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Be vigilant for depression, NICE guidelines advise

Health professionals are being encouraged to be alert to possible depression, particularly in those with a history of the disease or a chronic physical health problem, following publication of two clinical guidelines by the National Institute for Health and Clinical Excellence.

The main guideline makes recommendations on the identification and management of depression in adults in both primary and secondary care, and updates guidance published in 2004. The second guideline focuses on depression in adults who also have a long-term physical health condition.

As well as giving advice on psychosocial interventions, the guidelines consider treatment with antidepressants. Both state that anti-depressants should not be prescribed routinely for patients with fewer than five symptoms of depression (sub-threshold depressive symptoms) or mild depression.

However, antidepressants should be considered for patients with:

  • A past history of moderate or severe depression
  • Mild depression that complicates the care of a physical health problem
  • Initial presentation of sub-threshold depressive symptoms that have been present for a long time (typically at least two years)
  • Sub-threshold depressive symptoms or mild depression that persists after other treatments


David Taylor, chief pharmacist at the South London and Maudsley NHS Foundation Trust, was a member of the development group for the guideline on depression in adults who also have a chronic physical condition.

He told The Journal that although both guidelines highlight the need to consider the impact of co-morbidities, contraindications, side effects and drug interactions when choosing an antidepressant, this need is emphasised when a patient also has a chronic physical condition.

Dr Taylor added that clinicians are sometimes reluctant to treat patients with depression who have co-morbidities. “This reluctance may arise from concerns that antidepressants might impact on the physical condition or interact with its treatment,” Dr Taylor said.

He pointed out, however, that there is good evidence to support the use of antidepressants in patients with co-morbidities. “On balance they are likely to have a neutral effect on the physical condition or a beneficial effect,” he said.

He also pointed out that meta analyses of trials examining treatment of depression where a chronic physical condition co-exists suggest that selective serotonin reuptake inhibitors (SSRIs) and tricyclic and other antidepressants are all effective and that there is no clear difference between individual drugs or groups of drugs.

However, both guidelines suggest normally using SSRIs in generic form. NICE also states in its guidance that there is currently no evidence to support use of specific antidepressants for patients with particular chronic physical health problems.

Use of St John’s wort is not recommended by NICE, which advises that patients are told about the different potencies of preparations available and the potential serious interactions of St John’s wort with other drugs.

The guidelines, available on the NICE website, also describe how to choose antidepressant therapy, taking into account expected adverse events, potential interactions, the patient’s perceptions of treatment and toxicity in overdose.

Citation: The Pharmaceutical Journal URI: 10983762

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