The current draft guideline on the Recognition and Management of Depression in Adults is not fit for purpose

On the 17th November, a number of mental health organisations, including NSUN, came together to write a letter to Professor David Haslam, Chair of NICE, to formally request a further full stakeholder consultation of the next revision of the guideline on the Recognition and Management of Depression in Adults, prior to its formal publication.

Download the full briefing here

This was done because, along with many other stakeholders, there was concern about significant flaws in methodology, lack of transparency and several inconsistencies in the document.

The NICE depression guideline will impact on the care of millions of constituents – four in ten adults report experiencing depression at some time in their life (Mental Health Foundation). The sheer scale of depression in England and Wales should dictate that those charged with revising the 2009 guideline follow the most robust methodology in the most transparent way.

In our letter to the Chair of NICE we stated our view that, without a second consultation being granted to allow these serious concerns to be addressed, the guideline “will not be fit for purpose and will seriously impede good patient care and patient choice.”

In summary, our concerns relate to the following:

  • The draft guideline fails to meet the NHS agenda of ‘parity of esteem’, defined as valuing mental health equally with physical health.  Despite depression often manifesting itself as a long-term condition, or becoming a long-term condition if immediate care is inadequate, the current draft recommendations are all made on the basis of very short-term outcomes (often 6-12 weeks).  NICE guidelines for long term physical conditions would treat this evidence in question as inadequate, requiring at least 1 or 2 years follow-up data.  Follow-up data of 1-2 years has instead been completely ignored in the draft depression guideline.
  • The current draft guideline has largely ignored the voices of service users, using out-of-date evidence of service user experiences mostly dating back to before 2004 and has failed even to incorporate this evidence into recommendations.
  • The current draft guideline has used inadequate methods for working out whether a treatment has shown itself to be effective within a research study – ignoring the severity of depression at the start of the treatment. Much better methods exist for this and are widely used in the research community.
  • The current draft guideline used statistical analyses that are associated with serious and unique risks. These were inadequately reported and addressed (leading to violations of statistical assumptions in the approach adopted) and this therefore puts the resulting treatment recommendations into serious question.
  • The current draft guideline has an extremely narrow focus on symptom outcomes and fails to take into account other aspects of service user experience, which have long been called for, such as quality of life, relationships and ability to participate in work, education or society.
  • The current draft guideline is completely out of step with US and European guideline methodologies, having created its own method for categorising depression by longevity and severity – leading to erroneous and unhelpful classification of research studies, which do not match clinical or service user experiences.
  • These serious methodological flaws undermine patient choice, with recommendations based on a poor methodology.

The draft new guideline on depression in adults was sent out for stakeholder consultation between July and Sept 2017; the original publication date (January) has recently been pushed back until March 2018. We are currently awaiting a response from the Chair of NICE regarding our request that a second consultation be granted.

The guideline on depression produced by NICE must properly reflects the evidence base and have the support of people that the guideline will affect, as well as organisations working to support and treat people experiencing depression.

A cross-party letter and an Early Day Motion also raise the concerns.

If you would like to raise concerns individually or send the briefing to NICE directly in support, you can do so by emailing NICE with the subject heading, FAO Prof David Haslam - Concerns about Recognition and Management of Depression in Adults guideline.