The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
Box 1 Depression definitions (taken from DSM-IV)
Subthreshold depressive symptoms: Fewer than 5 symptoms of depression.
Mild depression: Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment.
Moderate depression: Symptoms of functional impairment are between 'mild' and 'severe'.
Severe depression: Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.
Not that a comprehensive assessment of depression should not rely simply on a symptom count, but should take into account the degree of functional impairment and/or disability (see the section on principles for assessment, coordination of care and choosing treatments).
Throughout this guideline, the term 'patient' is used to denote a person who has both depression and a chronic physical health problem.
This guideline is published alongside NICE's guideline on depression in adults: treatment and management, which makes recommendations on the identification, treatment and management of depression in adults aged 18 years and older, in primary and secondary care.
People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Healthcare professionals should follow our general guidelines for people delivering care:
When assessing a patient with a chronic physical health problem who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode.
In addition to assessing symptoms and associated functional impairment, consider how the following factors may have affected the development, course and severity of a patient's depression:
any history of depression and comorbid mental health or physical disorders
any past history of mood elevation (to determine if the depression may be part of bipolar disorder)
any past experience of, and response to, treatments
the quality of interpersonal relationships
living conditions and social isolation.
When assessing a patient with a chronic physical health problem and suspected depression, be aware of any learning disabilities or acquired cognitive impairments, and if necessary consider consulting with a relevant specialist when developing treatment plans and strategies.
When providing interventions for patients with a learning disability or acquired cognitive impairment who have a chronic physical health problem and a diagnosis of depression:
where possible, provide the same interventions as for other patients with depression
if necessary, adjust the method of delivery or duration of the intervention to take account of the disability or impairment.
Always ask patients with depression and a chronic physical health problem directly about suicidal ideation and intent. If there is a risk of self-harm or suicide:
assess whether the patient has adequate social support and is aware of sources of help
arrange help appropriate to the level of risk (see section on risk assessment and monitoring)
advise the patient to seek further help if the situation deteriorates.
All interventions for depression should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:
receive regular high-quality supervision
use routine outcome measures and ensure that the patient with depression is involved in reviewing the efficacy of the treatment
engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny where appropriate.
Where a patient's management is shared between primary and secondary care, there should be clear agreement between practitioners (especially the patient's GP) on the responsibility for the monitoring and treatment of that patient. The treatment plan should be shared with the patient and, where appropriate, with their family or carer.
If a patient's chronic physical health problem restricts their ability to engage with a preferred psychosocial or psychological treatment for depression (see sections on low-intensity psychosocial interventions, treatment options and psychological interventions), consider alternatives in discussion with the patient, such as antidepressants (see the section on antidepressant drugs) or delivery of psychosocial or psychological interventions by telephone if mobility or other difficulties prevent face-to face contact.
The stepped-care model provides a framework in which to organise the provision of services, and supports patients, carers and practitioners in identifying and accessing the most effective interventions (see figure 1). In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.
| Focus of the intervention | Nature of the intervention |
|---|---|
|
STEP 4: Severe and complex depression; risk to life; severe self-neglect |
Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care |
|
STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression |
Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions |
|
STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression |
Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions |
|
STEP 1: All known and suspected presentations of depression |
Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions |
Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors.
Collaborative care for step 3 is only for depression where the person has a chronic physical health problem and associated functional impairment.
The recommendations in this section are primarily for practitioners working in primary care and in general hospital settings. Practitioners should be aware that patients with a chronic physical health problem are at a high risk of depression, particularly where there is functional impairment.
Be alert to possible depression (particularly in patients with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking patients who may have depression 2 questions, specifically:
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
If a patient with a chronic physical health problem answers 'yes' to either of the depression identification questions (see recommendation 1.3.1.1) but the practitioner is not competent to perform a mental health assessment, they should refer the patient to an appropriate professional. If this professional is not the patient's GP, inform the GP of the referral.
If a patient with a chronic physical health problem answers 'yes' to either of the depression identification questions (see recommendation 1.3.1.1), a practitioner who is competent to perform a mental health assessment should:
ask 3 further questions to improve the accuracy of the assessment of depression, specifically:
during the last month, have you often been bothered by feelings of worthlessness?
during the last month, have you often been bothered by poor concentration?
during the last month, have you often been bothered by thoughts of death?
review the patient's mental state and associated functional, interpersonal and social difficulties
consider the role of both the chronic physical health problem and any prescribed medication in the development or maintenance of the depression
ascertain that the optimal treatment for the physical health problem is being provided and adhered to, seeking specialist advice if necessary.
When assessing a patient with suspected depression, consider using a validated measure (for example, for symptoms, functions and/or disability) to inform and evaluate treatment.
For patients with significant language or communication difficulties, for example patients with sensory impairments or a learning disability, consider using the Distress Thermometer and/or asking a family member or carer about the patient's symptoms to identify possible depression. If a significant level of distress is identified, investigate further.
If a patient with depression and a chronic physical health problem presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services.
Advise patients with depression and a chronic physical health problem of the potential for increased agitation, anxiety and suicidal ideation in the initial stages of treatment for depression; actively seek out these symptoms and:
ensure that the patient knows how to seek help promptly
review the patient's treatment if they develop marked and/or prolonged agitation.
Advise a patient with depression and a chronic physical health problem, and their family or carer, to be vigilant for mood changes, negativity and hopelessness, and suicidal ideation, and to contact their practitioner if concerned. This is particularly important during high-risk periods, such as starting or changing treatment and at times of increased personal stress.
If a patient with depression and a chronic physical health problem is assessed to be at risk of suicide:
take into account toxicity in overdose if an antidepressant is prescribed or the patient is taking other medication; if necessary, limit the amount of drug(s) available
consider increasing the level of support, such as more frequent direct or telephone contacts
consider referral to specialist mental health services.
When depression is accompanied by symptoms of anxiety, the first priority should usually be to treat the depression. When the patient has an anxiety disorder and comorbid depression or depressive symptoms, consult the NICE guideline for the relevant anxiety disorder (see the NICE topic page on depression) and consider treating the anxiety disorder first (since effective treatment of the anxiety disorder will often improve the depression or the depressive symptoms).
Offer patients with depression and a chronic physical health problem advice on sleep hygiene if needed, including:
establishing regular sleep and wake times
avoiding excess eating, smoking or drinking alcohol before sleep
creating a proper environment for sleep
taking regular physical exercise where this is possible for the patient.
For patients who, in the judgement of the practitioner, may recover with no formal intervention, or patients with mild depression who do not want an intervention, or patients with subthreshold depressive symptoms who request an intervention:
discuss the presenting problem(s) and any concerns that the patient may have about them
provide information about the nature and course of depression
arrange a further assessment, normally within 2 weeks
make contact if the patient does not attend follow-up appointments.
For patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering one or more of the following interventions, guided by the patient's preference:
a structured group physical activity programme
a group-based peer support (self-help) programme
individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
computerised cognitive behavioural therapy (CCBT).
Physical activity programmes for patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, should:
be modified (in terms of the duration of the programme and frequency and length of the sessions) for different levels of physical ability as a result of the particular chronic physical health problem, in liaison with the team providing care for the physical health problem
be delivered in groups with support from a competent practitioner
consist typically of 2 or 3 sessions per week of moderate duration (45 minutes to 1 hour) over 10 to 14 weeks (average 12 weeks)
be coordinated or integrated with any rehabilitation programme for the chronic physical health problem.
Group-based peer support (self-help) programmes for patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, should:
be delivered to groups of patients with a shared chronic physical health problem
focus on sharing experiences and feelings associated with having a chronic physical health problem
be supported by practitioners who should:
facilitate attendance at the meetings
have knowledge of the patients' chronic physical health problem and its relationship to depression
review the outcomes of the intervention with the individual patients
consist typically of 1 session per week delivered over a period of 8 to 12 weeks.
Individual guided self-help programmes based on the principles of CBT (and including behavioural activation and problem-solving techniques) for patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, should:
include the provision of written materials of an appropriate reading age (or alternative media to support access)
be supported by a trained practitioner, who typically facilitates the self-help programme and reviews progress and outcome
consist of up to 6 to 8 sessions (face-to-face and via telephone) normally taking place over 9 to 12 weeks, including follow-up.
CCBT for patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem, should:
be provided via a stand-alone computer-based or web-based programme
include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner, who typically provides limited facilitation of the programme and reviews progress and outcome
typically take place over 9 to 12 weeks, including follow-up.
Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild depression in patients with a chronic physical health problem (because the risk–benefit ratio is poor), but consider them for patients with:
a past history of moderate or severe depression or
mild depression that complicates the care of the physical health problem or
initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
subthreshold depressive symptoms or mild depression that persist(s) after other interventions.
Although there is evidence that St John's wort may be of benefit in mild or moderate depression, practitioners should:
not prescribe or advise its use by patients with depression and a chronic physical health problem because of uncertainty about appropriate doses, persistence of effect, variation in the nature of preparations and potential serious interactions with other drugs (including oral contraceptives, anticoagulants and anticonvulsants)
advise patients with depression of the different potencies of the preparations available and of the potential serious interactions of St John's wort with other drugs.
For patients with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem who have not benefited from a low-intensity psychosocial intervention, discuss the relative merits of different interventions with the patient and provide:
an antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]) or
one of the following high-intensity psychological interventions:
group-based CBT or
individual CBT for patients who decline group-based CBT or for whom it is not appropriate, or where a group is not available or
behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.
For patients with initial presentation of moderate depression and a chronic physical health problem, offer the following choice of high-intensity psychological interventions:
group-based CBT or
individual CBT for patients who decline group-based CBT or for whom it is not appropriate, or where a group is not available or
behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.
For patients with initial presentation of severe depression and a chronic physical health problem, consider offering a combination of individual CBT and an antidepressant.
The choice of intervention should be influenced by the:
duration of the episode of depression and the trajectory of symptoms
previous course of depression and response to treatment
likelihood of adherence to treatment and any potential adverse effects
course and treatment of the chronic physical health problem
patient's treatment preference and priorities.
For additional considerations on using antidepressants and other medications (including the assessment of the relative risks and benefits) for women who may become pregnant, please refer to the BNF and individual drug summary of product characteristics. For women in the antenatal and postnatal periods, also see also the NICE guideline on antenatal and postnatal mental health.
When an antidepressant is to be prescribed for a patient with depression and a chronic physical health problem, take into account the following:
the presence of additional physical health disorders
the side effects of antidepressants, which may impact on the underlying physical disease (in particular, SSRIs may result in or exacerbate hyponatraemia, especially in older people)
that there is no evidence as yet supporting the use of specific antidepressants for patients with particular chronic physical health problems
interactions with other medications.
When an antidepressant is to be prescribed, be aware of drug interactions and:
refer to appendix 1 of the BNF and the table of interactions in appendix 16 of the full guideline for information
seek specialist advice if there is uncertainty
if necessary, refer the patient to specialist mental health services for continued prescribing.
First prescribe an SSRI in generic form unless there are interactions with other drugs; consider using citalopram or sertraline because they have less propensity for interactions.
When prescribing antidepressants, be aware that:
dosulepin should not be prescribed
non-reversible monoamine oxidase inhibitors (MAOIs; for example, phenelzine), combined antidepressants and lithium augmentation of antidepressants should normally be prescribed only by specialist mental health professionals.
Take into account toxicity in overdose when choosing an antidepressant for patients at significant risk of suicide. Be aware that:
compared with other equally effective antidepressants recommended for routine use in primary care, venlafaxine is associated with a greater risk of death from overdose
tricyclic antidepressants (TCAs), except for lofepramine, are associated with the greatest risk in overdose.
Do not normally offer SSRIs to patients taking non-steroidal anti-inflammatory drugs (NSAIDs) because of the increased risk of gastrointestinal bleeding. Consider offering an antidepressant with a lower propensity for, or a different range of, interactions, such as mianserin, mirtazapine, moclobemide, reboxetine or trazodone.
If no suitable alternative antidepressant can be identified, SSRIs may be prescribed at the same time as NSAIDs if gastroprotective medicines (for example, proton-pump inhibitors) are also offered.
Do not normally offer SSRIs to patients taking warfarin or heparin because of their anti-platelet effect.
Use SSRIs with caution in patients taking aspirin. When aspirin is used as a single agent, consider alternatives that may be safer, such as trazodone, mianserin or reboxetine.
If no suitable alternative antidepressant can be identified, SSRIs may be prescribed at the same time as aspirin if gastroprotective medicines (for example, proton-pump inhibitors) are also offered.
Consider offering mirtazapine to patients taking heparin, aspirin or warfarin (but note that when taken with warfarin, the international normalised ratio [INR] may increase slightly).
Do not offer SSRIs to patients receiving 'triptan' drugs for migraine. Offer a safer alternative such as mirtazapine, trazodone, mianserin or reboxetine.
Do not normally offer SSRIs at the same time as monoamine oxidase B (MAO‑B) inhibitors such as selegiline and rasagiline. Offer a safer alternative such as mirtazapine, trazodone, mianserin or reboxetine.
Do not normally offer fluvoxamine to patients taking theophylline, clozapine, methadone or tizamidine. Offer a safer alternative such as sertraline or citalopram.
Offer sertraline as the preferred antidepressant for patients taking flecainide or propafenone, although mirtazapine and moclobemide may also be used.
Do not offer fluoxetine or paroxetine to patients taking atomoxetine. Offer a different SSRI.
When prescribing antidepressants, explore any concerns the patient with depression and a chronic physical health problem has about taking medication, explain fully the reasons for prescribing, and provide information about taking antidepressants, including:
the gradual development of the full antidepressant effect
the importance of taking medication as prescribed and the need to continue treatment after remission
potential side effects
the potential for interactions with other medications
the risk and nature of discontinuation symptoms with all antidepressants, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine), and how these symptoms can be minimised
the fact that addiction does not occur with antidepressants.
Offer written information appropriate to the patient's needs.
Prescribe antidepressant medication at a recognised therapeutic dose for patients with depression and a chronic physical health problem (that is, avoid the tendency to prescribe at subtherapeutic doses in these patients).
For patients started on antidepressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter, for example at intervals of 2 to 4 weeks in the first 3 months, and then at longer intervals if response is good.
A patient with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important.
If a patient with depression and a chronic physical health problem develops side effects early in antidepressant treatment, provide appropriate information and consider one of the following strategies:
monitor symptoms closely where side effects are mild and acceptable to the patient or
stop the antidepressant or change to a different antidepressant if the patient prefers or
in discussion with the patient, consider short-term concomitant treatment with a benzodiazepine if anxiety, agitation and/or insomnia are problematic, but:
do not offer benzodiazepines to patients with chronic symptoms of anxiety
use benzodiazepines with caution in patients at risk of falls
in order to prevent the development of dependence, do not use benzodiazepines for longer than 2 weeks.
Support and encourage a patient with a chronic physical health problem who has benefited from taking an antidepressant to continue medication for at least 6 months after remission of an episode of depression. Discuss with the patient that:
this greatly reduces the risk of relapse
antidepressants are not associated with addiction.
Review with the patient with depression and a chronic physical health problem the need for continued antidepressant treatment beyond 6 months after remission, taking into account:
the number of previous episodes of depression
the presence of residual symptoms
concurrent physical health problems and psychosocial difficulties.
More detailed advice on switching, sequencing, augmenting and combining antidepressants can be found in the section on further-line treatment in the NICE guideline on depression in adults. The recommendations below should be considered alongside recommendations 1.5.2.6 to 1.5.2.16 in the section on interactions of SSRIs with other medication in the current guideline.
If the patient's depression shows no improvement after 2 to 4 weeks with the first antidepressant, check that the drug has been taken regularly and in the prescribed dose.
If response is absent or minimal after 3 to 4 weeks of treatment with a therapeutic dose of an antidepressant, increase the level of support (for example, by weekly face-to-face or telephone contact) and consider:
increasing the dose in line with the summary of product characteristics if there are no significant side effects or
switching to another antidepressant as described in the section on further-line treatment in the NICE guideline on depression in adults if there are side effects or if the patient prefers.
If the patient's depression shows some improvement by 4 weeks, continue treatment for another 2 to 4 weeks. Consider switching to another antidepressant as described in the section on further-line treatment in the NICE guideline on depression in adults if:
response is still not adequate or
there are side effects or
the patient prefers to change treatment.
When switching from 1 antidepressant to another, be aware of:
the need for gradual and modest incremental increases in dose
interactions between antidepressants
the risk of serotonin syndrome (features include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus) when combinations of serotonergic antidepressants are prescribed.
If an antidepressant has not been effective or is poorly tolerated:
consider offering other treatment options, including high-intensity psychological treatments (see the section on psychological interventions)
prescribe another single antidepressant (which can be from the same class) if the decision is made to offer a further course of antidepressants.
Advise patients with depression and a chronic physical health problem who are taking antidepressants that discontinuation symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. These include increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating, abdominal symptoms and altered sensations. Explain that symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly.
When stopping an antidepressant, gradually reduce the dose, normally over a 4‑week period, although some patients may require longer periods, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine). This is not required with fluoxetine because of its long half-life.
Inform the patient that they should seek advice from their practitioner if they experience significant discontinuation symptoms. If discontinuation symptoms occur:
monitor symptoms and reassure the patient if symptoms are mild
consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms.
Delivering high-intensity psychological interventions
For all high-intensity psychological interventions, the duration of treatment should normally be within the limits indicated in this guideline. As the aim of treatment is to obtain significant improvement or remission the duration of treatment may be:
reduced if remission has been achieved
increased if progress is being made, and there is agreement between the practitioner and the patient with depression that further sessions would be beneficial (for example, if there is a comorbid personality disorder or psychosocial factors that impact on the patient's ability to benefit from treatment).
Group-based CBT for patients with depression and a chronic physical health problem should be:
delivered in groups (typically of between 6 and 8 patients) with a common chronic physical health problem
typically delivered over a period of 6 to 8 weeks.
Individual CBT for patients with moderate depression and a chronic physical health problem should be:
delivered until the symptoms of depression have remitted (over a period that is typically 6 to 8 weeks and should not normally exceed 16 to 18 weeks)
followed up by 2 further sessions in the 6 months after the end of treatment, especially if treatment was extended.
Individual CBT for patients with severe depression and a chronic physical health problem should be:
delivered until the symptoms of depression have remitted (over a period that is typically 16 to 18 weeks)
focused in the initial sessions (which typically should take place twice weekly for the first 2 to 3 weeks) on behavioural activation
followed up by 2 or 3 further sessions in the 12 months after the end of treatment.
Behavioural couples therapy for depression should normally be based on behavioural principles, and an adequate course of therapy should be 15 to 20 sessions over 5 to 6 months.
Collaborative care, which should form part of a well-developed stepped-care programme, could be provided at the primary or secondary care level. The interventions, which involve all sectors of care, require a coordinated approach to mental and physical healthcare, as well as a dedicated coordinator of the intervention located in and receiving support from a multi‑professional team, joint determination of the plan of care, and long-term coordination and follow-up.
Consider collaborative care for patients with moderate to severe depression and a chronic physical health problem with associated functional impairment whose depression has not responded to initial high-intensity psychological interventions, pharmacological treatment or a combination of psychological and pharmacological interventions.
Collaborative care for patients with depression and a chronic physical health problem should normally include:
case management which is supervised and has support from a senior mental health professional
close collaboration between primary and secondary physical health services and specialist mental health services
a range of interventions consistent with those recommended in this guideline, including patient education, psychological and pharmacological interventions, and medication management
long-term coordination of care and follow-up.
Practitioners providing treatment in specialist mental health services for patients with complex and severe depression and a chronic physical health problem should:
refer to the NICE guideline on depression in adults
be aware of the additional drug interactions associated with the treatment of patients with both depression and a chronic physical health problem (see recommendations 1.5.2.6 to 1.5.2.16)
work closely and collaboratively with the physical health services.