What are the guidelines for managing depression according to the National Institute for Health and Care Excellence (NICE)?

NICE Guidelines for Depression Management

NICE guidelines consistently receive the highest quality ratings among depression practice guidelines and are recognized as the gold standard for evidence-based depression management, with particular strengths in rigor of development, stakeholder involvement, and regular updates. 1

Assessment and Diagnosis

Establish diagnosis through direct clinical interview using DSM-5 criteria, requiring at least 5 symptoms over 2 weeks including depressed mood or anhedonia. 2

• Assess functional impairment across school/work, home, and peer/social domains 2
• Screen for comorbid psychiatric conditions including anxiety disorders, substance use disorders, and bipolar disorder risk 2
• Evaluate suicide risk in every patient regardless of depression severity 2
• Use standardized assessment tools (PHQ-9, HAM-D, MADRS, or QIDS-SR) to quantify severity and track treatment response 2
• Do not rely solely on screening tools—they aid diagnosis but cannot replace clinical interview 2

Severity Classification

• Mild depression: 5-6 symptoms with mild severity and minimal functional impairment 3, 2
• Moderate depression: Falls between mild and severe 3, 2
• Severe depression: All DSM-5 symptoms present, severe functional impairment, suicide plan/intent/recent attempt, psychotic symptoms, or first-degree family history of bipolar disorder 2

Treatment Recommendations by Severity

Mild Depression

• Active monitoring or CBT alone as first-line treatment 2
• Antidepressants should not be considered for initial treatment of adults with mild depressive episodes 1

Moderate Depression

• Either CBT or second-generation antidepressants (SSRIs/SNRIs) as first-line treatment 2
• Tricyclic antidepressants (TCAs) or fluoxetine should be considered 1, 4
• NICE specifically recommends family therapy or psychodynamic therapy as first-line options 1

Severe Depression

• Combination treatment with both antidepressant medication and psychotherapy 2
• Cognitive-behavioral therapy or interpersonal therapy as psychological treatment 1
• Problem-solving treatment should be considered as adjunct treatment 1

First-Line Psychotherapy Options

NICE guidelines recommend a broader range of psychotherapies compared to other guidelines:

• Cognitive-behavioral therapy (CBT) targeting thoughts and behaviors to improve mood 1, 3
• Interpersonal therapy (IPT) focusing on interpersonal problems that cause or exacerbate depression 1, 3
• Family therapy as a first-line option (unique to NICE) 1
• Psychodynamic therapy as a first-line option (unique to NICE) 1
• Problem-solving treatment for those in distress with impaired functioning 1

Pharmacological Treatment

Recommended Medications

• Fluoxetine is the only FDA-approved antidepressant for children and adolescents with depression 3
• Escitalopram is approved for adolescents aged 12 years and older 3
• Second-generation antidepressants (SSRIs/SNRIs) are recommended due to favorable safety profile 4

Medications to Avoid

NICE actively recommends against:

• Tricyclic antidepressants (TCAs) 1
• Venlafaxine 1
• Paroxetine 1
• St. John's Wort 1

This represents a key divergence from other guidelines like GLAD-PC, which lists paroxetine as an option. 1

Treatment Monitoring

• Begin monitoring within 1-2 weeks of treatment initiation 4, 2
• Monitor closely for increased suicidal ideation in the weeks following antidepressant initiation 1, 4
• Response to treatment is typically defined as 50% reduction in measured severity 4
• If inadequate response by 6-8 weeks, modify treatment by adjusting dose, switching antidepressants, or adding evidence-based psychotherapy 2

Maintenance and Relapse Prevention

• Antidepressant treatment should not be stopped before 9-12 months after recovery 1, 3, 4, 2
• For recurrent depression, maintenance treatment should extend to ≥1 year or longer 2
• All patients should be monitored monthly for 6-12 months after full symptom resolution 3
• For patients showing partial response to SSRI at maximum tolerated dosage, add evidence-based psychotherapy 3

Adjunctive Treatments

• Relaxation training and advice on physical activity may be considered as adjunct treatments 1, 4
• Bright light therapy is recommended for mild to moderate MDD, regardless of seasonal pattern 3
• Computer or internet-based treatment can be used as adjunct to pharmacotherapy or first-line based on patient preference 3

Safety Planning

• Establish comprehensive safety plan immediately, including restricting access to lethal means 2
• Engage a concerned third party and develop emergency communication mechanism 2
• Monitoring should be most intensive during initial treatment period when safety concerns are highest 2

Collaborative Care

• Clearly communicate and agree upon roles and responsibilities between primary care clinicians and mental health providers 3, 2
• Primary care clinicians should actively support depressed patients referred to mental health services 3
• For comorbid conditions (e.g., alcohol use disorder), use integrated care approach treating both conditions concurrently with same treatment team 2

Treatment-Resistant Depression

• If improvement is not seen within 6-8 weeks, consider mental health consultation 3
• Explore causes of partial response: poor adherence, comorbid disorders, ongoing conflicts or abuse 3
• For patients with partial or no response to two or more adequate pharmacologic trials, repetitive transcranial magnetic stimulation (rTMS) may be considered 3

Common Pitfalls to Avoid

• Inadequate follow-up: Failing to monitor monthly for 6-12 months after symptom resolution increases relapse risk 3
• Premature discontinuation: Stopping antidepressants before 9-12 months significantly increases relapse rates 1, 3, 4
• Ignoring comorbidities: Failure to screen for anxiety, substance use, and bipolar risk leads to inadequate treatment 2
• Using contraindicated medications: NICE specifically warns against TCAs, venlafaxine, paroxetine, and St. John's Wort 1
• Insufficient suicide monitoring: Not evaluating suicide risk at every visit regardless of severity is dangerous 2