26th January 2024

Management

All patients should be provided information about the nature and course of their illness.

Important principles in the management of depressive illness include recognising that people have a right to decline treatment and that the most appropriate, least intrusive, and resource-intensive treatment should be tried first.

If capacious patients do not want an intervention, use a watchful waiting approach, offering a follow-up in 2 weeks.

The image below outlines the NICE recommendations for patients who want treatment based on illness severity. They are listed in order of the Committee’s interpretation of clinical and cost-effectiveness.

Source: Adapted from (NICE, 2022c)(NICE, 2022a)(NICE, 2022b)

CBT: Cognitive Behavioural Therapy

BA: Behavioural Activation

IPT: Interpersonal Psychotherapy

STPP: Short-term Psychodynamic Psychotherapy

For a full explanation of these therapies, see https://www.nice.org.uk/guidance/ng222/chapter/recommendations#more-severe-depression

References: 

• NICE. (2022a). Depression in adults: discussing first-line treatments for less severe depression. NICE Guidance. NICE.
• NICE. (2022b). Depression in adults: treatment and management. Retrieved July 11, 2022, from https://www.nice.org.uk/guidance/ng222/chapter/Recommendations
• NICE. (2022c). Recommendations | Depression in adults. Retrieved July 4, 2022, from https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#recognition-and-assessment

Anti-depressant medication

No antidepressant is recommended above all others, and drugs should be chosen judicially based on patient factors (such as comorbidities, suicide risk, current medications) and side-effect profiles. SSRIs are often first-line as they are often safer in overdose and better tolerated than other classes.

In general:

Below is a list of common antidepressants and key considerations in their use. This list is not exhaustive.

References

• NICE. (2022b). Depression in adults: treatment and management. Retrieved July 11, 2022, from https://www.nice.org.uk/guidance/ng222/chapter/Recommendations
• NICE. (2021). Depression | CKS | NICE. Retrieved July 6, 2022, from https://cks.nice.org.uk/topics/depression/
• Pompili, M., Serafini, G., Innamorati, M., Ambrosi, E., Giordano, G., Girardi, P., … Lester, D. (2010). Antidepressants and Suicide Risk: A Comprehensive Overview. Pharmaceuticals, 3(9), 2861. https://doi.org/10.3390/PH3092861
• NICE. (n.d.). Antidepressant drugs | Treatment summaries. Retrieved July 4, 2022, from https://bnf.nice.org.uk/treatment-summaries/antidepressant-drugs/

Follow-up and treatment cessation

Initial review should occur 2 weeks after commencing medication unless there is an increased risk of self-harm or the patient is aged < 30 years, in which case they should be reviewed after 1 week. This is due to disturbances that may occur on initiation, such as over-stimulation, agitation, anxiety, psychosis, and increased impulsivity.

Regular reviews should then be scheduled every 2-4 weeks. To reduce the risk of relapse, the minimum recommended treatment duration is 6 months, but patients may safely continue treatment beyond this.

If no benefit is seen after 2 weeks, check adherence and consider increasing the dose, switching class of antidepressant, or adding psychological therapies.

Caution must be exercised when switching between antidepressants – specific guidance can be found in The Maudsley prescribing guidelines in psychiatry (authored by Taylor and Barnes, 2018).

Antidepressants should be reduced slowly over an average of 4 weeks to minimise discontinuation symptoms.

Discontinuation symptoms may include:

• Restlessness
• Problems sleeping
• Diaphoresis
• Abdominal symptoms
• Altered sensations (paraesthesia, electric shock feelings)
• Altered mood (irritability, anxiety, confusion)
• Headache

Discontinuation symptoms tend to start within a few days of treatment cessation and are self-limiting, resolving within 2 weeks in most cases.

If depression is treatment-resistant, Electroconvulsive Therapy (ECT) or lithium augmentation may be considered.

Electroconvulsive Therapy

ECT is a therapy in which generalised seizure activity is induced by an electric current passed through the patient’s brain via scalp electrodes. The patient is placed under general anaesthesia and is given muscle relaxants to prevent muscle spasms.

Risks include retrograde and anterograde amnesia, status epilepticus, laryngospasm, and headache.

Most patients will undertake a course of twice-weekly sessions for 6 weeks.

ECT should only be used to achieve rapid improvement in severe symptoms after other treatment options have failed or when the condition is considered life-threatening.

Situations in which ECT may be used:

• Treatment-resistant depression
• Life-threatening depression
• Catatonia
• Prolonged or severe manic episodes
• Psychotic depression

References

• Davidson, J. R. T., Miller, R. D., Turnbull, C. D., & Sullivan, J. L. (2006). Atypical Depression. Archives of General Psychiatry, 39(5), 527–534. https://doi.org/10.1001/archpsyc.1982.04290050015005
• NICE. (n.d.). Antidepressant drugs | Treatment summaries. Retrieved July 4, 2022, from https://bnf.nice.org.uk/treatment-summaries/antidepressant-drugs/
• NICE. (2021). Depression | CKS | NICE. Retrieved July 6, 2022, from https://cks.nice.org.uk/topics/depression/
• NICE. (2022). Depression in adults: discussing first-line treatments for more severe depression. NICE Guidance. NICE.
• NICE. (2022). Depression in adults: treatment and management. Retrieved July 11, 2022, from https://www.nice.org.uk/guidance/ng222/chapter/Recommendations
• NICE. (2009). Guidance on the use of electroconvulsive therapy. NICE. Retrieved from https://www.nice.org.uk/guidance/ta59/chapter/1-Guidance
• NICE. (2022). Recommendations | Depression in adults. Retrieved July 4, 2022, from https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#recognition-and-assessment
• Pompili, M., Serafini, G., Innamorati, M., Ambrosi, E., Giordano, G., Girardi, P., … Lester, D. (2010). Antidepressants and Suicide Risk: A Comprehensive Overview. Pharmaceuticals, 3(9), 2861. https://doi.org/10.3390/PH3092861
• WHO. (2019). ICD-10 Version: 2019. In ICD-10 Version: 2019. Retrieved from https://icd.who.int/browse10/2019/en#/V