NICE vs SIGN: Management of Depression (2025)

Depression is common across primary and secondary care, with significant impacts on quality of life, functioning, and suicide risk. In the UK, clinicians primarily look to NICE and the Scottish Intercollegiate Guidelines Network (SIGN) for direction. Both endorse stepped care, psychological interventions, and careful pharmacological management, but they diverge subtly in how prescriptive they are and how they frame risk, relapse prevention, and flexibility.

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This page compares NICE (e.g., NG222 for adults) and SIGN guidance to highlight where they agree, where emphasis differs, and how to apply their recommendations in practice. Links to authoritative sources are included for rapid verification.

Scope and orientation

NICE sets a stepped-care model with clear thresholds for intervention. It prioritises psychological therapies first for mild to moderate depression and specifies SSRIs (often sertraline or fluoxetine) as first-line pharmacotherapy when medication is appropriate. It includes strong guidance on suicide risk stratification, safeguarding, and when to seek specialist input.

SIGN broadly aligns with stepped care but allows slightly more flexibility to initiate pharmacotherapy early when clinically justified. It provides nuanced discussion of relapse prevention and long-term maintenance strategies.

Key framing: NICE is more prescriptive and algorithmic; SIGN is slightly more flexible and narrative, especially around maintenance and relapse prevention.

Initial management and treatment selection

NICE

• Stepped care, with psychological therapies (CBT, behavioural activation, guided self-help) for mild to moderate depression as first-line.
• SSRIs first-line pharmacotherapy when indicated; consider side-effect profiles and patient preference.
• Explicit prompts for suicide/self-harm risk assessment and safety planning at every stage.
• Emphasis on shared decision-making and informed consent for medication, including discussion of latency and side effects.

SIGN

• Stepped approach with similar first-line psychological options.
• Slightly broader acceptance of early pharmacotherapy where clinical judgement supports it (e.g., access barriers to therapy, severity, recurrence).
• Relapse prevention is woven throughout, with guidance on maintenance doses, review frequency, and when to taper.
• More narrative flexibility around combined therapy earlier when risk or impairment is high.

Practical takeaway: Both emphasise talking therapies first for mild to moderate depression; SIGN leaves a bit more room for earlier pharmacotherapy when warranted. Both agree on SSRIs as first-line medication.

Risk assessment and complexity

NICE places strong emphasis on suicide and self-harm risk stratification, safeguarding (including domestic abuse considerations), and clear thresholds for urgent referral. It is prescriptive about monitoring early in pharmacotherapy (especially younger adults) and ensuring patients know how to access support if risk escalates.

SIGN is aligned on risk but provides additional detail on relapse prevention, maintenance dosing, and how to structure long-term follow-up to reduce recurrence risk.

Key difference: NICE is more prescriptive about immediate risk stratification and early review timelines; SIGN provides more depth on sustaining remission and preventing relapse over time.

Stepped care and escalation

NICE defines clear steps: start with low-intensity psychosocial interventions for mild presentations, move to high-intensity therapy ± medication for moderate/severe, and consider combined therapy or specialist referral when risk or non-response persists.

SIGN follows similar steps but is more permissive about starting combined approaches sooner in certain clinical contexts (e.g., recurrent depression, significant functional impairment, barriers to accessing timely therapy).

Alignment: Core steps are similar; the main difference is prescriptiveness vs flexibility.

Pharmacology specifics

• First-line agents: Both favour SSRIs; NICE often cites sertraline/fluoxetine; SIGN aligns and discusses choice based on tolerability and past response.
• Monitoring: Both recommend early review after initiation (often 1–2 weeks for high-risk groups, then 4–6 weeks). NICE is explicit about suicidality monitoring post-initiation.
• Switching/augmentation: Both consider switching SSRIs or adding psychotherapy; SIGN offers more narrative guidance on sequencing and when to consider augmentation or specialist referral.
• Duration: Both endorse continuing antidepressants for at least six months after remission; SIGN elaborates on maintenance for recurrent depression.

Psychological therapies

Both guidelines endorse CBT, behavioural activation, interpersonal therapy, and guided self-help for mild to moderate depression, escalating to high-intensity modalities for moderate to severe cases. SIGN highlights relapse-prevention CBT and mindfulness-based approaches; NICE lists these but keeps a more structured stepwise ordering.

Special populations

• Perinatal: Both advise perinatal-specific pathways and careful risk/benefit of pharmacotherapy; NICE is prescriptive about specialist perinatal teams.
• Adolescents/young adults: Both stress careful monitoring of suicidality when starting medication; NICE is explicit about early follow-up intervals.
• Older adults: Consider comorbidities, drug interactions, and lower starting doses; both highlight non-pharmacological options and social support.

Practical flow you can apply

1. Assess severity and risk: Use a validated tool plus clinical judgement; check for suicidality and safeguarding concerns.
2. Offer psychological therapy first for mild–moderate: CBT/behavioural activation/guided self-help; discuss preferences and access.
3. Start SSRI if indicated: Shared decision-making; explain latency, side effects, and red flags; review early for risk, then at 4–6 weeks.
4. Escalate if needed: For non-response, consider switching SSRI or adding high-intensity therapy; refer for specialist input when risk is high or complexity persists.
5. Maintain and prevent relapse: Continue meds ≥6 months post-remission (longer for recurrent depression); consider relapse-prevention CBT; plan tapering carefully.

FAQs: quick clinic answers

Are the guidelines mostly concordant? Yes. NICE is more prescriptive; SIGN allows slightly earlier combined or pharmacological approaches when clinically justified.

Do both prefer SSRIs first-line? Yes. Choice is based on tolerability, patient preference, and past response.

How soon should I review after starting an SSRI? Typically within 1–2 weeks for higher-risk groups, then at 4–6 weeks to assess response and side effects.

When to refer? Significant suicide risk, psychosis, bipolar features, treatment-resistant depression, severe functional impairment, or diagnostic uncertainty.

How long to continue medication after remission? At least six months; longer for recurrent episodes, with a plan for maintenance and relapse prevention.

Source links (official)

• NICE NG222 – Depression in adults
• SIGN – Guidelines (see depression)
• CliniSearch depression guideline page

Why this matters

Depression care requires balancing evidence-based structure with real-world flexibility. NICE offers clear steps, risk stratification, and commissioning-friendly guidance. SIGN mirrors the core steps but provides more flexibility for earlier pharmacotherapy and deeper relapse-prevention strategies. Using both allows clinicians to tailor care, especially when access to psychological therapies varies or when managing recurrent or high-risk presentations.