NICE guidance on depression

Mental Health Nursing,  Jan 2005  by Pollock, Laurence

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The National Institute for Clinical Excellence (NICE) has issued a guideline for the NHS on the treatment and care of people with depression and anxiety.

The guidelines take account of the announcement by the Medicines and Healthcare Products Regulatory Agency (MHRA) on the safety of anti-depressant drug treatments and will support health professionals when implementing the MHRA's advice. The MHRA was tentative about links between SSRIs and suicide but said healthcare professionals should monitor patients in the early stages of treatment.

The NICE guideline also recommend effective psychological treatments for people with depression and anxiety and set national standards for care across England and Wales.

The guideline says that for mild and moderate depression, psychological treatments specifically focused on depression (such as problem-solving therapy, cognitive behaviour therapy and counselling) can be as effective as drug treatments and should be offered as treatment options.

It also recommends that:

* Antidepressants should not be used for the initial treatment of mild depression, because the risk-benefit ratio is poor.

* Where antidepressants are prescribed for moderate or severe depression it should be a selective serotonin reuptake inhibitor (SSRI), because SSRIs are as effective as tricyclic antidepressants and their use is less likely to be discontinued because of side effects.

The MHRA called for 'careful and frequent patient monitoring by healthcare professionals and, where appropriate, other carers in the early stages of treatment', particularly if a patient experienced worsening of symptoms or new symptoms after starting treatment.

Studies indicated that increases in the prescribing of SSRIs had not been associated with an increase in population suicide rates, although interpretation of these findings was difficult as a range of factors influenced population trends in suicide.

The MHRA says that from the available clinical trial data, both published and unpublished, a modest increase in the risk of suicidal thoughts and self-harm for SSRIs compared with placebo cannot be ruled out.

Evidence of a relationship between suicidal behaviour and increasing/decreasing dose was not robust; however, patients should be monitored around the time of dose changes for any new symptoms or worsening of disease.

Paul Farmer, Director of Public Affairs at Rethink said: 'Anti-depressants are very powerful medicines that need to be prescribed carefully, in the right circumstances and to the right people. At the heart of this issue are people with mental health problems who need to have access to both medical and nonmedical help.

The Mental Health Foundation also welcomed the guideline. But Andrew McCulloch, chief executive, said investment was needed to provide comprehensive counselling and psychotherapy services to combat existing long waiting lists. Lots more research was also needed to explore the effectiveness of other non-medical treatments.

The UK Council for Psychotherapy (UKCP) said that anti-depressants could cause suicidal tendencies in children and adults, and that their use should be restricted, with an increased availability of the 'talking therapies' on the NHS and via GPs.

The UKCP pointed to research by the Mental Health Foundation and the Depression Alliance, and case studies recorded by Dr Jane Milton of The British Psychoanalytical Society, to underline the effectiveness of the 'talking therapies'. Jane Milton has collated evidence on the efficacy of psychoanalysis and cognitive behaviour therapy. (CPD Bulletin Psychiatry 2000 vol 2 no. 2; The International Journal of Psychoanalysis, June 2001 Vol 82 (3) www.nice.org.uk www.mhra.gov.uk

Copyright Community Psychiatric Nurses Association Jan 2005
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