations on management of depression most relevant to primary care and services providing psychological therapies, from the NICE guideline published in June 2022,10 updating and replacing the 2009 guideline.1
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee (GC)’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. Definitions of evidence certainty (GRADE) are given in box 1.
In the new guideline, depression is classified as “less severe” and “more severe,” because the NICE 2009 recommendations, split into “mild to moderate” and “moderate to severe,” left ambiguity for moderate depression.1 More severe includes moderate and severe, and less severe includes mild and sub-threshold depression. Sub-threshold was defined as just below the cut-off on a validated depression scale for the evidence reviews. Clinically, sub-threshold is depression with fewer than five symptoms which nevertheless causes functional impairment.1112 All cut-offs are arbitrary to an extent, along a continuum of severity.
Tables 1 and 2 are modified from the guideline, and list recommended treatments for less severe and more severe depression, respectively, based on clinical and cost effectiveness evidence, informed by network meta-analysis of candidate treatments, and consideration by the Guideline Committee of factors related to implementation.
Treatment options for new episodes of less severe depression