Depression in adults: treatment and management

Resource impact summary report

This guideline covers identifying, treating, and managing depression in people aged 18 and over. It recommends treatments for first episodes of depression, further-line treatments and provides advice on preventing relapse and managing chronic depression, psychotic depression and depression with a coexisting diagnosis of personality disorder. The guideline updates and replaces the NICE guideline on depression in adults: recognition and management (CG90; published October 2009).

Since the publication of the 2009 guideline, the provision of psychological treatments has been significantly expanded by the Improving Access to Psychological Therapies (IAPT) programme. The NHS Mental Health Implementation Plan 2019/20 – 2023/24 stated that much has already been achieved for mental health across England since 2016. However, it also states that work is still needed to provide quality and timely mental health care for everyone who needs it, and to tackle inequalities in access, experience, and outcomes.

Clinical expert opinion suggests that the previous guideline has not been fully implemented across the country. Many people cannot access psychological therapy due to a shortage of suitably qualified therapists. There are also variations in the choices of psychological treatments available across services, and more work is needed to ensure a meaningful choice of depression treatments for all. Both problems that are being targeted in the NHS Mental Health Implementation Plan 2019/20-2023/24. There are long waiting times to access psychological therapies and other treatments.

Clinical experts also suggest that while significant resource has previously been used to improve primary care (IAPT) psychotherapy provision, this has not been the case for secondary care and will need to be addressed in order to effectively implement the guideline. Therefore, additional resources may be needed to fully implement the updated guideline.

The prevalence of adults with depression in England has steadily increased from 10.8% (4.8 million) in 2018/19 and 11.6% (5.1 million) in 2019/20 to around 12.3% in 2020/21 (Quality and Outcomes Framework, 2020-21), equivalent to around 5.4 million people. Further, the Office for National Statistics (ONS) reported that during the COVID-19 pandemic the prevalence of moderate or severe depressive symptoms among adults rose after the start of the pandemic. Therefore, the number of adults with depression in England may be higher than 5.4 million. Because clinical experts suggest the previous guideline has not been fully implemented this increase in prevalence may add further pressure and also increase the resource requirements for existing services.

As the previous guideline has not been fully implemented and the prevalence of depression is increasing, depending on current local practice, the following areas may require additional resources and result in additional costs to implement the guideline:

• expanding and improving access to IAPT services, or interventions offered by other NHS services, outside or in partnership with the NHS
• providing a wide range of NICE approved psychological therapies other than cognitive behavioural therapy (CBT), in both IAPT and secondary care services to comply with recommendations on choice of treatments
• expanding the availability and choice of psychotherapy in secondary care; this also relates to the new recommendation for combined CBT-antidepressant as first choice for moderate-severe depression, which, based on clinical expert opinion, is the dominant type of depression in secondary care
• new training programmes and additional training for both medical and non-medical staff; also, additional staff to ensure a wide range of NICE-recommended therapies can be delivered including monitoring access to the treatments
• extra time to assess risk or relapse, discuss treatment options and choices, and extra follow-up psychological sessions aimed at preventing relapse; this may also have resource implications for secondary care, where many treatment trials may be needed to achieve remission
• extra follow-up psychological sessions aimed at preventing relapse; clinical experts suggest that currently many services do not offer follow-up sessions as the services are not commissioned.

The NHS Mental Health Implementation Plan 2019/20 – 2023/24 states that access to IAPT services will be expanded to meet further demand for IAPT services. The plan commits baseline funding to clinical commissioning groups/integrated care systems of £310 million and £442 million in 2022/23 and 2023/24 respectively for IAPT services for adults with common mental illnesses.

There is also central or transformation funding distributed via Health Education England to improve access to evidence-based care, and to develop new models of integrated primary and community care for adults and older adults with severe mental illnesses. Therefore, in the NHS the updated recommendations may not necessarily result in more costs or resources beyond those covered by the implementation plan. However, any potential additional costs should be assessed at a local level.

Implementing the guideline may result in the following benefits and savings:

• improved access to IAPT services in line with the Five Year Forward View for Mental Health and Long-Term Plan commitments
• improved health and quality of life from early or better coordinated treatment that facilitates recovery, therefore preventing the need for more costly intensive treatments and support in the future
• reduced referrals to secondary care and inpatient admissions resulting from improved adherence with therapy and better outcomes
• fewer long-term prescriptions for antidepressant medication through effective safe prescribing and withdrawal management practice in line with the NICE guideline on medicines associated with dependence or withdrawal symptoms
• an increased range of interventions; therefore, increased choice of cost-effective treatment options available to people with depression; also, this may result in reduced variation in the treatments offered across the country.

The benefits and savings will accrue to both the NHS and social care organisations.

The resource impact summary report can be used in conjunction with the local resource impact template developed for the NICE guideline on medicines associated with dependence or withdrawal symptoms. Organisations can use the template to estimate the potential cost saving that may result from reduced use of long-term antidepressants.

Services for people with depression are commissioned by integrated care systems or clinical commissioning groups, NHS England and local authorities. Providers are primary care organisations, GPs, secondary care providers and mental health trusts. Providers may also be charities and third sector organisations. Services may be in cross-organisation community based models.