Professor Christopher Dowrick highlights the main recommendations from NICE Clinical Guideline 91 and discusses the stepped-care model on interventions
Depression is approximately two-to-three times more common in patients with a chronic physical health problem than in patients who have good physical health.1 It occurs in around 20% of people with a chronic physical health problem,2 such as cancer, heart disease, diabetes, musculoskeletal disorders, respiratory conditions, or neurological disease. A chronic physical health problem can both cause and exacerbate depression:3,4
- Pain, functional impairment, and disability associated with chronic physical health problems can greatly increase the risk of depression in people with physical illness
- Depression can exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes, including shortening life expectancy.
Depression often has a remitting and relapsing course, and symptoms may persist between episodes. Depressive symptoms below standard threshold criteria can be distressing and disabling if persistent. Furthermore, depression can be a risk factor in the development of a range of physical illnesses, such as cardiovascular disease.5 If a person has both depression and a chronic physical health problem, functional impairment is likely to be greater than if a person has depression or the physical health problem alone.6 Where possible, the key goal of an intervention for depression should be complete relief of symptoms. This is associated with better functioning7 and perhaps with better physical health outcomes.8 Treating depression in people with a chronic physical health problem may increase their quality of life and life expectancy.
In view of the substantial increase in research into depression during the previous 5 years, NICE updated its advice on the condition in the form of two guidelines: Clinical Guideline 90 (CG90) on the treatment and management of depression in adults (discussed in the December 2009 issue of Guidelines in Practice);9 and Clinical Guideline 91 (CG91) on the treatment and management of this condition in adults with a chronic physical health disorder.10 Given the high prevalence of depression in people with chronic physical health problems, and the potential complexity of management, it was felt necessary to have a separate guideline for this important group of patients. This article highlights the recommendations from CG91.
Identification and assessment
The presence of a physical illness can complicate the assessment of depression. Some symptoms, such as fatigue, are common to both mental and physical disorders. The NICE guideline advises practitioners to be alert to possible depression, particularly in patients with a past history of depression or a chronic physical health problem with associated functional impairment.10 It recommends asking two screening questions, specifically:10–11
- 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 the answer to either question is yes, it is worth proceeding to a fuller assessment. When assessing a patient with a chronic physical health problem who may have depression, the guideline emphasises the need to conduct a comprehensive assessment that does not rely simply on a symptom count. It advises taking into account both the degree of functional impairment and disability associated with the possible depression, and the duration of the episode.10 The guideline recommends consideration of how the following factors may have affected the development, course, and severity of a patient’s depression:
- Any history of depression and co-morbid 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.
During patient assessment of depression, there is a need to:10
- be, as always, sensitive to diverse cultural, ethnic, and religious backgrounds
- be aware of any learning disabilities or acquired cognitive impairments
- ask directly about suicidal ideation and intent.
Treatment and management
The NICE guideline contains a stepped-care model that provides a framework in which to organise the provision of services for patients with a chronic physical health problem and a diagnosis of depression (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.10 There is a strong emphasis throughout the guideline on active monitoring, involving regular clinical review of the patient’s condition.
|Figure 1: The stepped-care model10|
*Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric co-morbidity or psychosocial factors.
Low-intensity psychosocial interventions
For patients with persistent sub-threshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for patients with sub-threshold depressive symptoms that complicate the care of the chronic physical health problem, the NICE guideline found evidence to support one or more of the following interventions, guided by the patient’s preference:10
- 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).
Treatment for moderate depression
For patients with initial presentation of moderate depression and a chronic physical health problem, the guideline found evidence to support the following choice of high-intensity psychological interventions:10
- group-based CBT
- individual CBT for patients who decline group-based CBT or for whom it is not appropriate, or where a group is not available
- 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.
The NICE Guideline Development Group did not find sufficient evidence to recommend the routine use of antidepressants to treat sub-threshold depressive symptoms or mild depression in patients with a chronic physical health problem because the risk–benefit ratio is poor. However there was evidence supporting their use in patients with:10
- a past history of moderate or severe depression or
- mild depression that complicates the care of the physical health problem or
- initial presentation of sub-threshold depressive symptoms that have been present for a long period (typically at least 2 years) or
- sub-threshold depressive symptoms or mild depression that persist(s) after other interventions.
If an antidepressant is to be prescribed for a patient with depression and a chronic physical health problem, it is important to take into account: the presence of additional physical health disorders; the side-effects of antidepressants, which may impact on the underlying physical disease; and interactions with other medications.
There is no evidence to support the use of specific antidepressants for patients with particular chronic physical health problems,10 however, it is worth considering using citalopram or sertraline in the first instance because their cost–benefit ratio appears favourable,12 and they have less propensity for interactions. Selective serotonin reuptake inhibitors should be the first-line drug treatment for depression associated with physical illness.
The NICE guideline recommends 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.10 This recommendation is based on consistent evidence of benefit on a range of depression outcomes.13,14 Collaborative care has four essential components:10
- collaborative definition of a problem
- focus on specific, jointly agreed objectives
- a range of self-management and support services
- active and sustained follow-up.
Priorities for implementation
Most of the advice offered in the guideline is based on existing evidence of good clinical practice, and is therefore readily implementable. Ways of addressing two potential obstacles are considered below.
Limited consultation time
The need for careful and comprehensive assessment of patients with a chronic physical health problem who may have depression is clear, but the time involved in such an assessment may sometimes be problematic for busy GPs. One method of addressing this problem could be to involve other members of the extended primary care and community mental health teams in making such assessments. Follow up and monitoring of patients diagnosed with depression has been facilitated by recent amendments to the quality and outcomes framework.15
Access to services
The availability of specified psychosocial interventions, and of collaborative care programmes, is patchy across England and Wales. Therefore it may not always be possible for GPs to refer patients to the most appropriate intervention according to the stepped-care model. However there are government policy initiatives aimed towards increasing the availability of patient-led self-management groups16 and evidence-based psychosocial interventions.17 The best methods for delivering collaborative care to patients with depression within the UK healthcare systems are currently being investigated.18
The GP retains a central role in the diagnosis of depression in the context of physical illness. The NICE guideline gives the GP valuable information about what interventions are likely to be helpful in ongoing management, and hence should increase the confidence of both GP and patient in the likelihood of successful outcomes.
|NICE implementation tools|
NICE has developed the following tools to support implementation of Clinical Guideline 91 on Depression in adults with a chronic physical health problem. They are now available to download from the NICE website: www.nice.org.uk
A costing statement is available, which highlights the difficulties in estimating the national cost impact of NICE Clinical Guideline 91. It discusses possible areas of cost and resource shift relating to implementing the guideline recommendations.
The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.
- Egede L. Major depression in individuals with chronic medical disorders: Prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatry 2007; 29 (5): 409–416.
- Moussavi S, Chatterji S, Verdes E et al. Depression, chronic disease, and decrements in health: Results from the World Health Surveys. Lancet 2007; 370 (9590): 851–858.
- Cassano P, Fava M. Depression and public health: an overview. J Psychosom Res 2002; 54 (4): 849–857.
- Van Melle J, De Jonge P, Honig A et al. Effects of antidepressant treatment following myocardial infarction. Br J Psychiatry 2007; 190: 460–466.
- Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosom Med 1996; 58 (2): 99–110.
- Von Korff M, Katon W, Lin E et al. Potentially modifiable factors associated with disability among people with diabetes. Psychosom Med 2005; 67 (2): 233–240.
- Von Korff M, Scott K, Gureje O. Mind, Body, and Health: Global perspectives on mental disorders and physical illness from the World Mental Health Surveys (in press).
- Gilbody S, Bower P, Gask L et al. Is collaborative care effective for depression in the presence of physical illness? (in press).
- National Institute for Health and Care Excellence. Depression: the treatment and management of depression in adults (update). Clinical Guideline 90. London: NICE, 2009.Available at: www.nice.org.uk/guidance/CG90
- National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: Treatment and management. Clinical Guideline 91. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG91
- Whooley M, Avins A, Miranda J, Browner W. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997; 12 (7): 439–445.
- Cipriani A, Furukawa T, Salanti G et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 2009; 373 (9665): 746–758.
- Ell K, Unutzer J, Aranda M et al. Managing depression in home health care: a randomized clinical trial. Home Health Care Serv Q 2007; 26 (3): 81–104.
- Fortney J, Pyne J, Edlund M et al. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med 2007; 22 (8): 1086–1093.
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. London: BMA, NHS Employers, 2009.
- Rogers A, Kennedy A, Bower P et al. The United Kingdom Expert Patients Programme: results and implications from a national evaluation. Med J Australia 2008; 189 (Suppl 10): S21–24.
- Department of Health. IAPT commissioning for the whole community. London: DH, 2008.
- Richards D, Hughes-Morley A, Hayes R et al. Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression—study protocol. BMC Health Services Research 2009; 16 (9): 188. G
- Depression in patients with a chronic physical health problem can be effectively identified by using simple screening tools (as advised in the QOF for patients with coronary heart disease and diabetes)
- The guideline recommends that mild depression is best treated with non-pharmacological measures
- PBC collectives should work with PCTs, local trusts, the voluntary sector, and local authorities to commission a portfolio of such interventions
- Exercise-on-prescription schemes are useful and an evidence-based intervention for depression
- The IAPT scheme is being rolled out across England and could be adapted locally to meet needs
- Mental health services fall outside of the mandatory tariff for 2010
QOF=quality and outcomes framework; PBC=practice-based commissioning; PCT=primary care trust; IAPT=improving access to psychological therapies