Introduction
Understanding the depression nice guidelines is essential for every UK doctor, as depression is arguably the “common cold” of psychiatry—prevalent, recurring, but potentially fatal if mismanaged. In the UK, we have moved away from the historic approach of “pills for everyone” towards a more nuanced, evidence-based strategy known as the Stepped Care Model.
This model is the backbone of mental health provision in the NHS. It ensures that the most effective, least intrusive treatment is offered first, with intensity increasing only if the patient does not improve. For the UKMLA, this means you cannot simply prescribe an antidepressant to every patient who admits to feeling sad. You must be able to grade the severity of their condition, assess their suicide risk, and select the appropriate “step” from the NICE framework.
Whether you are in a General Practice consultation in the AKT or a Psychiatry station in the CPSA, your ability to navigate these guidelines will be tested. This comprehensive guide will walk you through the diagnostic criteria, the 4-Step model, pharmacological nuances, and the critical skill of risk assessment.
Key Takeaways
The 4-Step Model: Treatment intensity must match disease severity. We start with “Active Monitoring” for mild cases and escalate to Crisis Teams for life-threatening risk.
First-Line Pharmacotherapy: Sertraline is the gold standard first-line SSRI for most adults, but knowing how to titrate it and when to switch is vital.
Non-Pharmacological: Psychological interventions (CBT, IPT) are equal first-line partners to medication, especially in mild-to-moderate depression.
Risk Assessment: Recognizing the “Red Flags” of immediate suicide risk (plans, intent, final acts) is the single most important safety behaviour in psychiatry.
Treatment Resistance: Understanding when to augment, when to switch, and when to refer to secondary care is a key differentiator for high-scoring candidates.
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Diagnosing Depression: ICD-10 vs DSM-5
Before you can treat, you must diagnose. In the UK, we primarily use the ICD-10 criteria (International Classification of Diseases) rather than the American DSM-5, although they are very similar.
The diagnosis of a depressive episode requires symptoms to be present for at least 2 weeks and involves a change from previous functioning.
The “Core” Symptoms (The Big 3)
You must look for at least two of these for any diagnosis of depression:
Depressed Mood: Predominantly low mood for most of the day, almost every day.
Anhedonia: Loss of interest or pleasure in activities that used to be enjoyable.
Anergia: Decreased energy or increased fatigue.
The “Somatic” & Cognitive Symptoms
Also known as biological symptoms:
Loss of confidence or self-esteem.
Unreasonable feelings of self-reproach or excessive/inappropriate guilt.
Recurrent thoughts of death or suicide.
Diminished ability to think or concentrate (indecisiveness).
Change in psychomotor activity (agitation or retardation).
Sleep disturbance (typically early morning wakening).
Change in appetite (usually decreased) with corresponding weight change.
Grading Severity
This grading directly dictates your management under the depression nice guidelines.
| Severity | Criteria | Functional Impact |
|---|---|---|
| Mild | 2 Core + 2 Somatic Symptoms | Distressed but continues to function socially/occupationally. |
| Moderate | 2 Core + 3-4 Somatic Symptoms | Difficulty continuing with ordinary activities. |
| Severe | 3 Core + 4+ Somatic Symptoms | Considerable distress; cannot function. May include psychotic symptoms. |
For a broader overview of psychiatric presentations, refer to our guide on Master High-Yield Psychiatry.
The NICE Stepped Care Model (Overview)
The Stepped Care Model is central to the NICE Guideline [NG222]. The principle is simple: use the least intrusive, most effective intervention first.
Step 1: Assessment and Support (All patients).
Step 2: Low-intensity interventions (Mild to Moderate).
Step 3: High-intensity interventions & Pharmacology (Moderate to Severe).
Step 4: Specialist care (Severe/Complex/Life-threatening).
Step 1: All Presentations
This step applies to everyone who walks through the door with suspected depression.
Assessment
Before assigning a “Step,” you must perform a holistic assessment. This includes:
History of the presenting complaint.
Past psychiatric history.
Comorbidities: Is there hypothyroidism? Anaemia? Chronic pain? (See General Practice Essentials for ruling out organic causes).
Social situation (housing, debt, isolation).
Active Monitoring
For patients who, in your clinical judgement, may recover without formal intervention (e.g., mild symptoms driven by a temporary stressor):
Discuss the presenting problem.
Provide information about depression.
Reassess in 2 weeks.
Do not offer antidepressants yet.
Step 2: Persistent Subthreshold / Mild-Moderate Depression
If symptoms persist after active monitoring, or if the patient presents with mild-to-moderate depression, move to Step 2.
UKMLA Warning: Do not prescribe antidepressants as first-line treatment for Mild Depression unless there is a specific reason (e.g., history of moderate/severe depression, subthreshold symptoms persisting for >2 years, or mild depression complicating a chronic physical health problem).
Low-Intensity Psychological Interventions
The primary treatment here is psychological. Options include:
Individual Guided Self-Help: Based on CBT principles, supported by a trained practitioner.
Computerised CBT (cCBT): Online programs approved by NICE.
Structured Group Physical Activity: Exercising in a group setting (social + biological benefit).
Sleep Hygiene
Regulating circadian rhythms is crucial. Simple advice on avoiding caffeine, reducing screen time, and maintaining regular wake-up times can have a profound effect on mood.
Step 3: Persistent / Moderate-Severe Depression
If Step 2 fails, or if the patient presents initially with Moderate to Severe depression, move to Step 3.
The Shift: High-Intensity Interventions
At this stage, “guided self-help” is insufficient. The patient requires:
CBT (Cognitive Behavioural Therapy): Individual sessions.
Interpersonal Therapy (IPT): Focusing on relationship issues and life transitions.
Behavioural Couples Therapy: If the relationship is a contributing factor.
Pharmacological Intervention
This is the stage where Antidepressants (SSRIs) are formally introduced.
For moderate/severe depression, the combination of Antidepressant + High-Intensity Psychological Therapy is the gold standard.
Step 4: Severe / Complex / Risk to Life
This step involves patients who are:
Severely depressed (often with psychosis).
At significant risk of suicide.
Neglecting themselves (not eating/drinking).
Referral to Secondary Care
These patients need the Crisis Resolution and Home Treatment (CRHT) team or the Community Mental Health Team (CMHT).
Interventions
Inpatient Admission: If the risk cannot be managed in the community.
ECT (Electroconvulsive Therapy): Considered for severe, life-threatening depression where a rapid response is needed (e.g., catatonia or severe refusal of food/fluids).
Multi-drug combinations: Augmenting SSRIs with Antipsychotics (e.g., Quetiapine) or Lithium.
Mental Health Act: If the patient lacks capacity and is a danger to themselves, you may need to assess for detention. Refer to Mental Capacity Assessment for the principles of capacity vs. the MHA.
Pharmacological Management (Deep Dive)
Prescribing antidepressants is a core skill. You must know what to choose, how to counsel, and when to stop.
First Line: SSRIs
Sertraline or Citalopram or Fluoxetine.
Sertraline is generally preferred because it has a lower risk of drug-drug interactions and is safe post-myocardial infarction.
Dose: Start low (e.g., Sertraline 50mg OD) and review.
Second Line
If there is no response to the first SSRI (after checking compliance):
Switch to a different SSRI (e.g., from Sertraline to Citalopram).
OR Switch to a medication of a different class, such as Mirtazapine (useful if insomnia/poor appetite are prominent) or Venlafaxine (SNRI).
| Drug Class | Example | Key Notes for UKMLA |
|---|---|---|
| SSRI | Sertraline, Citalopram | First line. Watch for GI bleed risk (prescribe PPI if on NSAIDs) and Hyponatraemia. Citalopram causes QT prolongation. |
| NaSSA | Mirtazapine | Sedating. Causes weight gain. Good for elderly with insomnia/anorexia. |
| SNRI | Venlafaxine, Duloxetine | Second line. Monitor BP (can cause hypertension). High risk of withdrawal symptoms. |
| TCA | Amitriptyline | Third line. Dangerous in overdose (cardiotoxic). Anticholinergic side effects. |
For more on interactions, see Prescribing Safely for the UKMLA.
Essential Counselling Points
You must tell the patient:
Latency: “It takes 2 to 4 weeks to start working.”
Paradoxical effect: “You might feel more anxious or agitated in the first few days.”
Duration: “Once you feel better, you need to keep taking it for at least 6 months to prevent relapse.”
Stopping: “Do not stop abruptly, or you will get withdrawal symptoms (zaps, nausea, mood swings).”
Suicide Risk Assessment
This is arguably the most critical part of any psychiatric consultation. You must stratify risk into Low, Medium, or High.
The Hierarchy of Risk
Explore these three levels specifically:
Ideation: “Have you had thoughts that life is not worth living?” (Passive) -> “Have you thought about ending your life?” (Active).
Intent: “Do you intend to act on these thoughts?”
Plan/Preparation: “Have you made a plan? Have you stockpiled tablets? written a note? sorted your affairs?”
Protective Factors
Always ask: “What stops you from doing it?” (e.g., children, religion, fear of pain). Strong protective factors can mitigate risk.
Red Flag: If a patient has a specific plan, the means to carry it out (e.g., they have the tablets at home), and intent to do so, this is a Medical Emergency. Do not let them leave. Refer to Professionalism and Patient Safety for guidance on breaking confidentiality for safety.
Clinical Scenarios: Putting it into Practice
Scenario 1: The Young Professional
Patient: 24-year-old male. Feeling “down” for 3 months since a breakup. struggling to sleep. Still going to work but performance dropping. No suicide risk.
Step: Step 2 (Mild/Moderate).
Plan: Do not prescribe Sertraline yet. Offer “Active Monitoring” or refer for “Low-Intensity Psychological Intervention” (e.g., online CBT). Advice on sleep hygiene. Review in 2 weeks.
Scenario 2: The Elderly Patient
Patient: 78-year-old female. Lost 5kg in weight. Not sleeping. Believes her bowels have rotted away (nihilistic delusion).
Step: Step 4 (Severe/Psychotic).
Plan: This is severe depression with psychotic features. She needs urgent referral to the CMHT or Old Age Psychiatry. Mirtazapine might be a good choice (for sleep/appetite), but she likely needs antipsychotics or admission.
Practice Exercise: Test Your Knowledge
Question 1: A 45-year-old man with a history of Myocardial Infarction 6 months ago is diagnosed with moderate depression. Which antidepressant is the safest first-line choice?
A) Citalopram
B) Venlafaxine
C) Amitriptyline
D) Sertraline
E) Fluoxetine
Correct Answer: D (Sertraline). Sertraline is the safest SSRI post-MI as it has the least effect on the QT interval and cardiac conduction. Citalopram causes QT prolongation and is risky in cardiac patients. TCAs (Amitriptyline) are cardiotoxic.
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Question 2: A 30-year-old woman presents with low mood. She has 2 core symptoms and 4 somatic symptoms. She has stopped going to work and is neglecting her hygiene. What is the severity?
A) Subthreshold
B) Mild
C) Moderate
D) Severe
E) Psychotic
Correct Answer: C/D borderline. However, based on the count (2 Core + 4 Somatic), this technically fits Moderate depression (ICD-10 usually requires 3 Core for Severe). However, the functional impairment (neglect, stopped work) pushes it towards severe. In the Stepped Care model, she is clearly Step 3, requiring Medication + Therapy.
Frequently Asked Questions (FAQ) about Depression NICE Guidelines
Yes, generally. However, you must inform the patient that medication (especially Mirtazapine or TCAs) can cause drowsiness or blurred vision, particularly when first starting. They should see how the medication affects them before driving. They do not need to inform the DVLA unless the condition itself (e.g., severe depression with suicidal ideation or psychosis) affects their fitness to drive.
This is a life-threatening condition caused by excessive serotonin activity, usually from combining serotonergic drugs (e.g., SSRI + Tramadol + St John’s Wort). Symptoms include neuromuscular hyperactivity (tremor, hyperreflexia, clonus), autonomic instability (fever, tachycardia), and altered mental status (agitation). It requires immediate cessation of the offending drugs and supportive care.
No. St John’s Wort is an herbal remedy that acts like a weak SSRI and also induces liver enzymes (reducing the efficacy of other drugs like the Pill or Warfarin). Taking it with a prescribed SSRI significantly increases the risk of Serotonin Syndrome. Patients should be advised to stop it before starting prescribed antidepressants.
This is a complex risk-benefit balance. Mild depression is managed with psychological therapies (CBT). For moderate/severe depression, SSRIs may be needed. Sertraline and Fluoxetine are often used. Paroxetine is generally avoided (small risk of cardiac defects). The risks of untreated depression (poor self-care, suicide) often outweigh the small risks of medication. Always consult specialist resources (e.g., BUMPS) and the Patient.info Depression Guide.
When switching from one antidepressant to another, you often need a drug-free interval to prevent interactions (like Serotonin Syndrome). For example, when switching from Fluoxetine (which has a very long half-life) to another SSRI or MAOI, a long washout period (4-7 days or more) is required. Cross-tapering is safer for some other switches.
Electroconvulsive Therapy (ECT) is reserved for severe, life-threatening depression. Indications include: severe psychomotor retardation (catatonia), refusal of food and fluids leading to severe dehydration, treatment-resistant depression where multiple medications have failed, or high suicide risk where a rapid response is required.
For a first episode of depression, treatment should continue for at least 6 months after remission (recovery) to prevent relapse. If they stop as soon as they feel better, the relapse risk is high. For recurrent depression (2 or more episodes), maintenance treatment should continue for at least 2 years.
“Psychotic depression” is a severe subtype involving delusions (usually mood-congruent, like guilt, poverty, or rotting organs) or hallucinations. Step 3 (SSRI alone) is insufficient. These patients require Step 4 management, involving a combination of an Antidepressant + Antipsychotic (e.g., Quetiapine) and usually involvement of the Crisis Team or admission.
This is a specific CPSA scenario. You must assess their capacity. If they have capacity, you generally cannot treat them against their will unless the Mental Health Act (MHA) applies. However, for the MHA to apply, they usually need to have a mental disorder warranting detention for safety. In an emergency with immediate risk to life, Common Law allows you to act to save a life. You would keep them in a safe place and call for an urgent Mental Health Act Assessment.
Venlafaxine (an SNRI) is effective but has a higher side-effect burden than SSRIs. It is notorious for causing severe withdrawal symptoms (“brain zaps”) if missed or stopped suddenly. It is also more dangerous in overdose than SSRIs (cardiotoxicity) and can raise blood pressure. It is usually initiated by, or on the advice of, a specialist.
Conclusion
Mastering the depression nice guidelines requires you to think like a specialist but act like a generalist. The Stepped Care Model provides the safety net, ensuring you don’t over-medicate the mild cases or under-treat the severe ones.
Remember the golden rules for your exam:
Assess Severity: Count the symptoms (Core vs Somatic).
Step Up: Don’t jump to Step 3 for mild cases.
Safety First: A robust suicide risk assessment is non-negotiable.
Your Next Steps
Visualise the Steps: Draw the Stepped Care staircase from memory.
Check the BNF: Look up the interactions for Sertraline (especially NSAIDs and Warfarin).
Practice Risk Assessment: Role-play asking the “hard questions” about suicide plans with a study partner.
