Depression
NICE guideline Depression in adults: treatment and management. Published: Jun 2022.
NICE CKS Depression. Last revised: Apr 2025.
Guidelines
Management
Less Severe Depression (PHQ-9 <16)
Management depends on patient preference for treatment
Patients Not Wishing Treatment
Active monitoring, with the option to consider treatment at any time if needed
Patients Wishing treatment
1st line → Guided self-help
Alternative (if preference for antidepressant therapy) → Antidepressant therapy (SSRI being 1st line)
Other treatment options to consider (in descending order of appropriateness)
- Group CBT
- Group behavioural activation
- Individual CBT
- Individual behavioural activation
- Group exercise
- Group mindfulness and meditation
- Interpersonal psychotherapy
- SSRIs
- Counselling
- Short-term psychodynamic psychotherapy
In contrast to ‘more severe’ depression, anti-depressants are NOT routinely given first line for ‘less severe’ depression.
More Severe Depression (PHQ-9 ≥16)
1st line:
- CBT, and
- Antidepressant (1st line: SSRI or SNRI)
Note that antidepressant usually takes 4 weeks to start working
Follow Up / Initial Review
All patients require initial review after 2-4 weeks (irrespective of management plan/depression severity)
- Exception: arrange earlier initial review, after 1 week of starting antidepressant therapy in:
- All patients 18-25 y/o OR
- if there are particular concerns about risk of suicide
Anti-depressants, particularly SSRIs, are associated with a small but significant increased risk of new-onset suicidal ideation and behavior, particularly in the 18-25 y/o age group.
Duration of Antidepressant Therapy
- Antidepressants are typically continued for at least 6 months following symptom resolution, to prevent relapse
Further Treatment
Consider switching antidepressants to any of the following classes:
- SSRI
- SNRI
- TCA (only in secondary care)
- MAO-I (only in secondary care)
Consider combination treatment by adding:
- Another antidepressant class – mirtazapine, or trazodone
- 2nd generation antipsychotic (e.g. olanzapine, aripiprazole, quetiapine)
- Lithium
Vortioxetine is recommended as an option if no or limited response to 2 antidepressants
Consider electroconvulsive therapy if:
- Patient preference
- Rapid response is needed (e.g. life-threatening depression due to refusal to eat or drink)
- Other treatments have been unsuccessful
Switching Antidepressants Recommendations [Ref]
Most antidepressants can be switched directly (with no cross-tapering or drug-free period needed):
- SSRI (caution with fluoxetine – see below) → other SSRI OR SNRI
- SNRI → SSRI OR other SNRI
- TCA ↔ other TCA
Exceptions / Cautions (to prevent interactions & serotonin syndrome)
- Fluoxetine → any SSRI/SNRI/TCA
- Gradually taper down & discontinue fluoxetine → 4-7 days drug-free period → start new antidepressant (from low-dose).
- SSRI/SNRI ↔ TCA
- Cross-taper: taper the initial antidepressant down whilst simultaneously starting a low dose of the new antidepressant (slowly uptitrated); works vice-versa
- No need for a drug-free period
- Further detail: fluvoxamine/paroxetine, clomipramine
- SSRI/SNRI/TCA ↔ irreversible MOA inhibitors
- Gradually taper down & discontinue initial antidepressant → ≥ 2 weeks drug-free period (5 weeks after fluoxetine) → then start new antidepressant; works vice-versa
References
Original Guideline