NICE, the National Institute for Health and Care Excellence, is about to publish new guidelines on the ‘treatment of depression’. A consultation paper on the proposals has already been sent out. Publication, intended for January 2018, has been postponed following criticism by service-user organisations and politicians1,2. The controversy this update has generated illustrates very well the philosophy that currently drives ‘mental health thinking’ in the UK. Critics have raised serious concerns about the new proposals but they have not moved away from the position of medicalising depressed mood as an illness or disease.
I have found at least one partial exception to this generalisation. The Tavistock Institute3 has described a middle way between disorder and understandable adversity: Depression is a term that covers a multitude of human problems. For most sufferers, the difficulties express themselves in a different way . . . Whereas an infectious illness starts at a definable point and has a course limited to weeks and months, depression is different; increasingly we have come to recognise that depression is not best thought of as an acute illness but as a long term condition . . . It is thus more appropriate here, and in fact in the majority of cases, to understand the depression as part of what a person is, part of their personality . . . The depression, in this sense, is an authentic expression of their lives and its contents, and the negative thoughts and feelings need to be seen and respected as very important meaningful communications.
It is rather surprising that in 2018 we have to be reminded to take seriously what people say. The Tavistock Institute maintains that people referred to them will have a number of in-depth consultations to understand the nature of their difficulties. This need for assessment could hardly be challenged. Understanding the nature of a person’s complaints is likely to require a minimum of one to two hours of sensitive and open-ended interviewing. Moreover, initial impressions will probably have to be revised subsequently.
Despite nodding assent to the meaningfulness of ‘depressed mood’, the Tavistock Institute still describes ‘depression’ as a condition which needs to be managed, much like diabetes or asthma and that some briefer therapies may sometimes help with certain symptoms. Consequently, it seems happy to sit on the fence.
Detection of so-called depression according to NICE guidelines (CG90).
The guidelines suggest two questions to alert a worker to the presence of ’depression’: During the last month, have you often been bothered by feeling down, depressed or hopeless? and During the last month, have you often been bothered by having little interest or pleasure in doing things? If a person answers ‘yes’ to either question, it is recommended that a mental health assessment be performed by a competent person. Presumably, this has the purpose of distinguishing ‘ordinary woefulness’ from a ‘medical condition’. NICE assumes that the assessor would often be a GP. But how many GPs have the time to perform this function? Many people say they cannot even name their own GP. They see whoever happens to be available at the time of their appointment, which lasts minutes rather than hours.
NICE acknowledges that a comprehensive assessment should not be a simple symptom count (i.e. obtained from a questionnaire or standard set of questions). They advise taking into account functional impairment, psychiatric history, interpersonal relationships, living conditions, social isolation, and suicidal intent. This kind of assessment would certainly take some time. If actually carried out, one would expect that depressed mood severe enough to lead to suicide would be picked up at the primary care level. In fact, three quarters of people who intend to end or take their own life have been invisible to the secondary health care system.4 Their suicidal intent has not been detected earlier.
A thorough assessment should be able to identify obvious psychosocial causes of depressed mood but what should a GP or mental health assessor do about them? It is recommended that: Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Are these manuals flexible enough to take account of job loss, marital breakdown, debt, street crime, bullying, bereavement, and innumerable other possible kinds of adversity? Recommendations for manualised treatment resemble a prescription for a medication e.g. For all people with depression having individual CBT, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. In a non-manualised therapy, it makes sense to give a person time to reflect on making changes, time to collect relevant self-observations, and time to put change into practice at their own pace according to their actual opportunities to do so. The spacing of sessions is part of therapy decision-making and should not be dictated by considerations of an ‘adequate dose of psychological input’ as if two sessions were twice the strength of one session. The idea that therapy should be a certain length, with a predetermined spacing of sessions, is foreign to how most therapists work.
Is ‘depression’ a meaningful concept?
‘Feeling depressed’ is a common enough complaint. It refers to a state that varies from being mild and temporary to one with a range of behavioural and bodily effects that can be severe and life-threatening. The fact that similar words are used to describe this state along a continuum of severity is no guarantee that they are the expression of a unitary ‘illness’ or ‘disease’. In fact, psychiatrists distinguish several types of ‘depression’. The NICE guidelines are intended for major depressive disorder, dysthymia, sub-threshold depression and sub-threshold depressive symptoms. This is quite a large collection of possible states of mind. At present, psychiatry cannot cite a set of biomedical markers that would justify the concept of ‘depression’ as a disease. The belief that ‘major depression’ has any credibility as a meaningful medical concept is simply one example of the rhetoric of medicalisation. If it is the case that depressed mood has a variety of different causes (as in my experience seems to be the case), generic guidelines for its ‘treatment’ have little role to play.
We should also be wary of pathological explanations of ‘depression’ when analogous behaviour has been widely observed in animals, especially in those genera with dominance hierarchies, such as the primates. Part of this behavioural pattern is ‘giving in’ (i.e. conceding social defeat) and this may be accompanied by responses that solicit resources from others (e.g. begging, crying, agitation, self-harm, and helplessness). This pattern resembles the deferential, submissive, and often ineffectual behaviour of many people who describe themselves as depressed. This ethological perspective points us to psychosocial elicitors not a disease pathology.
As already noted, the NICE guidelines are broadly aimed at a group of people who would satisfy criteria for ‘major depressive disorder’ (MDD), a diagnosis supplied by the American Psychiatric Association.5 If MDD was actually a disease, one would expect to find (1) a cluster of signs and symptoms that can be reliably observed, and (2) an explanation of the cluster in terms of causal pathways discoverable within the body that are in some way distinct from the somatic correlates of everyday (‘non-clinical’) depressed mood. The criteria for MDD specify that a person must report one of two core symptoms and at least four of seven secondary symptoms. Some of these secondary symptoms are binary (e.g. insomnia or hypersomnia) and so the list effectively increases to 20. In 3703 individuals diagnosed according to these criteria, Fried and Nesse6 identified 1030 unique symptom profiles, of which 83.9% were endorsed by five or fewer people. If the medical syndrome that supposedly links all these symptoms together is a fiction, a unitary concept of depression might as well be dispensed with altogether7.
NICE recommendations for ‘treatment’
NICE was set up to analyse the evidence for various medical interventions. Primarily, the evidence consists of the results of randomised control trials, a method of research that was originally introduced into the field of medicine. While the method certainly has its uses, the design of these experiments and the conclusions that can be drawn from them often suffer from a variety of limitations. (These would require a more extended discussion).
NICE recommends a stepped approach to ‘treatment’. In other words, it advises beginning with advice, self-help, or computerised therapy, and then stepping up to a more intense form of psychological therapy, medication, or electro-convulsive therapy whenever whatever has already been tried fails. The rationale for this slow but steady approach makes some sense but given the slowness with which the referral system can operate, leading to lengthy delays before an appointment is offered, it is quite likely that a crisis situation will have become worse by the time help is available. The time-window in which something can be done quickly and effectively is often fairly short. In practice, GPs are quick to prescribe medication for ‘mild depression’ even though this is not the recommendation of either NICE or the World Health Organisation.
When ‘depression’ is persistent, or low intensity methods have failed, there is a recommendation to try either antidepressant medication (typically a SSRI) or a ‘high intensity’ psychological therapy (typically CBT). For ‘moderate to severe depression’ it is suggested that medication and psychological therapy could be combined. In the case of CBT, the advice is 16 to 20 sessions over 3 to 4 months, with bi-weekly sessions initially moving on to weekly, and then to follow-up sessions over the next 3-6 months.
As noted earlier, therapy is seen as analogous to a drug regime for which the method of delivery is prescribed in advance. It is stated that: There is little evidence to guide prescribing in relation to depression subtypes or personal characteristics. Do not routinely vary the treatment strategies for depression described in this guideline either by depression subtype (for example, atypical depression or seasonal depression) or by personal characteristics (for example, sex or ethnicity) as there is no convincing evidence to support such action. This really equates to saying that therapists do not possess the skills to make strategic decisions in therapy based on their formulation of a person’s problem according to their observations of a person’s personality and circumstances. These conclusions of NICE are based on a mindless approach to the evaluation and interpretation of research into therapeutic processes, chiefly randomised control studies.
Therapist competence is of course an issue that needs to be addressed. NICE advises monitoring and evaluating treatment adherence and practitioner competence. In the case of group-based CBT, it is stated that this should be delivered by two trained and competent practitioners. At the present time, it would be premature to say that therapist competence can be reliably assessed.8 Sampling by means of audio- or video-recording is expensive in terms of time and is rarely performed in routine practice. Monitoring by asking a client to complete a feedback form after each session is, in my opinion, insulting to the client and corrosive of the relationship. In any case, this is not a measure of therapist competence. Research has shown that even when agreement on ratings of therapist competence can be agreed, the relationship of these ratings to a successful outcome of therapy is weak or non-existent9. Therapist competence is still an area of research that is in its infancy.
A major failing of the NICE guidelines is that they make no mention of the potential contribution of the voluntary sector. There is a reference to befriending but this is viewed as an ‘adjunct‘ to treatment and should be limited to ‘trained volunteers’. This caution gives the impression that government departments and their advisors are fearful of allowing citizens to make any attempt to solve their own problems.
The New Savoy Conference discussing the anticipated NICE guidelines.
The New Savoy Partnership is a consortium of organisations that promotes freely available psychological therapy on the NHS. It held a conference on 27th April, 2018, to discuss the anticipated revised NICE guidelines on ‘depression’. Some of the speaker’s contributions are accessible on the Net. 10 Of chief interest here is the presentation of Jeremy Clarke, chair of the New Savoy Partnership and an expert advisor on the NICE guidelines committee. In response to earlier lobbying and previous NICE recommendations, the Government has strongly promoted and funded a new service, Improving Access to Psychological Therapies (IAPT), initially directed towards the ‘treatment’ of ‘depression and anxiety’. Clarke’s enthusiasm for IAPT, despite the very large number of people who have made use of it, has been tempered by population indicators of worsening ‘mental health’ since it was introduced. Rates of prescribing for anti-depressant medication have been rising, as have rates for suicide and self-harm. He also points that that there is a large difference in ‘recovery’ rates for ‘depression’ in IAPT between the least and most economically deprived areas of the country (35% vs 55%). He notes that the wellbeing of the personnel delivering the NHS service for ‘depression’ has deteriorated to the point of threatening staff retention and acceptable levels of job stress.
All of this calls into question government policies for tackling the problems of people who are currently diagnosed as ‘depressed’. Clarke does not take the next logical step of critiquing the medicalisation of personal and social problems and calling for non-medical answers to their resolution.
- Early day motion 980 – NICE guidelines on depression in adults. https://www.parliament.uk/edm/2017-19/980
- The current draft guideline on the Recognition and Management of Depression in Adults is not fit for purpose. https://www.nsun.org.uk/news/draft-nice-guideline-recognition-and-management-of-depression-in-adults-not-fit-for-purpose
- The Tavistock’s view of depression and what the draft NICE guidelines may be missing (2017). https://tavistockandportman.nhs.uk/about-us/news/stories/tavistocks-view-depression-and-what-draft-nice-guidelines-may-be-missing/
- Hawton. K., Casañas I Comabella, C., Haw, C. & Saunders, K. (2013) Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147, pp.17–28
- DSM-5 (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM–5). Arlington, VA, American Psychiatric Association.
- Fried, E. I. & Nesse, R. M. (2015) Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study. Journal of Affective Disorders. 172, pp.96-102.
- Fried, E. I. (2016) Depression – more than the sum of its symptoms, The Psychologist. 29(1), pp.42-43.
- Schmidt, I. D, Strunk, D. R., DeRubeis, R. J, Conklin, L. R. & Braun, J. D. (2018) Revisiting how we assess therapist competence in cognitive therapy. Cognitive Therapy and Research (online, March, 2018).
- Webb, C. A., DeRubeis, R. J. & Barber, J. P. (2010). Therapist’s adherence/competence and treatment outcome: A meta-analysis. Journal of Consulting and Clinical Psychology, 78, 200-211.
- New Savoy Partnership, news, 30 April, 2018. www.healthcareconferencesuk.co.uk/news/