NICE depression in adults: treatment and management 

(Update)

In November, 2018, 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 full stakeholder consultation of the next revision of the guideline on the Recognition and Management of Depression in Adults, prior to its formal publication. You can read the stakeholder position statement here.

Here's the response from NICE to issues raised by a coalition of stakeholders.

Below is the latest update on teh guidelines from NICE.

NICE will carry out further development work on the update. This further work is detailed below.

Long-term follow up data

NICE will now include long-term follow-up data in all its treatment reviews. The committee previously considered that long-term follow up data were not available across all comparisons of interests in the guideline and consequently long-term effectiveness would be subject to large potential biases. However, we accept that long-term effectiveness is an important outcome and we will now look for it in all treatment reviews. The committee will consider all long-term follow-up data found in making its recommendations and the relative importance attributed to it will be a judgement made by the committee based on the availability and quality of the long-term data.

Service user experience

The additional work on patient choice, which was begun in February 2019 will include a systematic review of primary studies of service user experience. This work focuses specifically on qualitative studies informing questions around choice of treatment, rather than more general studies of people’s experiences of depression (not linked to choice of treatment), which were not felt to be sufficiently relevant to the question. The findings of this work will be considered alongside quantitative results when recommendations are being written and quality assured and presented as such in the final guideline.

Trials where the majority of the population is clinically complex, chronic or treatment resistant

For the further-line treatment review, NICE will include studies of adults with depression showing an inadequate response to at least one previous intervention for the current episode and this will include the further-line treatment of psychotic depression, depression with coexisting personality disorder and chronic depression.

First-line treatment or relapse prevention of chronic depression (including dysthymia), and first-line treatment or relapse prevention of depression with coexisting personality disorder will remain as separate reviews, as the committee did not feel that it was appropriate to combine these populations for first-line treatment or relapse prevention. The committee reviewed the European Psychiatric Association classification but did not consider it appropriate to change the term to ‘persistent depression’ but considered that the grouping together of psychotic depression, depression with coexisting personality disorder and chronic depression for the further-line treatment review should allow the effectiveness of interventions for a more clinically complex population to be considered.

Partial recovery and classifications of severity

The guideline will look at continuous changes in scores on depression scales in every treatment question, which will capture changes for people who have both fully and partially recovered. This was agreed by the committee to be a better way to capture this data than the use of a dichotomous outcome for partial recovery. The categorisations of depression severity have been updated and are now based on published work by Wahl et al (2014) and others.

Network Meta-Analysis (NMA)

We do not accept that the use of NMA was inappropriate and we will continue to use NMAs both to assess clinical effectiveness and to inform the economic model in accordance with the NICE Guidelines Manual. However, pairwise data will be presented separately in the new version of the guideline to enable an easier comparison between direct and NMA results. There will also be a peer review of all NMAs by a NICE Technical Support Unit contractor and NICE will publish the code for its NMAs. NICE recognises that no statistical technique will ever lead to an indisputably ‘correct’ answer, since they all involve assumptions and extrapolations of the available data. Both the committee and quality assurance team will consider any limitations of the analysis and the confidence we have in it when making recommendations. The data from the NMA will also be considered alongside the other sources of data feeding into this question, including the pairwise data, economic model results and newly reviewed qualitative evidence.

Quality of Life and/or functioning outcome data

NICE will now include quality of life and functional status as outcomes in the treatment reviews. As with long-term data, the relative importance that will be attributed to this data cannot be stated upfront, since this will be a judgement made by the committee based on the availability and quality of data available for these outcomes.

The timelines for completing the work set out above are currently being developed. Once they are finalised, we will notify all stakeholders of a publication date for the Depression guideline, as well as the dates of the next consultation.

 

See our pages that sets out the position statement here.