NHS to give therapy for depression before medication under new guidelines

Millions of people with mild depression in England should be offered therapy, exercise, mindfulness or meditation before antidepressants, according to the first new NHS guidelines in more than a decade.

Under draft guidance, the National Institute for Health and Care Excellence (Nice) recommends the “menu of treatment options” be offered to patients by health professionals before medication is considered.

Currently, those with mild depression are offered antidepressants or a high-intensity psychological intervention, such as cognitive behavioural therapy (CBT). The shake-up forms part of the first new recommendations to identify, treat and manage depression in adults since 2009.

According to the Office for National Statistics (ONS), about one in six (17%) adults experienced some form of depression this summer. The rate is higher than before the pandemic, when 10% of adults experienced it. Younger adults and women are more likely to be affected, the ONS found.

A 2019 review showed 17% of the adult population in England (7.3 million people) had been prescribed antidepressants in the year 2017-18.

Dr Paul Chrisp, director of the centre for guidelines at Nice, said: “The Covid-19 pandemic has shown us the impact depression has had on the nation’s mental health. People with depression need these evidence-based guideline recommendations available to the NHS, without delay.”

Under the changes, those with “less severe depression”, which includes people with mild depression, should be involved in conversations with doctors about what would suit them best, but group cognitive behavioural therapy (CBT) could be offered as a first treatment. CBT “focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently”.

This could be followed by offers of seven other treatments including individual CBT, self help, group exercise or group mindfulness or meditation, before medication is discussed as an option.

Group exercise will typically involve three 60-minute sessions a week for 10 weeks, Nice said. Alternatively, patients could opt for group mindfulness or meditation, which Nice said usually consist of eight weekly two-hour sessions and focus on “concentrating on the present, observing and sitting with thoughts and feelings and bodily sensations, and breathing exercises”.

The guideline adds: “Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference.”

A similar range of psychological interventions, along with the option of antidepressant medication, should be available to those choosing a first-line treatment for “more severe depression”.

When considering treatment options, Nice said people should also be encouraged to discuss what may be contributing to their depression, and the patient’s experience of any prior episodes of depression or treatments.

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.”

The guidance recommends doctors discuss mental health waiting lists with patients. It also contains new recommendations for those stopping antidepressants.

People who are considering taking, or stopping, antidepressants medication should talk with their healthcare professional about the benefits and risks, Nice said. Doctors 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.

Figures from the NHS Business Services Authority show more than 20 million antidepressants were prescribed between October and December 2020 – a 6% increase compared with the same three months in 2019.

“There has been significant progress in science and medicine in the past 12 years,” said retired solicitor Catherine Ruane, a lay member on the guideline committee who acted as a carer to two family members with depression. “This guideline emphasises a greater amount of patient choice and takes greater account of the things that really matter to the patients and their carers.”

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• Mental health
• National Institute for Health and Care Excellence
• NHS
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• England
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