Professor Carolyn Chew-Graham discusses NICE Clinical Guideline 90 on depression in adults and emphasises the importance of the GP’s role in its implementation
By the year 2020, depression is predicted to be second only to cardiovascular disease in terms of the world’s most disabling diseases.1 The prevalence of depression may be as high as 30% in older people,2 and around 20% in people with chronic physical health problems such as diabetes and heart disease.3,4
The starting point for providing effective treatment for depression is recognition of the problem and the first point of access is usually primary care. Management of patients with depression should be a core part of general practice, but GPs have long been criticised for failing to make the diagnosis or to manage patients appropriately.5,6 Recent work suggests that GPs, by virtue of their longitudinal relationship with patients, are ideally placed to detect depression and are able to rule it out with reasonable accuracy in most individuals who are not depressed, but they may have difficulty diagnosing the condition in all true cases.7
Need for update
In 2004, NICE published Clinical Guideline 23 on the management of depression in primary and secondary care.8 Updates to this guidance were published in October 2009 in the form of two guidelines: Clinical Guideline 90 (CG90) on the treatment and management of depression in adults;9 and Clinical Guideline 91 (CG91) on the treatment and management of this condition in adults with a chronic physical health disorder.10 This article highlights the recommendations from CG90, and it will be followed by a feature in the January 2010 issue of Guidelines in Practice focusing on CG91.
The NICE guideline on depression in adults was updated to provide current evidence-based recommendations on its management, while acknowledging the role of GPs in supporting patients who have been diagnosed with the condition. It shifts the emphasis from screening to identification of depression, and modifies the stepped-care model presented in the original guideline (see Figure 1).9
|Figure 1: The stepped-care model9|
|*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
†Only for depression where the person also has a chronic physical health problem and associated functional impairment (see ‘Depression in adults with a chronic physical health problem: treatment and management’ [NICE Clinical Guideline 91]10)
National Institute for Health and Care Excellence (NICE) (2009) CG90. Depression: the treatment and management of depression in adults (update). London: NICE. Reproduced with permission. Available from www.nice.org.uk/CG90
Role of the general practitioner
Effective communication and established rapport between the GP and patient are vital in enabling patient disclosure of symptoms, assessment, and open discussion of the possibility of depression as a diagnosis. Doctors with poor communication skills and who do not provide time and empathy are more likely to collude with patients, reinforcing beliefs that depression is a result of life circumstances. Patients may not disclose their symptoms unless the GP explores sensitively.11
The original NICE guideline on the management of depression (CG23)8 suggested that the role of the GP was through passive ‘watchful waiting’—a phrase believed by many GPs to undervalue their ongoing work with distressed patients. In contrast, the updated 2009 guideline emphasises the importance of the role of GPs in the support and management of patients with depression. In contrast to the 2004 NICE guideline, the updated guidance, CG90,9 is not as explicit about the role of primary care, specifically where the responsibility of primary care ends, and that of other more specialist providers begin. This is because GPs should be involved in all steps of the model.
General practitioners, however, need to be wary of falsely diagnosing and treating depression; one study has showed that although the probability of prescribing antidepressants in primary care was associated with the severity of the depression, almost half of the patients who were prescribed antidepressants, were not actually depressed.12 Other authors have drawn attention to the dangers of an erroneous diagnosis of depression in patients with a slight psychological malaise and few functional consequences. This can lead to the risk of unnecessary and potentially dangerous medicalisation of distress.13,14
The NICE guideline describes a stepped-care model for the assessment and management of depression (see Figure 1, above, and Table 1, for key learning points).9 This model provides a framework in which to organise the provision of services supporting both patients, carers, and healthcare professionals in identifying and accessing the most effective interventions. The least intrusive, most effective intervention is provided first. If a patient does not benefit from that intervention, or declines an intervention, they should be offered an appropriate intervention from the next step.9
Identification and assessment
General practitioners have an essential part to play in the identification of depression, particularly in people who are at higher risk. The use of two case-identification questions (see Box 1) is advocated by the NICE guideline either opportunistically in consultations with patients with chronic health problems or those with a past history of depression or as part of the holistic clinical assessment of the patient.9 It is hoped that this process will be facilitated by a NICE guideline for primary care that will integrate the identification and assessment of people with common mental health problems and identify care pathways (to be published in 2011).
There is some evidence that a further question, ‘is this something with which you would like help?’, increases the usefulness of the case-identification questions in practice.15 The NICE guideline does not make any recommendations on using this query, but some GPs may believe that this is an important supplementary question, which will help them further explore the patient’s ideas, concerns, and expectations within the consultation. It is recommended that a comprehensive assessment is undertaken, which could include the use of a validated measure (e.g. patient health questionnaire-9 [PHQ-9]).9,16 Clinical assessment should not be based solely on a calculation of the number of symptoms, but should take into account:9
- the degree of associated functional impairment
- the duration of the episode of depression
- past history of depression
- past history of mood elevation
- response to any previous treatment
- the patient’s social situation.
In addition, it is vital that healthcare professionals explore, in partnership with the patient, any suicidal ideas or plans, or any experience of self harm; strategies should be discussed to help prevent the patient from acting on such ideas or plans.9
|Box 1: Case identification questions for depression9|
A ‘no’ response to both questions makes depression highly unlikely
In step 1, NICE suggests that the GP performs ‘active monitoring’ for patients:9
- who may recover with no formal intervention
- with mild depression who prefer not to have an intervention
- with subthreshold depressive symptoms who request an intervention.
Active monitoring should be considered more than simply being prepared to review the patient in 2 weeks (see Table 1).9 General practitioners will require basic skills in counselling, motivational interviewing, and behavioural activation in order to be effective in this role. Clearly, this will have training implications for the profession.
Low-intensity psychosocial interventions
Step 2 states that patients who have a mild to moderate depressive illness should be offered low-intensity psychosocial interventions. The GP should be aware of which services are available in their locality, such as third-sector services (provided by the voluntary sector but commissioned by a local primary care trust), a local improving access to psychological therapies (IAPT) service,17 or a primary care mental health team. The GP needs to be able to explain to a patient what the low-intensity intervention might entail and assess whether the patient would find this acceptable. Therefore, GPs require a working knowledge of the low-intensity interventions recommended by the NICE guideline, which include:9
- computerised cognitive behavioural therapy (cCBT)
- facilitated self-help based on CBT principles
- structured-group physical activity programmes.
Contact with the patient should not end because referral has taken place; indeed the QOF recommends follow up of the patient and a further assessment of symptoms, using PHQ-9, to monitor progress.18
In the stepped-care model (see Figure 1), pharmacological treatments are indicated in steps 2 (depending on presentation and previous treatment), 3 and 4.9 Before prescribing drug treatment, the GP needs to obtain agreement from the patient that they have a depressive illness, which may benefit from drug treatment.
The patient’s views on tablets, and antidepressants in particular, and any myths should be unearthed, discussed, and dispelled. Reassurance is often needed that antidepressants are not addictive. Involvement of the patient in decisions regarding treatment is a fundamental principle. If the patient agrees to try an antidepressant, they can be involved in the choice of medicine. With so many antidepressants to choose from it is important to match the antidepressant to the patient, depending on:9
- drug interactions and contraindications
- previous patient experience of such drugs.
The NICE guideline recommends that, if an antidepressant is required a selective serotonin reuptake inhibitor (SSRI) in generic form should be prescribed first.9 Patients must be told not to expect immediate results and should be advised of commonly occurring side-effects. Information sheets can help to back up discussion within the consultation. It is important to tell the patient at the outset about the risks of discontinuation, symptoms, and how to avoid them, and that they should not stop taking medication once they have recovered.
Patients should be reviewed within 2 weeks of the first prescription and then at least monthly after that. If on review at 2–4 weeks, improvement has not occurred to the satisfaction of the patient, the GP needs to check side-effects and concordance with medication and encourage the patient to persevere with treatment. If after 6–8 weeks, no improvement has occurred, the GP may have discussions with the patient on changing the antidepressant: initially to a different SSRI or a better-tolerated newer-generation antidepressant; and subsequently, an antidepressant of a different pharmacological class that may be less well tolerated. Antidepressants should usually be continued for up to 6 months after recovery, and longer in recurrent depression.9
It is essential that the GP asks the patient if they have used St John’s wort. Although St John’s wort may be of benefit in mild to moderate depression, GPs should not prescribe or advise its use because of uncertainty about appropriate doses, persistence of effect, variation in nature of preparations, and potentially serious interactions with other drugs (including oral contraceptives, anticoagulants, and anticonvulsants).9
High-intensity psychological interventions
Step 3 of the NICE model recommends high-intensity psychological interventions for patients with moderate to severe depression.9 Such interventions focus primarily on CBT and must be delivered by competent therapists (appropriately supervised) within a recognised service, such as IAPT.17 The GP should continue to support the patient while they are waiting for treatment and once discharged from high-intensity therapy.
Supporting the patient
In all steps of the model, the GP needs to provide support to the patient and explore the patient’s views on their problems and decide whether a label of depression is acceptable to the patient. Older patients may require reassurance that depression is not a sign of ‘senility’ or a harbinger of dementia.
The GP should provide information about depression, treatment options, and resources available locally (this constitutes ‘psychoeducation’).9 All practices should have access to leaflets or web-based materials that they can share with patients. Information for patients about sleep hygiene and basic self-help advice should also be readily available.9 The GP should discuss appropriate and available management options, which will be dependent upon the comprehensive assessment and the PHQ-9 score, if used, and by the patient’s views and preferences.
Effective commissioning, appropriate services, and development of care pathways are needed to enable early referral—in the past GPs have felt the need to prescribe rather than leave patients languishing on a long waiting list for a psychological therapy.
Clinical Guideline 90 on the management of depression strengthens the role of the GP, emphasising the need for active follow up and support of people with depression in primary care. The New Horizons initiative,19 which replaces the National Service Framework for Mental Health, stresses the importance of well-being, resilience, prevention, and early intervention, further emphasising the role of the GP in supporting people with, or at risk of, mental health problems. General practitioners need to ensure that they have the skills necessary not only to identify depressive symptoms, but also to provide ongoing support to their patients. Primary care needs to consider the value of the longitudinal relationship20 and the provision of continuity of care to facilitate more effective care for people with depression.
|NICE implementation tools|
NICE has developed the following tools to support implementation of Clinical Guideline 90 on Depression: the treatments and management of depression in adults. 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 90. 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.
- The use of validated tools to assist in diagnosis and to monitor response to treatment is now incentivised in the QOF
- The role of the GP in active monitoring is emphasised
- The NICE guideline reinforces the importance of psychological therapies in the treatment of depression
- Access to these services, however, has been poor, encouraging over-reliance on pharmacotherapy
- Local PBC groups should actively look to commission these services and in particular look to build IAPT into local service provision
- Local care pathways including formulary choice of antidepressants (of low-acquisition cost) and triggers for referral to secondary care and talking therapies could encourage the best use of local resources
- Mental healthcare services for depression are currently outside the scope of payment by results and prices can be negotiated locally
- Murray C, Lopez A. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997; 349 (9064): 1498–1504.
- Van’t Veer-Tazelaar P, van Marwijk H, Jansen A et al. Depression in old age (75+), the PIKO study. J Affect Disord 2008; 106 (3): 295–299.
- Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res 2002; 53 (4): 859–863.
- Evans D, Charney D, Lewis L et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 2005; 58 (3): 175–189.
- Goldberg D, Huxley P. Common mental disorders. London: Routledge, 1992.
- Kessler D, Lloyd K, Lewis G, Gray D. Cross-sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ 1999; 318 (7181): 436–439.
- Mitchell A, Vaze, A, Rao S. Meta-analysis of unassisted recognition of depression in primary care: Importance of false positives and false negatives. Lancet 2009 (submitted for publication).
- National Institute for Health and Care Excellence. Depression: management of depression in primary and secondary care. Clinical Guideline 23. London: NICE, 2004.
- 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
- Goldberg D, Jenkins L, Millar T, Faragher E. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993; 23 (1): 185–193.
- Kendrick T, King F, Albertella L, Smith P. GP treatment decisions for patients with depression: an observational study. British J Gen Pract 2005; 55 (513): 280–286.
- Aragones E, Pinol, J, Labad A. The overdiagnosis of depression in non-depressed patients in primary care. Fam Pract 2006; 23 (3): 363–368.
- Dowrick C. Beyond depression. 2nd edn. Oxford: Oxford University Press, 2004.
- Arroll B, Goodyear-Smith F, Kerse N et al. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ 2005; 331 (7521): 884.
- Kroenke K, Spitzer R, Williams J. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16 (9): 606–613.
- Improving Access to Psychological Therapies. www.iapt.nhs.uk (accessed 10 November 2009).
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. London: BMA, NHS Employers, 2009.
- Department of Health website. New horizons in mental health. www.dh.gov.uk/en/Healthcare/Mentalhealth/NewHorizons/index.htm (accessed 11 November 2009).
- Chew-Graham C, Shiers D, Beeston D. Is personal care important in the diagnosis of depression in older people? Br J Gen Pract 2008: 58 (555): 675–676.G