Depression is often under recognised. This can be addressed by using latest NICE guidance to ensure effective assessment and appropriate intervention
Brendan Masterson, PGDip, BSc, RMN, is psychological therapist, Dorset Healthcare Foundation Trust; Clare Taylor, DPhil, MPhil, BA, is editor, National Collaborating Centre for Mental Health; Stephen Pilling, PhD, MSc, BSc, is joint director, National Collaborating Centre for Mental Health, and professor of clinical psychology and clinical effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London.
Masterson B et al (2010) Depression 1: identifying the condition and offering initial treatment for adults. Nursing Times; 106: 31, early online publication.
Nurses must ensure their practice remains up to date and that they are aware of changes in the evidence base for managing depression. This two-part unit on the updated NICE guideline on depression outlines some of the key areas that were updated and the implications for nursing practice.
Keywords Mental health, Depression, Evidence base
- This article has been double-blind peer reviewed
1. Know the procedures involved in the screening and assessment of depression and understand nurses’ role in this process.
2. Identify the initial interventions recommended for persistent subthreshold depressive symptoms and mild to moderate depression.
The treatment of depression is constantly evolving and developing as the evidence base changes. As 4-10% of the world’s population are affected by this condition over the course of a lifetime (Waraich et al, 2004), it is vital that nurses remain updated on major changes in clinical guidelines and the evidence base.
The National Institute for Health and Clinical Excellence (2009a) recently updated its previous guideline (NICE, 2004) on treating and managing depression in adults. Many areas of the previous guideline have been updated; the new document covers the treatment and management of subthreshold depressive symptoms (including dysthymia symptoms), which were not part of the scope of the 2004 guidance.
The new guideline:
- Provides detailed advice on identification and assessment;
- Promotes the use of low intensity psychological interventions to improve access to treatment;
- Consolidates the evidence on the use of high intensity psychological interventions;
- Includes some limited revisions of the recommendations for the use of antidepressants;
- Provides detailed advice on sequencing treatments after inadequate response;
- Includes new advice on providing interventions competently and effectively.
Shortly after the NICE (2009a) update was published last October, the Improving Access to Psychological Therapies (IAPT) programme committed to making the therapies recommended in the guideline available via IAPT services, and drafted competency frameworks for delivering such therapies, which are due to be published in the next few months (IAPT, 2010).
This guidance is also accompanied by the NICE (2009b) guideline on depression in adults with long term conditions, summarised in a previous Guided learning article (Haddad et al, 2009a; 2009b).
The new NICE (2009a) guideline widens the range of depressive disorders covered and takes a more flexible approach to diagnostic categories, emphasising, for example, that healthcare professionals should take account of the level of impairment accompanying symptoms rather than relying simply on a calculation of number of symptoms.
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In contrast to the previous guideline, which used the diagnostic classifications of ICD-10 (World Health Organization, 1992), the new guideline uses the DSM-IV (American Psychiatric Association, 1994) definitions of severity (see Haddad et al, 2009a). It also covers depressive symptoms below the DSM-IV (and ICD-10) threshold for a diagnosis of depression because it is recognised that these can be distressing and impairing if persistent. The new guidelines adopt DSM-IV criteria because nearly all of the evidence is based on studies in which depression is defined by these criteria.
The stepped care model
Although there have been a considerable number of service focused developments since the last guideline was developed, the overall framework for the provision of services adopted by NICE for this update continues to be based on stepped care. The stepped care model supports patients, carers and practitioners in identifying and accessing the most effective interventions. It remains the best developed system for ensuring access to cost effective interventions for depression, and has also been adopted by the IAPT programme (Department of Health, 2007) as the framework for service delivery.
In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines it, they should be offered an appropriate one from the next step. While the general principles of the stepped care model are consistent nationally, protocols for service access differ depending on the area and care setting. It is therefore important for nurses to recognise how the model is delivered in their own area and identify the referral pathways.
Identification and assessment
Haddad et al (2009a) noted that depression is under recognised. Nurses are often well placed to monitor and screen for depression as part of their regular contact with patients. It is therefore essential for them to be aware of the potential for the people in their care to be depressed and to screen for this accordingly.
NICE(2004) recommended the use of two simple questions to identify depression (Whooley et al, 1997), and the updated guidance also promotes the use of these questions (Box 1) as a key priority for implementation. Nursing staff across a range of settings can use these questions quickly and easily to effectively monitor patients.
If a patient answers yes to either (or both) questions, this should be followed up by a more detailed assessment, which involves checking for all depressive symptoms and associated impairments and may involve using another instrument that has better overall psychometric properties (the Hospital Anxiety and Depression Scale, Zigmond and Snaith, 1983; or the Patient Health Questionnaire-9, Spitzer et al, 1999).
The new guideline also places greater emphasis on staff being culturally competent when performing mental health assessments and aware of any learning disabilities. They also need to be move beyond simple symptom counting to consider associated impairment and disability and the wide range of psychological and social factors likely to affect the course of depression and its response to treatment.
Therefore when assessing people with possible depression it is important to ask about any personal and family history of depression and of elevated mood (which may indicate bipolar disorder). It can also add to the overall clinical picture to ask how symptoms have responded to any previous treatments for depression, the quality of interpersonal relationships and living conditions.
If a patient has significant language or communication difficulties, the updated guideline advises using the Distress Thermometer (Roth et al, 1998), which is a visual scale on which the patient marks their response to a single question: how distressed have you been during the past week on a scale of 0 to 10? Scores of 4 or more indicate a level of distress that should be investigated further.
Any person with depression should be assessed for their risk of suicide; this should be part of their mental health assessment and involves questions about suicidal ideas, intentions or plans, and any history of self harm. People who present a significant immediate risk to themselves or others should be referred to a specialist mental health service.
Box 1. Questions to identify depression
Consider asking people who may have depression two questions:
1. During the last month have you often been bothered by feeling down, depressed or hopeless?
2. During the last month, have you often been bothered by having little interest or pleasure in doing things?
Initial treatment for persistent subthreshold symptoms and mild to moderate depression
Nurses across the disciplines are often well placed to deliver or help in providing interventions once depression has been recognised. This can be achieved by nurses acting as educators, which can involve providing information or obtaining advice from an appropriate agency where necessary. Often nurses are also ideally placed to monitor symptoms since they are frequently patients’ most regular point of contact with services. In addition, they can support the delivery of low intensity psychosocial interventions either as part of, or in association with, the IAPT programme.
As a preliminary strategy, the updated guideline advises what is termed “active monitoring” for people with mild depression and those who are likely to recover without formal treatment, who do not want any interventions, or people with subthreshold depressive symptoms who request an intervention.
Advice on improving quality of sleep may also be helpful, as sleep disturbance is a common symptom of depression.
If further intervention is required, NICE (2009a) recommends offering one or more of the following low intensity psychosocial interventions: a group based physical activity programme, guided self-help and/or computerised CBT. As there is little evidence comparing the interventions, the choice of low intensity treatment should be guided by clients’ preference.
The NICE guideline cautions that antidepressants should not be used routinely to treat persistent subthreshold symptoms or mild depression because the ratio of risks to benefits is poor, but can be considered for specific groups in step 2.
The updated guideline builds on the foundations of its previous version. The stepped care approach, with its emphasis on offering the least intrusive, most effective intervention first, remains, but the new guideline has been revised to recognise the impact of persistent subthreshold symptoms. The updated guideline also cautions against relying on symptom counting when measuring severity and advises taking into account the degree of impairment that symptoms have on patients.
Nurses across the specialties are often well placed to gauge the degree of such functional impairment and refer patients for specialist care. More fundamentally, nurses can also play a key role in addressing the under recognition of depression by using the simple screening process.
- Part 2 of this unit, to be published next week, focuses on treating moderate to severe depression and depression (subthreshold and mild) that has not responded to low intensity interventions
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