Step 3: P

Persistent
ersistent subthreshold depressiv
depressive e
symptoms or mild to moder
moderate
ate depression with
inadequate response to initial interv
interventions,
entions, and
moder
moderate
ate and sesevvere depression in adults

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/depression
NICE Pathway last updated: 24 April 2018

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

Depression Page 1 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

Depression Page 2 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

1 Person with inadequate response to initial interventions, or moderate

or severe depression

No additional information

2 Treatment options

Choosing treatments

Choice of intervention should be influenced by the:

duration of the episode and trajectory of symptoms

previous illness course and response to treatment
likelihood of adherence and potential adverse effects
person's preference
course and treatment of any chronic physical health problem.
Treatment options for people without a chronic physical health problem

For people with persistent subthreshold depressive symptoms or mild depression to moderate
depression who have not benefited from a low-intensity psychosocial intervention, discuss
different interventions with the person and provide:

an antidepressant (normally an SSRI) or

a high-intensity psychological intervention, normally one of the following:
CBT

IPT
behavioural activation (but note that the evidence is less robust than for CBT or
IPT)
behavioural couples therapy for people who have a regular partner and where the
relationship may contribute to the development or maintenance of depression, or
where involving the partner is considered to be of potential therapeutic benefit.

For people who decline the options above, consider1:

counselling for people with persistent subthreshold depressive symptoms or mild to

moderate depression; offer 6–10 sessions over 8–12 weeks

Depression Page 3 of 14
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1
Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in
treating depression.

Depression Page 4 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

short-term psychodynamic psychotherapy for people with mild to moderate depression;

offer 16–20 sessions over 4–6 months.

For people with moderate or severe depression, combine antidepressants with a high-intensity
psychological intervention (CBT or IPT).

Treatment options for people with a chronic physical health problem

For people with persistent subthreshold depressive symptoms or mild to moderate depression
who have not benefited from a low-intensity psychosocial intervention, provide an
antidepressant (normally an SSRI) or one of the following high-intensity psychological
interventions:

group-based CBT or
individual CBT (if group-based CBT is declined, not appropriate or not available) or
behavioural couples therapy for people who have a regular partner and where the
relationship may contribute to the development or maintenance of depression, or where
involving the partner is considered to be of potential therapeutic benefit.

For people with initial presentation of moderate depression, offer group-based CBT, individual
CBT or behavioural couples therapy.

For people with severe depression, consider offering both individual CBT and an
antidepressant.

Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

Depression in adults

6. Moderate to severe depression and no existing chronic physical health problem

7. Moderate depression and a chronic physical health problem

8. Severe depression and a chronic physical health problem

Depression Page 5 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

3 Delivering high-intensity psychological interventions1

Interventions for people without a chronic physical health problem

Individual CBT

Typically deliver 16–20 sessions over 3–4 months.

Consider 3–4 follow-up sessions over the next 3–6 months.

For moderate or severe depression, consider 2 sessions per week for the first 2–3 weeks.

IPT

Typically deliver 16–20 sessions over 3–4 months.

For severe depression, consider 2 sessions per week for the first 2–3 weeks.

Behavioural activation

Typically deliver 16–20 sessions over 3–4 months.

Consider 3–4 follow-up sessions over the next 3–6 months.

For moderate or severe depression, consider 2 sessions per week for the first 3–4 weeks.

Behavioural couples therapy

Typically deliver 15–20 sessions over 5–6 months.

Interventions for people with a chronic physical health problem

Group-based CBT

Typically deliver in groups of 6–8 people with a common physical health problem, over 6–8
weeks.

1
Duration of interventions can be tailored to individual circumstances.

Depression Page 6 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

Individual CBT

Deliver until symptoms have remitted but typically:

6–8 weeks (no longer than 16–18 weeks) for moderate depression plus 2 follow-up
sessions in the next 6 months
16–18 weeks for severe depression plus 2 or 3 follow-up sessions in the next 12 months;
offer twice-weekly sessions for the first 2–3 weeks focusing on behavioural activation.

Behavioural couples therapy

Typically deliver 15–20 sessions over 5–6 months.

4 Antidepressant treatment

See Depression / Antidepressant treatment in adults

5 Combining psychological and drug treatment

For people with moderate or severe depression without a chronic physical health problem,
combine antidepressants with a high-intensity psychological intervention (CBT or IPT).

For people with severe depression and a chronic physical health problem, consider offering both
individual CBT and an antidepressant.

If a person's depression has not responded to either pharmacological or psychological

interventions, consider combining antidepressants with CBT.

Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

Depression in adults

6. Moderate to severe depression and no existing chronic physical health problem

8. Severe depression and a chronic physical health problem

Depression Page 7 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

6 Is there a response to interventions?

No additional information

7 Continuation and relapse prevention

See Depression / Continuation and relapse prevention for adults with depression

8 Considering referral and/or enhanced care

If a person's depression has not responded to various augmentation and combination

treatments, consider referral to a specialist practitioner or service.

Enhanced care

Do not routinely provide medication management as a separate intervention for people with
depression.

For people with severe depression, or with moderate depression and complex problems,
consider referring to specialist mental health services for a programme of coordinated
multiprofessional care.

If a person with long-standing moderate or severe depression would benefit from additional
social or vocational support, consider:

befriending as an adjunct to pharmacological or psychological treatments; trained

volunteers should provide at least weekly contact for 2–6 months
a rehabilitation programme if depression has resulted in long-term loss of work or
disengagement from social activities.

9 Collaborative care for people with a chronic physical health problem

Consider collaborative care for people with moderate to severe depression and a chronic
physical health problem with associated functional impairment whose depression has not

Depression Page 8 of 14
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 Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

responded to initial high-intensity psychological interventions, pharmacological treatment or a

combination of these.

Collaborative care should normally include:

case management which is supervised by a senior mental health professional

close collaboration between primary and secondary physical health services and specialist
mental health services
a range of interventions consistent with those recommended in this guideline
long-term coordination of care and follow-up.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Depression in adults

9. Collaborative care

10 Step 4: Complex and severe depression

See Depression / Step 4: Complex and severe depression in adults

Depression Page 9 of 14
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Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

Glossary

CAMHS

child and adolescent mental health services

CAPA

child and adolescent psychiatric assessment

CBT

cognitive behavioural therapy

CCBT

computerised cognitive behavioural therapy

DSM-IV

diagnostic and Statistical Manual of Mental Disorders

ECT

electroconvulsive therapy

HoNOSCA

Health of the Nation Outcome Scales for Children and Adolescents

ICD-10

International Statistical Classification of Diseases and Related Health Problems (tenth edition)

IPT

interpersonal therapy

K-SADS

schedule for affective disorders and schizophrenia for school-age children

Depression Page 10 of 14
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Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

MAOI

monoamine oxidase inhibitor

MFQ

mood and feelings questionnaire

Mild depression

few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and
symptoms result in only minor functional impairment, according to DSM-IV

Moderate depression

symptoms of depression or functional impairment are between mild and severe

NSAID

non-steroidal anti-inflammatory drug

SDQ

strengths and difficulties questionnaire

Severe depression

most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms

SSRI

selective serotonin reuptake inhibitor

Subthreshold depressive symptoms

fewer than 5 symptoms according to DSM-IV

TCA

tricyclic antidepressant

Depression Page 11 of 14
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Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

Tier 1

primary care services including GPs, paediatricians, health visitors, school nurses, social
workers, teachers, juvenile justice workers, voluntary agencies and social services

Tier 2

child and adolescent mental health services relating to workers in primary care including clinical
child psychologists, paediatricians with specialist training in mental health, educational
psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists,
counsellors, community nurses/nurse specialists and family therapists

Tier 3

specialised child and adolescent mental health services for more severe, complex or persistent
disorders including child and adolescent psychiatrists, clinical child psychologists, nurses
(community or inpatient), child and adolescent psychotherapists, occupational therapists,
speech and language therapists, art, music and drama therapists, and family therapists

Tier 4

tertiary-level child and adolescent mental health services such as day units, highly specialised
outpatient teams and inpatient units

Sources

Depression in adults with a chronic physical health problem: recognition and management
(2009) NICE guideline CG91

Depression in adults: recognition and management (2009 updated 2016) NICE guideline CG90

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and

Depression Page 12 of 14
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Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Depression Page 13 of 14
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Step 3: P
Persistent
ersistent subthreshold depressiv
depressivee symptoms or mild to moder
moderate
ate NICE Pathways
depression with inadequate response to initial interv
interventions,
entions, and moder
moderate
ate and
se
sevvere depression in adults

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Depression Page 14 of 14
© NICE 2018. All rights reserved. Subject to Notice of rights.