Issue date: October 2009
NICE clinical guideline 90
Developed by the National Collaborating Centre for Mental Health
Depression
The treatment and management of
depression in adults

This is a partial update of NICE clinical
guideline 23

NICE clinical guideline 90
Depression: the treatment and management of depression in adults (partial
update of NICE clinical guideline 23)

Ordering information
You can download the following documents from www.nice.org.uk/CG90
• The NICE guideline (this document) – all the recommendations.
• A quick reference guide – a summary of the recommendations for healthcare
professionals.
• ‘Understanding NICE guidance’ – a summary for patients and carers.
• The full guideline – all the recommendations, details of how they were developed, and
reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’,
phone NICE publications on 0845 003 7783 or email and
quote:
• N2016 (quick reference guide)
• N2017 (‘Understanding NICE guidance’).

1 Guidance 11
1.1 Care of all people with depression 11
1.2 Stepped care 16
1.3 Step 1: recognition, assessment and initial management 17
1.4 Step 2: recognised depression – persistent subthreshold depressive
symptoms or mild to moderate depression 19
1.5 Step 3: persistent subthreshold depressive symptoms or mild to
moderate depression with inadequate response to initial interventions, and
moderate and severe depression 22
1.6 Treatment choice based on depression subtypes and personal
characteristics 30
1.7 Enhanced care for depression 31
1.8 Sequencing treatments after initial inadequate response 31
1.9 Continuation and relapse prevention 35
1.10 Step 4: complex and severe depression 38
2 Notes on the scope of the guidance 44
3 Implementation 44
4 Research recommendations 44
5 Other versions of this guideline 54
6 Related NICE guidance 55
7 Updating the guideline 56
Appendix A: The Guideline Development Group 57
Appendix B: The Guideline Review Panel 61
Appendix C: Assessing depression and its severity 62
Appendix D: Recommendations from NICE clinical guideline 23 64
NICE clinical guideline 90 – Depression 4

This guideline is a partial update of NICE clinical guideline 23 (published
December 2004, revised April 2007) and replaces it. Appendix D has a list of
recommendations for which the evidence has not been updated since the original

1
In both ICD-10 and DSM-IV.
2
In both ICD-10 and DSM-IV.
3
In ICD-10 only.
NICE clinical guideline 90 – Depression 5
impairment to meet the criteria for full diagnosis. Symptoms are considered
persistent if they continue despite active monitoring and/or low-intensity
intervention, or have been present for a considerable time, typically several
months. (For a diagnosis of dysthymia, symptoms should be present for at least
2 years
4
It should be noted that classificatory systems are agreed conventions that seek
to define different severities of depression in order to guide diagnosis and
treatment, and their value is determined by how useful they are in practice. After
careful review of the diagnostic criteria and the evidence, the Guideline
Development Group decided to adopt DSM-IV criteria for this update rather than
ICD-10, which was used in the previous guideline (NICE clinical guideline 23).
This is because DSM-IV is used in nearly all the evidence reviewed and it
provides definitions for atypical symptoms and seasonal depression. Its definition
of severity also makes it less likely that a diagnosis of depression will be based
solely on symptom counting. In practical terms, clinicians are not expected to
switch to DSM-IV but should be aware that the threshold for mild depression is
higher than ICD-10 (five symptoms instead of four) and that degree of functional
impairment should be routinely assessed before making a diagnosis. Using
DSM-IV enables the guideline to target better the use of specific interventions,
such as antidepressants, for more severe degrees of depression.
.)
A wide range of biological, psychological and social factors, which are not


for the treatment of depression only. The guidance in TA59 remains unchanged
for the use of ECT in the treatment of catatonia, prolonged or severe manic
episodes and schizophrenia.
6

5
Available from: www.nice.org.uk/TA59
for the treatment of depression only.
The guidance in TA97 remains unchanged for the use of CCBT in panic and
phobia and obsessive compulsive disorder.
6
Available from: www.nice.org.uk/TA97
NICE clinical guideline 90 – Depression 7
Person-centred care
This guideline offers best practice advice on the care of adults with depression.
Treatment and care should take into account patients’ needs and preferences.
People with depression should have the opportunity to make informed decisions
about their care and treatment, in partnership with their practitioners. If patients
do not have the capacity to make decisions, practitioners should follow the
Department of Health’s advice on consent (available from
www.dh.gov.uk/consent) and the code of practice that accompanies the Mental
Capacity Act (summary available from www.publicguardian.gov.uk).
Good communication between practitioners and patients is essential. It should be
supported by evidence-based written information tailored to the patient’s needs.
Treatment and care, and the information patients are given about it, should be
culturally appropriate. It should also be accessible to people with additional
needs such as physical, sensory or learning disabilities, and to people who do
not speak or read English.
If the patient agrees, families and carers should have the opportunity to be

or pleasure in doing things?
NICE clinical guideline 90 – Depression 9
Low-intensity psychosocial interventions
• For people with persistent subthreshold depressive symptoms or mild to
moderate depression, consider offering one or more of the following
interventions, guided by the person’s preference:
− individual guided self-help based on the principles of cognitive behavioural
therapy (CBT)
− computerised cognitive behavioural therapy (CCBT)
7
− a structured group physical activity programme.

Drug treatment
• Do not use antidepressants routinely to treat persistent subthreshold
depressive symptoms or mild depression because the risk–benefit ratio is
poor, but consider them for people with:
− a past history of moderate or severe depression or
− initial presentation of subthreshold depressive symptoms that have been
present for a long period (typically at least 2 years) or
− subthreshold depressive symptoms or mild depression that persist(s) after
other interventions.
Treatment for moderate or severe depression
• For people with moderate or severe depression, provide a combination of
antidepressant medication and a high-intensity psychological intervention
(CBT or IPT).
Continuation and relapse prevention
• Support and encourage a person who has benefited from taking an
antidepressant to continue medication for at least 6 months after remission of
an episode of depression. Discuss with the person that:
− this greatly reduces the risk of relapse

functioning. Can occur with or without psychotic symptoms.
Note that a comprehensive assessment of depression should not rely simply on a
symptom count, but should take into account the degree of functional impairment
and/or disability (see section 1.1.4).
This guideline is published alongside ‘Depression in adults with a chronic
physical health problem: treatment and management’ (NICE clinical
guideline 91), which makes recommendations on the identification, treatment and
management of depression in adults aged 18 years and older who also have a
chronic physical health problem.
1.1 Care of all people with depression
1.1.1 Providing information and support, and obtaining informed
consent
1.1.1.1 When working with people with depression and their families or carers:

NICE clinical guideline 90 – Depression 12
• build a trusting relationship and work in an open, engaging and
non-judgemental manner
• explore treatment options in an atmosphere of hope and optimism,
explaining the different courses of depression and that recovery is
possible
• be aware that stigma and discrimination can be associated with a
diagnosis of depression
• ensure that discussions take place in settings in which
confidentiality, privacy and dignity are respected.
1.1.1.2 When working with people with depression and their families or carers:
• provide information appropriate to their level of understanding about
the nature of depression and the range of treatments available
• avoid clinical language without adequate explanation
• ensure that comprehensive written information is available in the
appropriate language and in audio format if possible

management, including how families or carers can support the
person
depression, consider:
• offering a carer’s assessment of their caring, physical and mental
health needs if necessary
• providing information about local family or carer support groups and
voluntary organisations, and helping families or carers to access
these
• negotiating between the person and their family or carer about
confidentiality and the sharing of information.

8
Depression is described as ‘chronic’ if symptoms have been present more or less continuously
for 2 years or more.

NICE clinical guideline 90 – Depression 14
1.1.4 Principles for assessment, coordination of care and
choosing treatments
1.1.4.1 When assessing a person who may have depression, conduct a
comprehensive assessment that does not rely simply on a symptom
count. Take into account both the degree of functional impairment
and/or disability associated with the possible depression and the
duration of the episode.
1.1.4.2 In addition to assessing symptoms and associated functional
impairment, consider how the following factors may have affected the
development, course and severity of a person’s depression:
• any history of depression and comorbid mental health or physical
disorders
• any past history of mood elevation (to determine if the depression
may be part of bipolar disorder

1.1.4.6 Always ask people with depression directly about suicidal ideation and
intent. If there is a risk of self-harm or suicide:
• assess whether the person has adequate social support and is
aware of sources of help
• arrange help appropriate to the level of risk (see section 1.3.2)
• advise the person to seek further help if the situation deteriorates.
1.1.5 Effective delivery of interventions for depression
1.1.5.1 All interventions for depression should be delivered by competent
practitioners. Psychological and psychosocial interventions should be
based on the relevant treatment manual(s), which should guide the
structure and duration of the intervention. Practitioners should
consider using competence frameworks developed from the relevant
treatment manual(s) and for all interventions should:
• receive regular high-quality supervision
• use routine outcome measures and ensure that the person with
depression is involved in reviewing the efficacy of the treatment

NICE clinical guideline 90 – Depression 16
• engage in monitoring and evaluation of treatment adherence and
practitioner competence – for example, by using video and audio
tapes, and external audit and scrutiny where appropriate.
1.1.5.2 Consider providing all interventions in the preferred language of the
person with depression where possible.
1.2 Stepped care
The stepped-care model provides a framework in which to organise the provision
of services, and supports patients, carers and practitioners in identifying and
accessing the most effective interventions (see figure 1). In stepped care the
least intrusive, most effective intervention is provided first; if a person does not
benefit from the intervention initially offered, or declines an intervention, they
should be offered an appropriate intervention from the next step.

STEP 4
: Severe and complex
a

depression; risk to life; severe
self-neglect
Low-intensity psychosocial interventions,
psychological interventions, medication and
referral for further assessment and interventions

Medication, high-intensity psychological
interventions, combined treatments,
collaborative care
b
and referral for further
assessment and interventions
Medication, high-intensity
psychological interventions,
electroconvulsive therapy, crisis
service, combined treatments,
multiprofessional and inpatient care

Focus of the
intervention

Nature of the
intervention

Assessment, support, psychoeducation, active
monitoring and referral for further assessment and


10
The Distress Thermometer is a single-item question screen that will identify distress coming
from any source. The person places a mark on the scale answering: ’How distressed have you
been during the past week on a scale of 0 to 10?’ Scores of 4 or more indicate a significant level
and/or asking a family

NICE clinical guideline 90 – Depression 18
member or carer about the person’s symptoms to identify possible
depression. If a significant level of distress is identified, investigate
further.
1.3.2 Risk assessment and monitoring
1.3.2.1 If a person with depression presents considerable immediate risk to
themselves or others, refer them urgently to specialist mental health
services.
1.3.2.2 Advise people with depression of the potential for increased agitation,
anxiety and suicidal ideation in the initial stages of treatment; actively
seek out these symptoms and:
• ensure that the person knows how to seek help promptly
• review the person’s treatment if they develop marked and/or
prolonged agitation.
1.3.2.3 Advise a person with depression and their family or carer to be vigilant
for mood changes, negativity and hopelessness, and suicidal ideation,
and to contact their practitioner if concerned. This is particularly
important during high-risk periods, such as starting or changing
treatment and at times of increased personal stress.
1.3.2.4 If a person with depression is assessed to be at risk of suicide:
• take into account toxicity in overdose if an antidepressant is
prescribed or the person is taking other medication; if necessary,
limit the amount of drug(s) available

no formal intervention, or 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 that the
person may have about them
• provide information about the nature and course of depression

NICE clinical guideline 90 – Depression 20
• arrange a further assessment, normally within 2 weeks
• make contact if the person does not attend follow-up appointments.
1.4.2 Low-intensity psychosocial interventions
1.4.2.1 For people with persistent subthreshold depressive symptoms or mild
to moderate depression, consider offering one or more of the following
interventions, guided by the person’s preference:
• individual guided self-help based on the principles of cognitive
behavioural therapy (CBT)
• computerised cognitive behavioural therapy (CCBT)
11
• a structured group physical activity programme.

Delivery of low-intensity psychosocial interventions
1.4.2.2 Individual guided self-help programmes based on the principles of
CBT (and including behavioural activation and problem-solving
techniques) for people with persistent subthreshold depressive
symptoms or mild to moderate depression should:
• include the provision of written materials of an appropriate reading
age (or alternative media to support access)
• be supported by a trained practitioner, who typically facilitates the
self-help programme and reviews progress and outcome
• consist of up to six to eight sessions (face-to-face and via

• be based on a structured model such as ‘Coping with Depression’
• be delivered by two trained and competent practitioners
• consist of 10 to 12 meetings of eight to ten participants
• normally take place over 12 to 16 weeks, including follow-up.
1.4.4 Drug treatment
1.4.4.1 Do not use antidepressants routinely to treat persistent subthreshold
depressive symptoms or mild depression because the risk–benefit
ratio is poor, but consider them for people with:

NICE clinical guideline 90 – Depression 22
• a past history of moderate or severe depression or
• initial presentation of subthreshold depressive symptoms that have
been present for a long period (typically at least 2 years) or
• subthreshold depressive symptoms or mild depression that
persist(s) after other interventions.
1.4.4.2 Although there is evidence that St John’s wort may be of benefit in
mild or moderate depression, practitioners should:
• not prescribe or advise its use by people with depression because
of uncertainty about appropriate doses, persistence of effect,
variation in the nature of preparations and potential serious
interactions with other drugs (including oral contraceptives,
anticoagulants and anticonvulsants)
• advise people with depression of the different potencies of the
preparations available and of the potential serious interactions of
St John’s wort with other drugs.
1.5 Step 3: persistent subthreshold depressive symptoms
or mild to moderate depression with inadequate
response to initial interventions, and moderate and
severe depression
1.5.1 Treatment options

• counselling for people with persistent subthreshold depressive
symptoms or mild to moderate depression
• short-term psychodynamic psychotherapy for people with mild to
moderate depression.

NICE clinical guideline 90 – Depression 24
Discuss with the person the uncertainty of the effectiveness of
counselling and psychodynamic psychotherapy in treating depression.
1.5.2 Antidepressant drugs
Choice of antidepressant
12
1.5.2.1 Discuss antidepressant treatment options with the person with
depression, covering:

• the choice of antidepressant, including any anticipated adverse
events, for example side effects and discontinuation symptoms (see
1.9.2.1), and potential interactions with concomitant medication or
physical health problems
13
• their perception of the efficacy and tolerability of any
antidepressants they have previously taken.

1.5.2.2 When an antidepressant is to be prescribed, it should normally be an
SSRI in a generic form because SSRIs are equally effective as other
antidepressants and have a favourable risk–benefit ratio. Also take the
following into account:
• SSRIs are associated with an increased risk of bleeding, especially
in older people or in people taking other drugs that have the
potential to damage the gastrointestinal mucosa or interfere with
clotting. In particular, consider prescribing a gastroprotective drug in

gradually) with venlafaxine, duloxetine and TCAs.
• The specific cautions, contraindications and monitoring
requirements for some drugs. For example:
− the potential for higher doses of venlafaxine to exacerbate
cardiac arrhythmias and the need to monitor the person’s blood
pressure
− the possible exacerbation of hypertension with venlafaxine and
duloxetine
− the potential for postural hypotension and arrhythmias with TCAs
− the need for haematological monitoring with mianserin in elderly
people.
15

14
Consult appendix 1 of the BNF for information on drug interactions and ‘Depression in adults
with a chronic physical health problem: treatment and management’ (NICE clinical guideline 91).

15
Consult the BNF for detailed information.