the treatment and management of depression in adults

707 Pages·2010·2.6 MB·English

Depression
THE NICE GUIDELINE ON THE TREATMENT AND
MANAGEMENT OF DEPRESSION IN ADULTS
UPDATED EDITION
DEPRESSION
THE TREATMENT AND
MANAGEMENT OF DEPRESSION
IN ADULTS (UPDATED EDITION)
National Clinical Practice Guideline 90
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Health &
Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists
© The British Psychological Society
& The Royal College of Psychiatrists, 2010
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from
the publishers. Enquiries in this regard should be directed to the British
Psychological Society.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from
the British Library.
ISBN: 978-1-904671-85-5
Printed in Great Britain by Stanley Hunt.
Additional material: data CD-Rom created by Pix18
(www.pix18.co.uk)
developed by National Collaborating Centre for Mental Health
The Royal College of Psychiatrists
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commissioned by National Institute for Health and Clinical Excellence
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published by The British Psychological Society
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and
The Royal College of Psychiatrists
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www.rcpsych.ac.uk
Contents
CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERS 7
ACKNOWLEDGEMENTS 10
1 PREFACE 11
1.1 National guidelines 11
1.2 The national depression guideline 14
2 DEPRESSION 17
2.1 The disorder 17
2.2 Aetiology 25
2.3 Economic costs of depression 26
2.4 Treatment and management in the National Health Service 28
3 METHODS USED TO DEVELOP THIS GUIDELINE 34
3.1 Overview 34
3.2 The scope 34
3.3 The Guideline Development Group 35
3.4 Clinical questions 37
3.5 Systematic clinical literature review 38
3.6 Health economics methods 47
3.7 Methods for reviewing experience of care 49
3.8 Stakeholder contributions 51
3.9 Validation of the guideline 51
4 EXPERIENCE OF CARE 52
4.1 Introduction 52
4.2 Personal accounts – people with depression 52
4.3 Personal accounts – carers 68
4.4 Qualitative analysis 71
4.5 Review of the qualitative literature 83
4.6 From evidence to recommendations 86
4.7 Recommendations 94
5 CASE IDENTIFICATION AND SERVICE DELIVERY 97
5.1 Introduction 97
5.2 The identification of depression in primary care and
community settings 98
5.3 Service delivery systems in the treatment and management
of depression 121
5.4 Stepped care 124
5.5 Collaborative care 129
3
Contents
5.6 Medication management 141
5.7 Crisis resolution and home treatment teams 146
5.8 Acute day hospital care 149
5.9 Non-acute day hospital care 151
5.10 Non-statutory support 153
5.11 Research recommendation 155
6 INTRODUCTION TO PSYCHOLOGICAL AND
PSYCHOSOCIAL INTERVENTIONS 157
6.1 Introduction 157
6.2 Recommending psychological and psychosocial treatments 157
6.3 How do psychological and psychosocial interventions
become evidence based? 158
6.4 Contextual factors that impact on clinical practice 164
6.5 Databases searched and inclusion/exclusion criteria 168
6.6 Studies considered 168
7 LOW-INTENSITY PSYCHOSOCIAL INTERVENTIONS 170
7.1 Computerised cognitive behavioural therapy 170
7.2 Guided self-help 181
7.3 Physical activity programmes 190
7.4 From evidence to recommendations – low-intensity
psychosocial interventions 212
7.5 Recommendations 213
8 HIGH-INTENSITY PSYCHOLOGICAL INTERVENTIONS 215
8.1 Cognitive behavioural therapies 215
8.2 Behavioural activation 238
8.3 Problem solving 242
8.4 Couples therapy 246
8.5 Interpersonal therapy 249
8.6 Counselling 261
8.7 Short-term psychodynamic psychotherapy 267
8.8 Rational emotive behavioural therapy 272
8.9 Economic modelling 274
8.10 From evidence to recommendations 291
8.11 Recommendations 296
8.12 Research recommendations 300
9 INTRODUCTION TO PHARMACOLOGICAL AND PHYSICAL
INTERVENTIONS 304
9.1 Introduction 304
9.2 Dose and duration of antidepressant treatment: evidence
from clinical practice 306
9.3 Limitations of the literature: problems with randomised
controlled trials in pharmacology 308
9.4 Studies considered for review – additional inclusion criteria 309
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Contents
9.5 Issues and topics covered by this review 311
9.6 Placebo-controlled randomised controlled trials of antidepressants 313
9.7 Selective serotonin reuptake inhibitors versus placebo 315
9.8 Tricyclic antidepressants versus placebo 319
9.9 From evidence to recommendations 326
9.10 Recommendation 327
10 PHARMACOLOGICAL INTERVENTIONS 328
10.1 Introduction 328
10.2 Use of individual drugs in the treatment of depression 329
10.3 Tricyclic antidepressants 330
10.4 Selective serotonin reuptake inhibitors 336
10.5 Escitalopram 341
10.6 The thread study 354
10.7 Monoamine oxidase inhibitors 354
10.8 Third-generation antidepressants 360
10.9 St John’s wort 387
10.10 Health economics evidence 391
10.11 Network meta-analysis of newer antidepressants 398
10.12 Economic model for the cost-effectiveness of
pharmacological interventions for people with depression 399
10.13 From evidence to recommendations 411
10.14 Clinical practice recommendations 412
10.15 When to change antidepressant treatment when symptoms
of depression are not improving 413
11 FACTORS INFLUENCING CHOICE OF ANTIDEPRESSANTS 418
11.1 Introduction 418
11.2 The pharmacological management of depression in older adults 418
11.3 The effect of sex on antidepressant choice 424
11.4 The pharmacological management of depression with
psychotic symptoms 425
11.5 The pharmacological management of atypical depression 427
11.6 The physical and pharmacological management of depression
with a seasonal pattern 430
11.7 Dosage issues for tricyclic antidepressants 451
11.8 Antidepressant discontinuation symptoms 453
11.9 The cardiotoxicity of antidepressants 457
11.10 Depression, antidepressants and suicide 462
12 THE PHARMACOLOGICAL AND PHYSICAL MANAGEMENT OF
DEPRESSION THAT HAS NOT ADEQUATELY RESPONDED TO
TREATMENT, AND RELAPSE PREVENTION 466
12.1 Introduction 466
12.2 Approach to the reviews 467
12.3 Pharmacological ‘next-step’ treatment for depression that has
not adequately responded to treatment 469
5
Contents
12.4 Electroconvulsive therapy 508
12.5 Other non-pharmacological physical treatments 528
12.6 The pharmacological management of relapse prevention 530
13 THE MANAGEMENT OF SUBTHRESHOLD DEPRESSIVE
SYMPTOMS 536
13.1 Introduction 536
13.2 Pharmacological interventions for subthreshold depressive
symptoms and persistent subthreshold depressive symptoms
(dysthymia) 537
13.3 Psychological and other strategies for the treatment of
persistent subthreshold depressive symptoms (dysthymia) 555
13.4 From evidence to recommendations 563
13.5 Recommendations 564
13.6 Research recommendation 564
14 SUMMARY OF RECOMMENDATIONS 565
14.1 Care of all people with depression 565
14.2 Stepped care 567
14.3 Step 1: recognition, assessment and initial management 568
14.4 Step 2: recognised depression – persistent subthreshold
depressive symptoms or mild to moderate depression 569
14.5 Step 3: persistent subthreshold depressive symptoms or mild to
moderate depression with inadequate response to initial
interventions, and moderate and severe depression 571
14.6 Treatment choice based on depression subtypes and
personal characteristics 576
14.7 Enhanced care for depression 576
14.8 Sequencing treatments after initial inadequate response 577
14.9 Continuation and relapse prevention 579
14.10 Step 4: complex and severe depression 582
14.11 Research recommendations 585
15 APPENDICES 591
16 REFERENCES 647
17 ABBREVIATIONS 696
6
Guideline Development Group members
GUIDELINE DEVELOPMENT GROUP MEMBERS
Professor Ian Anderson (Chair, Guideline Development Group)
Professor of Psychiatry, University of Manchester
Professor Stephen Pilling
Director, National Collaborating Centre for Mental Health
Director, Centre for Outcomes Research and Effectiveness, University College
London
Ms Alison Barnes
Service User Member
Ms Linda Bayliss
Research Assistant (May 2008 to August 2008), National Collaborating Centre for
Mental Health
Ms Victoria Bird
Research Assistant, National Collaborating Centre for Mental Health
Ms Rachel Burbeck
Lead Systematic Reviewer, National Collaborating Centre for Mental Health
Dr Carolyn Chew-Graham
General Practitioner and Senior Lecturer in Primary Care, University of Manchester
Mr Jeremy Clarke
Psychological Therapist, Lambeth Primary Care Trust
Mr Matthew Dyer
Health Economist, National Collaborating Centre for Mental Health
Ms Esther Flanagan
Project Manager (2009), National Collaborating Centre for Mental Health
Ms Catherine Harris
Carer member and Local Councillor
Ms Sarah Hopkins
Project Manager (until 2008), National Collaborating Centre for Mental Health
7
Guideline Development Group members
Dr Mark Kenwright
Consultant Cognitive Behavioural Psychotherapist, Ealing Cognitive Behavioural
Therapy Service
Professor Willem Kuyken
Professor of Clinical Psychology and Co-Director, Mood Disorders Centre, School
of Psychology, University of Exeter
Ms Angela Lewis
Research Assistant, National Collaborating Centre for Mental Health
Professor Glyn Lewis
Professor of Psychiatric Epidemiology, University of Bristol
Mr Ryan Li
Project Manager (2008), National Collaborating Centre for Mental Health
Mr Brendan Masterson
Clinical Nurse Leader, Affective Disorders Unit, Bethlem Royal Hospital
Dr Nick Meader
Systematic Reviewer, National Collaborating Centre for Mental Health
Mr Alan Meudell
Service User Member, Healthy Minds at Work
Dr Alex Mitchell
Consultant Psychiatrist and Honorary Lecturer in Liaison Psychiatry, University of
Leicester
Dr Richard Moore
Clinical Psychologist, Cambridge and Peterborough NHS Foundation Trust
Dr Suffiya Omarjee
Health Economist, National Collaborating Centre for Mental Health
Ms Carol Paton
Chief Pharmacist, Oxleas NHS Foundation Trust
Dr Alejandra Perez
Systematic Reviewer, National Collaborating Centre for Mental Health
Ms Peny Retsa
Health Economist (until 2008), National Collaborating Centre for Mental Health
8
Guideline Development Group members
Ms Maria Rizzo
Research Assistant, National Collaborating Centre for Mental Health
Ms Jennie Robertson
Research Assistant (from September 2008), National Collaborating Centre for
Mental Health
Mr Rob Saunders
Research Assistant (2008), National Collaborating Centre for Mental Health
Ms Christine Sealey
Centre Manager, National Collaborating Centre for Mental Health
Ms Beth Shackleton
Project Manager (until 2008), National Collaborating Centre for Mental Health
Dr Thomas Shackleton
General Practitioner, Suffolk
Ms Sarah Stockton
Senior Information Scientist, National Collaborating Centre for Mental Health
Dr Clare Taylor
Editor, National Collaborating Centre for Mental Health
Ms Jane Wood
Nurse, Strategic Development Manager, Mental Health, Leeds Primary Care Trust
9