Step 2: Recognised depression in adults –

persistent subthreshold depressiv

depressivee symptoms or
mild to moder
moderate
ate depression

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/depression
NICE Pathway last updated: 24 April 2018

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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 Step 2: Recognised depression in adults – persistent subthreshold depressiv
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ate depression

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 Step 2: Recognised depression in adults – persistent subthreshold depressiv
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symptoms or mild to moder
moderate
ate depression

1 Person with persistent subthreshold depressive symptoms or mild to

moderate depression

No additional information

2 Initial management and advice

Depression with anxiety

When depression is accompanied by symptoms of anxiety, usually treat the depression first. But
if the person has an anxiety disorder and comorbid depression or depressive symptoms,
consider treating the anxiety disorder first (see what NICE says on generalised anxiety
disorder).

Sleep hygiene

Offer advice on sleep hygiene, including:

establishing regular sleep and wake times

avoiding excess eating, smoking or drinking alcohol before sleep
creating a proper environment for sleep
taking regular physical exercise if possible.
Active monitoring

For people who may recover with no formal intervention, people with mild depression who do
not want an intervention, or people with subthreshold depressive symptoms who request an
intervention:

discuss the presenting problem(s) and any concerns the person has
arrange a further assessment, normally within 2 weeks
provide information about depression
make contact if the person does not attend appointments.

3 Does person have a chronic physical health problem?

No additional information

Depression Page 3 of 15
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 Step 2: Recognised depression in adults – persistent subthreshold depressiv
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ate depression

4 Low-intensity psychosocial interventions or group-based CBT for

people without a chronic physical health problem

For people with persistent subthreshold depressive symptoms or mild to moderate depression,
consider offering one or more of the low-intensity psychosocial interventions described below,
guided by the person's preference.

Individual guided self-help based on CBT principles (and including behavioural

activation and problem-solving techniques)

The intervention should:

include written materials (or alternative media)

be supported by a trained practitioner who reviews progress and outcome
consist of up to 6–8 sessions (face-to-face and by telephone) over 9–12 weeks, including
follow-up.
CCBT1

The intervention should:

be provided via a stand-alone computer-based or web-based programme

explain the CBT model, encourage tasks between sessions, and use thought-challenging
and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner who reviews progress and outcome
typically take place over 9–12 weeks, including follow-up.
A structured group physical activity programme

The intervention should:

be delivered in groups supported by a competent practitioner

typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10–14 weeks.

Group-based CBT

For people who decline a low-intensity psychosocial intervention, consider group-based CBT.
The intervention should:

be based on a model such as 'Coping with depression'

Depression Page 4 of 15
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1
This recommendation updates the recommendations on depression only in 'Computerised cognitive behaviour
therapy for depression and anxiety' (NICE technology appraisal guidance 97).

Depression Page 5 of 15
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 Step 2: Recognised depression in adults – persistent subthreshold depressiv
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moderate
ate depression

be delivered by two trained and competent practitioners

consist of 10–12 meetings of 8–10 participants
typically take place over 12–16 weeks, including follow-up.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Depression in adults

4. Low-intensity interventions for persistent subthreshold depressive symptoms or mild to

moderate depression

5 Low-intensity psychosocial interventions for people with a chronic

physical health problem

For people with persistent subthreshold depressive symptoms or mild to moderate depression
and a chronic physical health problem, and for people with subthreshold depressive symptoms
that complicate the care of the chronic physical health problem, consider offering one or more of
the low-intensity psychosocial interventions described below, guided by the person's preference.

A structured group physical activity programme

The intervention should:

be modified for different abilities according to the physical health problem, in liaison with the
team treating the physical health problem
be delivered in groups supported by a competent practitioner
typically consist of 2–3 sessions per week (lasting 45 minutes to 1 hour) over 10–14 weeks
be coordinated with any rehabilitation programme for the physical health problem.
A group-based peer support (self-help) programme

The intervention should:

be delivered to groups of people with a shared chronic physical health problem

focus on sharing experiences and feelings associated with having a chronic physical health
problem

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moderate
ate depression

be supported by practitioners who should facilitate attendance, understand the chronic

physical health problem and its relationship to depression, and review outcomes
consist typically of 1 session per week over 8–12 weeks.
Individual guided self-help based on CBT principles (and including behavioural
activation and problem-solving techniques)

The intervention should:

include written materials (or alternative media)

be supported by a trained practitioner who reviews progress and outcome
consist of up to 6–8 sessions (face-to-face and by telephone) over 9–12 weeks, including
follow-up.
CCBT1

The intervention should:

be provided via a stand-alone computer-based or web-based programme

explain the CBT model, encourage tasks between sessions, and use thought-challenging
and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner who reviews progress and outcome
typically take place over 9–12 weeks, including follow-up.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Depression in adults

4. Low-intensity interventions for persistent subthreshold depressive symptoms or mild to

moderate depression

6 When to consider drug treatment

For people with depression without a chronic physical health problem

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or

mild depression, but consider them for people with:

Depression Page 7 of 15
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1
This recommendation updates the recommendations on depression only in 'Computerised cognitive behaviour
therapy for depression and anxiety' (NICE technology appraisal guidance 97).

Depression Page 8 of 15
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 Step 2: Recognised depression in adults – persistent subthreshold depressiv
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symptoms or mild to moder
moderate
ate depression

a past history of moderate or severe depression or

initial presentation of subthreshold depressive symptoms present for at least 2 years or
subthreshold depressive symptoms or mild depression persisting after other interventions.
For people with depression and a chronic physical health problem

Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild

depression, but consider them for people with:

mild depression that complicates the care of the physical health problem or
a past history of moderate or severe depression or
initial presentation of subthreshold depressive symptoms present for at least 2 years or
subthreshold depressive symptoms or mild depression persisting after other interventions.
St John's Wort

Do not prescribe or advise use of St John's wort for depression. Explain the different
potencies of the preparations available and the potential serious interactions of St John's wort
with other drugs (including oral contraceptives, anticoagulants and anticonvulsants).

For more information about antidepressants, see antidepressant treatment.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Depression in adults

5. Antidepressants for persistent subthreshold depressive symptoms or mild depression

7 Inadequate response to initial interventions

No additional information

Depression Page 9 of 15
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moderate
ate depression

8 Step 3: Persistent subthreshold depressive symptoms or mild to

moderate depression with inadequate response to initial
interventions, and moderate and severe depression

See Depression / Step 3: Persistent subthreshold depressive symptoms or mild to moderate

depression with inadequate response to initial interventions, and moderate and severe
depression in adults

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ate depression

Glossary

CAMHS

child and adolescent mental health services

CAPA

child and adolescent psychiatric assessment

CBT

cognitive behavioural therapy

CCBT

computerised cognitive behavioural therapy

DSM-IV

diagnostic and Statistical Manual of Mental Disorders

ECT

electroconvulsive therapy

HoNOSCA

Health of the Nation Outcome Scales for Children and Adolescents

ICD-10

International Statistical Classification of Diseases and Related Health Problems (tenth edition)

IPT

interpersonal therapy

K-SADS

schedule for affective disorders and schizophrenia for school-age children

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MAOI

monoamine oxidase inhibitor

MFQ

mood and feelings questionnaire

Mild depression

few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and
symptoms result in only minor functional impairment, according to DSM-IV

Moderate depression

symptoms of depression or functional impairment are between mild and severe

NSAID

non-steroidal anti-inflammatory drug

SDQ

strengths and difficulties questionnaire

Severe depression

most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms

SSRI

selective serotonin reuptake inhibitor

Subthreshold depressive symptoms

fewer than 5 symptoms according to DSM-IV

TCA

tricyclic antidepressant

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Tier 1

primary care services including GPs, paediatricians, health visitors, school nurses, social
workers, teachers, juvenile justice workers, voluntary agencies and social services

Tier 2

child and adolescent mental health services relating to workers in primary care including clinical
child psychologists, paediatricians with specialist training in mental health, educational
psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists,
counsellors, community nurses/nurse specialists and family therapists

Tier 3

specialised child and adolescent mental health services for more severe, complex or persistent
disorders including child and adolescent psychiatrists, clinical child psychologists, nurses
(community or inpatient), child and adolescent psychotherapists, occupational therapists,
speech and language therapists, art, music and drama therapists, and family therapists

Tier 4

tertiary-level child and adolescent mental health services such as day units, highly specialised
outpatient teams and inpatient units

Sources

Depression in adults with a chronic physical health problem: recognition and management
(2009) NICE guideline CG91

Depression in adults: recognition and management (2009 updated 2016) NICE guideline CG90

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and

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practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Depression Page 14 of 15
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Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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