The current draft guideline on the Recognition and Management of Depression in Adults is not fit for purpose
On the 17th November, the signatories to this briefing wrote to David Haslam, Chair of NICE, to formally request a further full stakeholder consultation of the next revision of the guideline on the Recognition and Management of Depression in Adults, prior to its formal publication.
We did this because, along with many other stakeholders, we are extremely concerned about significant flaws in methodology, lack of transparency and inconsistencies in the document.
The NICE depression guideline will impact on the care of millions of constituents – four in ten adults report experiencing depression at some time in their life (Mental Health Foundation). The sheer scale of depression in England and Wales should dictate that those charged with revising the 2009 guideline follow the most robust methodology in the most transparent way.
In our letter to the Chair of NICE we stated our view that, without a second consultation being granted to allow these serious concerns to be addressed, the guideline “will not be fit for purpose and will seriously impede good patient care and patient choice.”
In summary, our concerns relate to the following:
- The current draft guideline has used inadequate methods for working out whether a treatment has shown itself to be effective within a research study – ignoring the severity of depression at the start of the treatment. Much better methods exist for this and are widely used in the research community.
- The draft guideline fails to meet the NHS agenda of ‘parity of esteem’, defined as valuing mental health equally with physical health. Despite depression often manifesting itself as a long-term condition, or becoming a long-term condition if immediate care is inadequate, the current draft recommendations are all made on the basis of very short-term outcomes (often 6-12 weeks). NICE guidelines for long term physical conditions would treat this evidence in question as inadequate, requiring at least 1 or 2 years follow-up data. Follow up data of 1-2 years has instead been completely ignored in the draft depression guideline.
- The current draft guideline has largely used out-of-date evidence of service user experiences mostly dating back to before 2004 and has failed even to incorporate this evidence into recommendations.
- The current draft guideline used statistical analyses that are associated with serious and unique risks. These were inadequately reported and addressed (leading to violations of statistical assumptions in the approach adopted) and this therefore puts the resulting treatment recommendations into serious question.
- The current draft guideline has an extremely narrow focus on symptom outcomes and fails to take into account other aspects of service user experience which have long been called for such as quality of life, relationships and ability to participate in work, education or society.
- The current draft guideline is completely out of step with US and European guideline methodologies. The Guidance Development Group has created its own method for categorising depression by longevity and severity – leading to erroneous and unhelpful classification of research studies which do not match clinical, service user experiences or research outcomes.
- These serious methodological flaws undermine patient choice, with recommendations based on a poor methodology.
The draft new guideline on depression in adults was sent out for stakeholder consultation between July and Sept 2017; the original publication date (January) has recently been pushed back until March 2018.
We are currently awaiting a response from the Chair of NICE regarding our request that a second consultation be granted. In the meantime, and in light of past experience suggesting that this request is unlikely to be granted, we would like to meet with you to explore the issues raised in this briefing.
Given the prevalence of depression among the population, we believe it behoves us to do all we can to ensure that the guideline on depression produced by NICE properly reflects the evidence base and enjoys the support of patients as well as organisations working to support and treat people experiencing depression.
This briefing was produced on behalf of:
Professor Sir Simon Wessely, Regius Chair of Psychiatry, King’s College London, President, Royal Society of Medicine, Past President, Royal College of Psychiatrists
Professor Clare Gerada, General Practitioner and Senior Partner Hurley Group, Medical Director Practitioner Health Programme
Dr David Taylor, Hon. Consultant Psychiatrist Tavistock and Portman NHS Trust; Visiting Professor UCL Psychoanalysis Unit
Dr Susan McPherson, Senior Lecturer and Research Impact Director, School of Health and Social Care, University of Essex
Dr Andrew Reeves, Chair British Association for Counselling and Psychotherapy (BACP)
Gary Fereday, CEO, British Psychoanalytic Council (BPC)
Sarah Yiannoullou, Managing Director, National Survivor User Network (NSUN)
Dr Susan Mizen, Chair, Medical Psychotherapy Faculty, Royal College of Psychiatrists Dr Felicitas Rost, President, Society for Psychotherapy Research (SPR) UK
Andrew Balfour, CEO, Tavistock Relationships
Professor Sarah Niblock, CEO, UK Council for Psychotherapy (UKCP)