Carol comes to see you. She is 45, recently divorced, has a stressful job, has money worries and she is struggling with her teenage children and increasingly dependent elderly parents. Life is tough for Carol. She tries to keep things together for the kids but is frequently tearful, she feels overwhelmed at work, she is exhausted and feels like she is walking through wet cement all day. She collapses asleep in front of the TV at 10pm but then jolts wide awake at 2am and can’t get back to sleep. Finally, she comes to see you for help.
Carol is an everyday consultation for us in General Practice. Of the huge iceberg of mental health problems floating around in the community, specialist adult mental health teams only deal with the tiny tip at the surface. The vast majority are managed safely and effectively by us in primary care, with the help and input of our colleagues in psychological services such as IAPT in the NHS. But access to psychological therapies has always been limited, and although prescribing medication for people overwhelmed with life’s problems has never felt comfortable, in the absence of viable alternatives to help people of course we do. Often. And as life’s problems have multiplied in recent years, and stigma about mental health problems and antidepressants has decreased, we are now in a situation where an incredible 1 in 7 people in England are taking prescription antidepressants. We have now truly become ‘Prozac nation’ with huge implications for patients, society and our workloads.
Against this background, this week, NICE unveiled the draft depression in adults guideline. This is the long-awaited update to their original depression guideline CG80 which dates way back to 2009. The update has been mired in controversy, with successive versions rejected by multiple stakeholders unhappy with the methodology NICE used, their prioritisation of randomised controlled trials meaning that many talking therapies were not included, not taking patient views into account and for adopting a one fits all approach.
The new version has addressed these concerns, with a much greater choice of treatment options for the management of depression. The guideline places a lot of emphasis on patient choice and encourages us to ‘explore treatment options in an atmosphere of hope and optimism’.
With Carol, for a diagnosis of depression we may ‘consider’ using a validated symptom score (e.g. PHQ9) to inform and evaluate treatment, but a more holistic approach to diagnosis and categorisation based on an individualised ‘comprehensive clinical assessment’ is encouraged which does not rely on ‘symptom counts’. We then categorise the depression into two categories, less severe (which previously we would have considered subthreshold or mild) and more severe (previously moderate and severe) depression.
Carol has symptoms of depression, but she is functioning and not at risk of suicide or self-harm. You feel she is in the ‘less severe’ category. NICE have produced an extensive ‘menu’ of first-line treatment options from which she can now choose. The choice is dizzying with eleven treatment options on the menu for less severe depression, and ten for more severe depression. The range of different interventions is very wide. Gone is the mantra that CBT is the only recommended psychological therapy as interpersonal therapy, counselling and even short-term psychodynamic psychotherapy are options she can choose. Or, she may prefer mindfulness, meditation, behavioural activation or group exercise. SSRIs are also a first line option, if she chooses them.
This extensive menu of options looks great for both Carol and for us. However, there are two very big elephants in the room which are not addressed. Firstly, that old chestnut of time. Once we have listened to and assessed Carol, diagnosed and risk assessed her where will the time be to go through all these eleven options with her? Social prescribers and link workers will have a key role here, but this may mean a further wait before she even has all the treatment options discussed with her. Secondly, that other old chestnut of availability. Where are the chefs that are going to produce all these tasty looking dishes on the menu? I have an image of a customer in a restaurant excitedly choosing from an extensive and mouth-watering menu, only to be repeatedly told by the waiter that 9 out of the 11 dishes are ‘off at the moment’.
Overall, however, I think this draft guideline is to be welcomed as it adopts a more holistic, individualised and patient-centred approach to depression that emphasises patient choice and shared decision making and de-emphasizes prescribing. It is in step with the zeitgeist of improving wellbeing, lifestyle medicine and the importance of social prescribing. However, it looks very aspirational and although it may hopefully lever organisational change and service delivery (‘commissioners should ensure patients can express a preference for NICE recommended treatments and that they are available in a timely manner’) for now the options for Carol remain limited, and we may still have to prescribe antidepressants for her after all.
As well as new cases of depression, the draft guideline covers lots of other challenging areas including managing relapses and treatment resistant depression and there is also new strengthened advice on withdrawal reactions and tapering. The final guideline is due to be published next Spring and of course, we shall have it covered for you on Hot Topics Spring 22!