NICE guideline

This effectively advocates a 'stepped care' approach (http://www.nice.org.uk/ page.aspx?o=236667). It advocates screening, although it is disputed that this would meet standard UK criteria for the introduction of screening programmes (Gilbody et al., 2006). Watchful waiting, that is, review in 2 weeks, is advocated for mild cases, and seems sensible. Guided self-help and short-term psychological treatment for mild and moderate cases are probably less realistic, however, due to lack of availability of same in primary care.

Prescription of a specific serotonin reuptake inhibitor (SSRI) is the next step advocated, and this aroused some controversy, even though it was essentially preaching to the choir, as SSRIs and later drugs have effectively taken over in primary care. Few GPs would now start with a tricyclic, let alone monoamine oxidase inhibitors (MAOIs). For initial presentation of severe depression, treatment-resistant depression, or recurrent depression, a combination of CBT and medication is suggested, but this again seems a counsel of perfection, in view of the limited availability of CBT.

The guideline contains disappointingly little on the community mental health team. The help of such professionals is, in practice, more available than psychological treatment; it is probably also more suitable for rehabilitation of chronic patients, who may need help with practical matters such as benefits and return to work.

Regarding ECT, NICE suggests that it should be 'used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective, and/or when the condition is considered to be potentially life-threatening, in individuals with a severe depressive illness', advice that seems reasonable.

However, NICE opposes maintenance ECT, the practice of giving a periodical application, say, once a month, to try to prevent recurrence in chronic severe depressive illness. This practice, although rare in adult psychiatry, is not uncommon in elderly psychiatry, where the frail older patient may experience fewer side-effects from ECT than from medication. This particular recommendation of NICE has therefore caused controversy.

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