NICE guidance for depression
Depression is a mood disorder seen across ages; UK management follows NICE stepped care with specialist assessment guiding when to refer and what to offer.
Applies to adults, young people, and older adults in UK clinical practice.
The National Institute for Health and Care Excellence (NICE) guidance for depression provides a stepped-care model to ensure treatment intensity is matched to the severity and persistence of the condition, recommending that for individuals presenting with persistent subthreshold depressive symptoms or mild to moderate depression, the first step involves assessment, support, psychoeducation, and active monitoring, followed by the offer of low-intensity psychosocial interventions such as guided self-help based on cognitive behavioural therapy (CBT) principles, computerised CBT, or group physical activity programmes; for those with moderate to severe depression, or where response to low-intensity interventions is insufficient, a range of high-intensity psychological interventions should be offered, including CBT, interpersonal therapy (IPT), or behavioural activation, and for severe depression, the recommendation is for a combination of antidepressants and a high-intensity psychological intervention, with the choice of antidepressant being a selective serotonin reuptake inhibitor (SSRI) considered first-line due to their better safety profile in overdose compared to tricyclic antidepressants, whilst also emphasising the importance of discussing the potential benefits and risks, including the increased risk of suicidal thoughts and behaviour in young people under 30 during the initial treatment phases, and ensuring regular follow-up, typically weekly for the first month, to monitor efficacy and side effects; for treatment-resistant depression, defined as an inadequate response to two sequential antidepressants given at an adequate dose and duration, the guidance advises augmenting the current antidepressant with another medication such as lithium or an antipsychotic like aripiprazole, or considering referral for specialist mental health services for assessment for treatments such as electroconvulsive therapy (ECT) which is reserved for severe, treatment-resistant depression where a rapid response is required or when other treatments have failed, and throughout all steps, the guidance stresses the necessity of a collaborative approach with the patient, involving them in all decision-making, providing clear information about their condition and treatment options, and paying particular attention to the needs of specific groups such as pregnant or breastfeeding women, where the risks and benefits of medication must be carefully weighed, and individuals with chronic physical health problems, where an integrated care approach is essential; the guidance also highlights the importance of promoting self-management and relapse prevention strategies, including the continuation of antidepressant medication for at least six months after remission to reduce the risk of relapse, and for those with recurrent depression, considering longer-term maintenance treatment.
Stepped care and treatment options
Depression management in the UK follows a stepped-care model, which matches the intensity of treatment to the severity and persistence of the individual's depression, aiming to provide the most effective and least intrusive intervention first. Step 1 involves assessment, support, and active monitoring for all individuals presenting with depressive symptoms; this includes psychoeducation about depression, addressing social factors like isolation or debt, and promoting self-management strategies such as guided self-help materials based on cognitive behavioural therapy (CBT) principles or structured physical activity programmes, with a follow-up appointment typically within two weeks to assess progress. For those with persistent subthreshold depressive symptoms or mild to moderate depression that has not responded to Step 1 interventions, or for those presenting with moderate depression initially, Step 2 offers low-intensity psychosocial interventions, which include facilitated self-help (where a practitioner supports the patient in using self-help materials over several sessions), computerised CBT (CCBT), and group-based physical activity programmes; these interventions are designed to be accessible and can be delivered by a range of trained practitioners within primary care settings. If a patient's depression is moderate to severe, or if they have not responded to a low-intensity intervention at Step 2, Step 3 involves referral for high-intensity psychological interventions, such as individual CBT, interpersonal therapy (IPT), behavioural activation, or counselling for depression, which are typically delivered by qualified psychological therapists within Improving Access to Psychological Therapies (IAPT) services or equivalent secondary care mental health teams; for moderate depression, a high-intensity psychological intervention is often considered alongside antidepressant medication, with the choice depending on patient preference, past treatment history, and the presenting clinical picture. Step 4 is reserved for patients with severe and complex depression, treatment-resistant depression, or those at significant risk of self-harm, and involves a combination of treatments including specialist psychological therapies, a range of antidepressant medications (often involving sequential trials if there is inadequate response), and consideration of adjunctive treatments such as lithium or antipsychotics for treatment-resistant cases, with care typically coordinated by community mental health teams (CMHTs) or specialist services; for severe depression with psychosis, a combination of antidepressant and antipsychotic medication is essential, and electroconvulsive therapy (ECT) may be considered for severe, treatment-resistant depression where there is an imminent life-threatening risk.
Antidepressant medication is a key treatment option across the steps, with selective serotonin reuptake inhibitors (SSRIs) being the first-line pharmacological choice due to their better tolerability and safety profile in overdose compared to older tricyclic antidepressants (TCAs); medication should be initiated at a therapeutic dose and continued for at least six months after remission to reduce the risk of relapse, and all patients starting antidepressants must be informed about the potential for increased anxiety or agitation in the initial weeks and the possibility of discontinuation symptoms upon stopping. Throughout the stepped-care process, treatment decisions should be made collaboratively with the patient, taking into account their preferences, cultural background, and comorbidities, and regular review of treatment efficacy and side effects is crucial; for patients who do not respond adequately to a first-line treatment, switching to an alternative antidepressant from a different class or augmenting with a psychological therapy or another medication should be considered, and referral to secondary care mental health services is indicated if there is a poor response to two different treatments, significant risk, or diagnostic uncertainty. The overall goal is to achieve remission of symptoms and functional recovery, with a focus on relapse prevention through continued support and, where appropriate, long-term maintenance therapy.
Medication and psychological therapies
When managing depression in adults, the choice between medication and psychological therapies, or a combination of both, should be guided by a shared decision-making process that considers the severity and duration of the episode, the patient’s treatment preferences and past history, and the presence of any comorbid conditions; for persistent subthreshold depressive symptoms or mild to moderate depression, NICE guidelines recommend offering individual high-intensity psychological interventions such as cognitive behavioural therapy (CBT), behavioural activation, or interpersonal psychotherapy (IPT) as first-line treatments, or group-based CBT if the patient prefers it, while also considering the option of medication, particularly if the patient has a history of moderate or severe depression or if psychological treatments are declined or ineffective; for moderate to severe depression, a combination of an antidepressant and a high-intensity psychological therapy is recommended, as evidence suggests this approach is more effective than either treatment alone, with the selection of an antidepressant being based on factors such as side-effect profile, safety in overdose, previous response, potential interactions, and cost, typically starting with a selective serotonin reuptake inhibitor (SSRI) at a therapeutic dose, whilst being mindful of the increased risk of suicidal thoughts and self-harm in the initial weeks of treatment, particularly in young adults, necessitating closer monitoring; for patients who do not respond adequately to an initial SSRI after 4-6 weeks at an adequate dose, switching to an alternative antidepressant, such as another SSRI or a different class like a serotonin-noradrenaline reuptake inhibitor (SNRI) or mirtazapine, should be considered, and for those with treatment-resistant depression, augmentation strategies with medications like lithium or an antipsychotic such as aripiprazole, or referral for specialist review and consideration of therapies like electroconvulsive therapy (ECT) for severe, treatment-resistant depression where rapid response is needed, may be appropriate; psychological therapies should be delivered by trained and accredited practitioners, with the course of treatment typically consisting of 16 to 20 sessions over 3 to 4 months for high-intensity therapies, and it is crucial to actively engage the patient throughout, reviewing treatment response regularly and discussing the planned duration of antidepressant treatment, which should be continued for at least 6 months after remission to reduce the risk of relapse, with longer-term maintenance treatment considered for patients who have experienced multiple previous episodes; for all patients, regardless of the treatment modality chosen, providing information about depression, supporting self-management, and promoting healthy lifestyle factors such as physical activity and sleep hygiene are integral components of care, and clinicians should be vigilant for signs of deterioration or the emergence of suicidal ideation, ensuring clear and accessible crisis plans are in place.
Review and relapse prevention
Long-term management of depression requires a proactive and structured approach to review and relapse prevention, with the primary goals being sustained recovery, early identification of warning signs, and minimisation of future episodes. Following an initial treatment phase that achieves symptom remission, clinicians should not discharge patients but instead initiate a period of continuation treatment, typically lasting at least six months for a first episode, using the same antidepressant medication and/or psychological therapy at the effective dose that brought about recovery, as stopping treatment prematurely significantly increases the risk of relapse. For patients experiencing a recurrent episode (their second or subsequent episode), the recommendation is for maintenance treatment for at least two years, and often longer, particularly for those with frequent or severe recurrences, significant residual symptoms, or associated functional impairment. The frequency of follow-up reviews should be tailored to individual need, starting more frequently (e.g., every 2-4 weeks) in the early stages of stability and gradually extending to every 1-3 months, or longer if the patient remains well; these reviews are crucial opportunities to monitor mood, medication adherence, side effects, and overall functioning. A key component of relapse prevention is psychoeducation, where clinicians should work collaboratively with the patient to develop a personalised relapse prevention plan; this plan should include a clear description of the patient's unique early warning signs (e.g., sleep disturbance, loss of interest, irritability), a list of coping strategies (such as behavioural activation, mindfulness, or contacting support networks), and specific agreed actions to take if symptoms re-emerge, including how to seek help promptly. For patients on antidepressants, discussions about the potential benefits and risks of long-term use should be held, addressing any concerns about dependence and emphasising that maintenance treatment is a preventive strategy for a chronic relapsing condition; if a patient wishes to discontinue medication, this should be planned carefully, involving a gradual taper over several weeks or months to minimise withdrawal symptoms, which can be mistaken for relapse, with close monitoring during and after the process. Psychological approaches remain important in the maintenance phase; for example, mindfulness-based cognitive therapy (MBCT) is specifically recommended for patients who have experienced three or more episodes of depression, as it teaches skills to disengage from habitual negative thought patterns that can trigger relapse. Attention should also be paid to comorbid physical health conditions, substance use, and psychosocial stressors (like unemployment or relationship difficulties), as addressing these factors is integral to sustaining recovery. The involvement of family or carers, with the patient's consent, can be valuable in supporting the individual and helping to recognise early signs of relapse. Ultimately, effective review and relapse prevention is a shared endeavour between the clinician and the patient, fostering self-management and resilience while ensuring a clear pathway for rapid re-intervention if needed, thereby reducing the substantial personal and societal burden of recurrent depression.