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| Step | Focus of the Intervention |
Nature of the Intervention |
| Step 4: | Severe and complex depression; risk to life; severe neglect | Medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multiprofessional and inpatient care |
| Step 3: | Persistent sub-threshold 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 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 |
Assessment of a patient for depression should be a comprehensive assessment that does not rely simply on a symptom count. It is important to consider the degree of functional impairment and / or disability associated with the possible depression, and the duration of the episode.
Antidepressants are not recommended in the initial treatment of mild depression i.e. step 1, because the risk-benefit ratio is poor.
Consider antidepressants in people with a past history of moderate or severe depression.
Consider antidepressants in people where symptoms persist after other interventions have been used.
Antidepressants are not routinely recommended for the treatment of persistent subthreshold depression because the risk-benefit ratio is poor.
Consider antidepressants in people with a history of moderate or severe depression.
Consider antidepressants in people with an initial presentation of subthreshold depressive symptoms that have been present for a long period, typically at least 2 years.
Consider antidepressants in people where symptoms persist after other interventions have been used.
Antidepressants should be prescribed alongside a high-intensity psychological intervention e.g. CBT or IPT.
Support and encourage patients who have benefitted from taking an antidepressant to continue medication for at least 6 months after remission of an episode of depression
Patients at risk of relapse i.e. those with a history of relapse despite antidepressant medication, or who have been unable to continue antidepressant treatment, or who have residual symptoms should be offered one of the following psychological interventions:
Individual CBT for people who have relapsed despite antidepressant medication; for people with a significant history of depression; for people with residual symptoms despite treatment.
Mindfulness-based cognitive therapy for people who are currently well but have experienced 3 or more previous episodes of depression.
Watchful waiting, a telephone call or consultation monthly.
A consultation or telephone call every 2 weeks.
A consultation or telephone call every week.
It is important to maintain regular contact with the patient with a moderate or severe depression in order to ensure concordance with their antidepressant medication and to ensure there is no relapse of symptoms.
All patients:
Consultation or telephone call every 2-3 months following remission.
Depression is often a chronic disease and continuation of antidepressants for 4-9 months after achieving remission helps to reduce relapse. NICE 2009 recommends continuation of antidepressants for 6 months after remission of symptoms.
40-50% of depressed patients may experience a new episode of depression within 2 years of a first episode of major depression.
Following recurrence of depression the relapse rate increases to 75%.
Long-term maintenance on antidepressants for patients with a recurrence of depression significantly reduces recurrence.
Many patients with a recurrence of symptoms do not seek help immediately, annual monitoring of patients with a history of depression may therefore be useful to detect early signs of relapse.
Clinicians should maintain a high level of suspicion when this group of patients are seen in the interim for other problems.
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and informative material on the subject of depression. Last updated 10 February 2012 Website designed and created by Penny Louch |
