1. Common mental health disorders: identification and pathways to care
Implementing NICE guidance within primary care
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline ‘Common mental health disorders: identification and pathways to care’. This guideline has been written for healthcare professionals, especially those in primary care, and other staff who care for people with common mental health disorders.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2011
NICE clinical guideline 123

2. What this presentation covers
Scope
Background
Key recommendations for implementation Primary care costs avoided and benefits Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the key recommendations for implementation.
Next, we will summarise the primary care costs that can be avoided and benefits that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.

3. Scope
The guideline aims to improve access to care and the identification and recognition of common mental health disorders, and provide advice on principles for local care pathways. Advice from existing NICE guidelines has been combined with new recommendations on access, assessment and local care pathways.
Common mental health disorders include depression, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder.
NOTES FOR PRESENTERS:
Key points to raise:
This guideline was developed specifically for primary care. It includes recommendations that are drawn from other guidelines that are of particular relevance to primary care.
Content for the guideline is drawn from the following existing NICE guidelines:
Antenatal and postnatal mental health. NICE clinical guideline 45 (2007). Available from
Depression in adults with a chronic physical health problem: treatment and management. NICE clinical guideline 91 (2009). Available from
Depression: the treatment and management of depression in adults. NICE clinical guideline 90 (2009). Available from
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. NICE clinical guideline 113 (2011). Available from
Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. NICE clinical guideline 31 (2005). Available from
Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. NICE clinical guideline 26 (2005). Available from

4. Epidemiology
15% of the population are affected by common mental health disorders
Women are 1.5 to 2.5 times more likely to experience depression than men
34% of South Asian women have a common mental health disorder compared with 10% of South Asian men
NOTES FOR PRESENTERS:
Key points to raise:
Half of those affected by a common mental health disorder have significant symptoms that warrant a professional healthcare intervention.
Depression and anxiety disorders tend to have a higher prevalence in women.
Prevalence rates are significantly higher for women across all categories of disorder, except for panic disorder and obsessive-compulsive disorder.
Between 1993 and 2007 common mental health disorders in women aged years increased by about one fifth.
In South Asian women, the impact of having children, exposure to domestic or sexual violence, adverse experiences in childhood and women’s relative poverty are all cited as reasons for the higher prevalence of common mental health disorders.
The 2007 Office for National Statistics household survey of adult psychiatric morbidity in England found people living in households with the lowest levels of income were more likely to have a disorder than those living in the highest income households.
King and colleagues (2008) identified five immutable risk factors for depression: younger age, female gender, lower educational achievement, previous history of depression and family history of depression (see the full version of the guideline for further details).

5. Background
Depression is a leading cause of disability – and it is projected to become the second most common cause of loss of disability-adjusted life years in the world
Only a small minority of people who experience anxiety disorders receive treatment
Recognition of anxiety disorders in primary care is particularly poor
NOTES FOR PRESENTERS:
Key points to raise:
Up to 90% of diagnosed cases of depression and anxiety disorders are treated in primary care.
Bullet 2: This is estimated to take effect by 2020 (World Bank, 1993). Disability-adjusted life years are the years of potential life lost due to premature mortality combined with the years of productive life lost due to disability.
Depressive illness causes a greater decrease in health state than major chronic physical illnesses like angina, arthritis, asthma, and diabetes. Moussavi S, Chatterji S, Verdes E, et al Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370: 851–858.
Depression can also exacerbate the pain, distress and disability associated with physical diseases, and can adversely affect outcomes.
Social effects from depression include: greater dependence upon welfare and benefits with loss of self-esteem and self-confidence; social impairments, including reduced ability to communicate and sustain relationships during the illness with knock-on effects after an episode; and longer term impairment in social functioning, especially for those who have chronic or recurrent disorders.
Department of Health national strategy documents:
No health without mental health (2011). The national mental health strategy.
Delivering better mental health outcomes for people of all ages (2011). The accompanying cross-government outcomes framework for the mental health strategy.
The NHS outcomes framework 2011/12 (2010) . Domain 4 of the framework: ‘Improving experience of healthcare for people with mental illness’. The related indicator is ‘Patient experience of community mental health services’.
Talking therapies: a four-year plan of action (2011). Outlines how the Government’s four-year commitment to expanding access to psychological therapies will be delivered from April 2011.

6. Abbreviations used
CBT - cognitive behavioural therapy ERP - exposure and response prevention EMDR - eye movement desensitisation and reprocessing GAD - generalised anxiety disorder OCD - obsessive compulsive disorder IPT - interpersonal psychotherapy PTSD - post-traumatic stress disorder A full glossary of terms used in the guidance can be found alongside this slide set on the NICE website
NOTES FOR PRESENTERS: Key points to raise:
Exposure and response prevention (ERP): is a psychological intervention used for people with OCD.
It aims to help people to overcome their need to engage in obsessional and compulsive behaviour.
With the support of a practitioner, the person is exposed to whatever makes them anxious, distressed or fearful.
Rather than avoiding the situation, or repeating a compulsion, the person is trained in other ways of coping with anxiety, distress or fear.
The process is repeated until the person no longer feels this way.
Eye movement desensitisation and reprocessing (EMDR): a psychological intervention for people with PTSD.
During EMDR, the person is asked to concentrate on an image connected to the traumatic event and the related negative emotions, sensations and thoughts, while paying attention to something else.
After each set of eye movements (about 20 seconds), the person is encouraged to discuss the images and emotions they felt during the eye movements.
The process is repeated with a focus on any difficult, persisting memories. Once the person feels less distressed about the image, they are asked to concentrate on it while having a positive thought relating to it.
The treatment is usually 8 to 12 sessions and should be regular and continuous (usually at least once a week).

7. Key priorities for implementation
Areas identified as key priorities for implementation:
Identification
Improving access to services
Developing local care pathways
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into three areas of key priority and within these there are a number of recommendations that we will consider in turn.
In addition, we will refer to the primary care costs that could be avoided and benefits gained by implementing this guidance.

8. Identification: depression
Be alert for possible depression, particularly in those with a past history or possible somatic symptoms of depression, or a chronic physical health problem
Consider asking:
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
NOTES FOR PRESENTERS:
Further points to raise from recommendation :
If a person answers ‘yes’ to either of the above questions consider depression and follow the recommendations for assessment.
Recommendation in full:
Be alert to possible depression (particularly in people with a past history of depression, possible somatic symptoms of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions, specifically:
During the last month, have you often been bothered by feeling down, depressed or hopeless?
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 of the above questions consider depression and follow the recommendations for assessment (see section 1.3.2).
Adapted from ‘Depression’ (NICE clinical guideline 90). Available from:

9. Identification: anxiety 1
Be alert to possible anxiety disorders, particularly in those with a past history or possible somatic symptoms of an anxiety disorder, or who have experienced a recent traumatic event.
Consider asking about feelings of anxiety and the ability to stop or control worry, using the GAD-2 scale.
NOTES FOR PRESENTERS:
Key points to raise: The 2-item Generalized Anxiety Disorder (GAD-2) scale is featured on the following slide.
Recommendation in full:
Be alert to possible anxiety disorders (particularly in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or in those who have experienced a recent traumatic event). Consider asking the person about their feelings of anxiety and their ability to stop or control worry, using the 2-item Generalized Anxiety Disorder scale (GAD-2; see appendix D of the NICE guideline).
If the person scores three or more on the GAD-2 scale, consider an anxiety disorder and follow the recommendations for assessment (see section 1.3.2).
If the person scores less than three on the GAD-2 scale, but you are still concerned they may have an anxiety disorder, ask the following: 'Do you find yourself avoiding places or activities and does this cause you problems?'. If the person answers 'yes' to this question consider an anxiety disorder and follow the recommendations for assessment (see section 1.3.2).

10. Identification: anxiety 2
Consider asking:
Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
NOTES FOR PRESENTERS:
Key points to raise:
The GAD-2 short screening tool consists of the first two questions of the GAD-7.
Recommendation can be found in full in the notes of the previous slide.
GAD-2 is the first two questions of the GAD-7 scale
The GAD-7 tool was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

11. Identification: anxiety 3
Score of 3 or more consider an anxiety disorder and follow the recommendations for assessment Score of less than 3 but you still have concerns that the person may have an anxiety disorder ask:
Do you find yourself avoiding places or activities and does this cause you problems?
NOTES FOR PRESENTERS:
Additional points to raise from recommendation :
For a score of three or more on the GAD-2 scale, the recommendations for assessment can be found in section of the guideline, Assessment.
If the person answers 'yes' to this avoidance question consider an anxiety disorder and follow the recommendations for assessment.
Recommendation can be found in full in the notes of slide 8.
N.B. The scoring of more or less than 3 applies to the use of the two GAD-2 questions

12. Identification
For significant communication difficulties, consider using the Distress Thermometer and/or asking a family member or carer about the person’s symptoms
If identification questions indicate a common mental health disorder, a competent practitioner should perform a mental health assessment If this professional is not the person’s GP, inform the GP of the referral
NOTES FOR PRESENTERS:
Additional points to raise from the guidance:
Examples of when the Distress Thermometer should be considered include for people with sensory impairments or those with a learning disability. [ ]
If a significant level of distress is identified, offer further assessment or seek the advice of a specialist. [ ]
The mental health assessment should include a review of the person’s mental state and associated functional, interpersonal and social difficulties. [ ]
Additional information:
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 of distress that should be investigated further.
For further information see 'The IAPT Data Handbook' Appendix C: IAPT Provisional Diagnosis Screening Prompts (available from
Recommendations , and can be found in full in the quick reference guide.

13. Assessment Consider using:
A diagnostic or problem identification tool, for example the Improving Access to Psychological Therapies (IAPT) screening prompts tool
A validated measure relevant to the disorder to inform assessment and support evaluation of interventions: item Patient Health Questionnaire (PHQ-9) Hospital Anxiety and Depression Scale (HADS) item Generalized Anxiety Disorder scale (GAD-7)
NOTES FOR PRESENTERS:
Additional points to raise from the guidance:
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 1.3.3, risk assessment and monitoring) - advise the person to seek further help if the situation deteriorates.
Additional information:
The IAPT screening prompts tool sets out a stepwise approach to questions about the experience, duration of the symptoms and impact on functioning based on ICD-10 criteria. It is intended to be brief and can be integrated into a broader assessment of the presenting problem.
It was explicitly designed to aid IAPT staff and other working in primary care to differentiate between depression and the anxiety disorders.
For further information see 'The IAPT Data Handbook' Appendix C: IAPT Provisional Diagnosis Screening Prompts (available from
Recommendation is in full below and can be found in full in the quick reference guide. When assessing a person with a suspected common mental health disorder, consider using: a diagnostic or problem identification tool or algorithm, for example, the Improving Access to Psychological Therapies (IAPT) screening prompts tool
a validated measure relevant to the disorder or problem being assessed, for example, the 9-item Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale (HADS) or the 7-item Generalized Anxiety Disorder scale (GAD-7) to inform the assessment and support the evaluation of any intervention. For further information see 'The IAPT Data Handbook' Appendix C: IAPT Provisional Diagnosis Screening Prompts (available from
Ask directly about suicidal ideation and intent

14. Assessment: core components
Staff conducting assessments should be able to: - determine the nature, duration and severity of the presenting disorder - take into account symptom severity and associated functional impairment - identify appropriate treatment and referral options in line with relevant NICE guidance
Consider factors that may affect the development, course and severity of a person’s presenting problem: history of mental health disorder or chronic physical health - past experience and response to treatments - quality of interpersonal relationships - living conditions and social isolation
NOTES FOR PRESENTERS:
Additional points to raise from the guidance:
Staff conducting assessment of suspected common mental health disorders should be competent in assessing the presenting problem in line with the service setting in which they work.
Staff should also be competent in:
- relevant verbal and non-verbal communication skills, including the ability to elicit problems, the perception of the problem(s) and their impact, tailoring information, supporting participation in decision-making and discussing treatment options
- the use of formal assessment measures and routine outcome measures in a variety of settings and environments. [ ]
Other factors to consider include a family history of any mental health disorder; a history of domestic violence or sexual abuse; and employment and immigration status. [ ]
Recommendation is in full below and can be found in full in the quick reference guide. All staff carrying out the assessment of common mental health disorders should be competent in:
relevant verbal and non-verbal communication skills, including the ability to elicit problems, the perception of the problem(s) and their impact, tailoring information, supporting participation in decision-making and discussing treatment options
the use of formal assessment measures and routine outcome measures in a variety of settings and environments.

15. Severity of common mental health disorders: definitions
Mild relatively few core symptoms, a limited duration and little impact on day-to-day functioning
Moderate all core symptoms of the disorder plus other related symptoms, duration beyond that required by minimum diagnostic criteria, and a clear impact on functioning
Severe most or all symptoms of the disorder, often of long duration and with very marked impact on functioning
Persistent subthreshold symptoms and associated functional impairment that do not meet full diagnostic criteria but have a substantial impact on a person’s life, and which are present for a significant period of time
NOTES FOR PRESENTERS:
Key points to raise:
The details on this slide are not part of the recommendations, but are included in the guideline to aid healthcare professionals when establishing the severity of common mental health disorders.
Some symptoms may be mild and self-limiting, which refers to symptoms that are improving.
Behaviour that may be indicative of a severe stage of common mental health disorder is for example, an inability to participate in work-related activities and withdrawal from interpersonal activities.
To be considered to have a persistent subthreshold common mental health disorder, a person’s symptoms should usually have been present for a minimum of 6 months and possibly up to several years.

16. Stepped-care model CMHDs presentation and severity
Recommended interventions
Step 1 All disorders – known and suspected presentations
All disorders: Identification, assessment, psychoeducation, active monitoring; referral for further assessment and interventions
Step 2 Persistent subthreshold depressive symptoms or mild to moderate depression; GAD; mild to moderate panic disorder; mild to moderate OCD; PTSD (including mild to moderate)
Depression
GAD and panic disorder
OCD
PTSD
All disorders – Support groups, educational and employment support services; referral for further assessment and interventions
Step 3 Persistent subthreshold depressive symptoms; mild to moderate depression not responded to a low-intensity intervention; moderate or severe depression; GAD with functional impairment or has not responded to low-intensity intervention; moderate to severe panic disorder; OCD with moderate or severe functional impairment; PTSD
GAD Panic disorder
NOTES FOR PRESENTERS:
Key points to raise:
A stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions.
The model presents the key assessment and treatment interventions from this guideline. Recommendations focused solely on specialist mental health services are not included.

17. Improving access to services
Collaborate to develop local care pathways that:
support integrated delivery across primary and secondary care
have clear and explicit entry criteria
focus on entry and not exclusion criteria
have multiple means and points of access, including self-referral
have a designated lead to oversee care
promote access for people from socially excluded groups
NOTES FOR PRESENTERS:
Additional points to raise from recommendations on improving access to services:
Primary and secondary care clinicians, managers and commissioners should work together to design care pathways.
To increase access, provide primary care and specialist mental health services in a variety of settings, including community, homes, and outside working hours.
Provide service information in a range of languages and formats.
For people who may find it difficult to attend a specific service, consider modifications to the method of delivery for assessments, interventions and outcome monitoring e.g. via text messages, , telephone, and computers
Ensure local competence in culturally sensitive assessments, and provide translation services where necessary.
Examples of socially disadvantaged people include those from black and minority ethnic groups, older people, those in prison or in contact with the criminal justice system and ex-service personnel.
Consider providing crèches, assistance with travel, and advocacy services where appropriate.
Recommendations , and can be found in full in the quick reference guide.

18. Developing local care pathways:1
Design local care pathways that promote a stepped-care model of integrated delivery to:
provide least intrusive, most effective interventions first
have explicit criteria for different levels of intervention
not base movement between levels on a single criteria
monitor progress and outcomes
minimise the need for transition between services
establish clear access and entry points
have designated staff responsible for coordination of care
NOTES FOR PRESENTERS:
Additional points to raise from recommendations and :
Clear criteria for thresholds should be agreed to establish access and movement between the different levels of the pathway.
Symptom severity should not be used alone as a criteria for referral or movement between different levels of intervention.
If the results of monitoring or review indicate poor treatment outcomes, a person should be moved to a higher step on the pathway for a more intensive intervention.
Clear links to other care pathways - including those for physical healthcare needs - should be identified.
Additional information:
Primary and secondary care clinicians, managers and commissioners should work together to design local care pathways.
Recommendations and can be found in full in the quick reference guide.

19. Developing local care pathways: 2
Develop protocols for communicating information:
for service users about their care
with other professionals (including GPs)
between services within the pathway
to services outside the pathway
Robust systems should be in place to ensure routine reporting of outcomes
NOTES FOR PRESENTERS:
Additional key points to raise from recommendations and :
Where appropriate, information regarding service user’s treatment should also be shared with families and carers.
Individual routine outcome measurement systems should be in place.
Effective electronic systems should be adopted for the routine reporting and aggregation of outcome measures.
Effective systems should be in place for the audit and review of clinical and cost-effectiveness of the care pathway.
Recommendations and can be found in full in the quick reference guide.

20. Primary care costs avoided and benefits
Due to variation in current practice, it is not possible to quantify the national cost impact of the NICE recommendations. The following areas may incur savings through drug costs avoided by meeting additional demand with treatments such as talking therapies.
People with mild panic disorder. People with mild depression or anxiety or both.
Estimated reduction in need - GP services and medications
60%
Saving in GP visits and drug costs
£ 471 per person
People who have mild - moderate OCD.
Estimated reduction in need of medications
53%
Saving in drug costs
£202 per person
NOTES FOR PRESENTERS:
NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. However, different areas may vary from the national average and it is important to look at the recommendations most likely to have a resource impact to make sure that local practice matches the national average.
There may be cost savings in primary care as a result of reduced use of medication such as anti-depressants where people respond to other therapies such as group counselling and cCBT, and resources released in terms of reduced GP visits to monitor progress and response to medication. In research carried out by the Mental Health Foundation, 60% of GP’s surveyed said they would prescribe antidepressants less frequently if other options were available to them (Medical Health foundation 2005).
Early intervention is important because this reduces the chances of subsequent admission to hospital. Early psychological treatment, though expensive, can reduce significantly the repeated GP visits and drug prescriptions, which are becoming a serious burden on the NHS (Layard R 2005).
NICE has developed a costing template to allow for an assessment of local needs to be made. This tool is available from the NICE website. The following recommendations may incur increased costs:
Developing systems and assessing needs to support access and increase uptake of services
recommendations and may increase activity for some local services and incur costs such as a service coordinator to manage continuity of care, overtime or shift allowance payments and accommodation costs for services provided in the community. There may also be costs associated with venue hire and advertising services.
Each locality will have different needs, the costing template allows for these costs to be assessed locally.
Providing a range of support services to facilitate access and uptake of services (recommendation )
Modifying the method and mode of delivery of assessment and treatment (recommendation )
Once these systems are in place, the recurring costs of texts, s and telephone calls are relatively small. The costing template allows for any non recurring costs to be estimated.
There may be additional costs of providing bilingual therapists or independent translators as a result of facilitating greater access to services, this may have significant cost impact in localities where there are high numbers of people from different ethnic backgrounds. Service providers would need to assess local demographics and ensure recruitment of bilingual therapists and other staff is representative of the local community.

21. Interventions for anxiety: potential costs
Cost of intervention
Identification and assessment
Minimal
Low-intensity psychological interventions (LIPI)
£540 for 6 sessions or £45 per person based on a group of 12
Drug treatment
From £189 to £449
High-intensity psychological interventions (HIPI)
£1125 per person for 15 sessions
Highly specialist treatment
As shown for drug treatment & HIPI but combined.
Inpatient episode £6496
NOTES FOR PRESENTERS:
Generalised anxiety disorder (GAD) is one of a range of anxiety disorders that includes panic disorder (with and without agoraphobia), post-traumatic stress disorder, obsessive–compulsive disorder, social phobia, specific phobias (for example, of spiders) and acute stress disorder.
Intervention costs featured on the slide: Identification and assessment
There are unlikely to be any significant costs in this intervention it is about existing services indentifying early and communicating the diagnosis of GAD.
Low-intensity psychological Interventions
Psychoeducational groups are the only addition to the list of NICE recommended interventions for this step since NICE clinical guideline 22. Therefore it is those costs that are provided in the table on this slide.
Drug treatment
The drug treatment cost is calculated as one initiation visit, two visits over the first 8 weeks of treatment and one during the maintenance period–a total of four GP visits at a cost of £35 per visit (Curtis 2009).The treatment period, based upon GDG expert opinion, is 8 weeks of initial treatment and 6 months of maintenance treatment. High-intensity psychological Interventions
This consists of cognitive behavioural therapy (CBT) or applied relaxation. CBT and applied relaxation, each lasting 1 hour. The estimated cost is £1125 per 15 sessions. This is based on a unit cost for clinical psychologists of £75 per hour of client contact (Curtis 2009).
Highly specialist treatment
This could involve offering a combination of psychological interventions and drug treatment, a multidisciplinary team assessment and an inpatient episode of care. The cost of an inpatient episode of care based on an average length of stay of 22.4 days at a daily rate of £290 for a stay in a mental health unit is £6496. Currently 4% of people with GAD are estimated to have an inpatient episode of care.

22. Interventions for depression: potential costs
Intervention stages
Potential additional costs
Principles for assessment, coordination of care and treatment choice
It is estimated these recommendations will not incur any additional costs
Step 2: recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression
Consideration should be given to the resourcing of group-based peer support (self-help) programmes
Step 3: persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
Any costs or savings resulting from these recommendations are likely to be based on local practice
NOTES FOR PRESENTERS: NICE guidelines CG90 and CG91 cover the treatment and management of depression in adults aged 18 years and over in primary and secondary care, and the treatment and management of depression in adults with a chronic physical health problem. Examples of physical health problems may include cancer, heart disease, diabetes, or a musculoskeletal, respiratory or neurological disorder.
Principles for assessment, coordination of care and choosing treatments The guidelines cover the need to consider diverse cultural, ethnic and religious backgrounds and any learning difficulties or acquired cognitive impairments when working with people with depression. These issues are not specific to depression and it is suggested that training should be provided to professionals as part of ongoing continuing professional development programmes
Step 2: recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression Recommendation in CG91 includes offering a group-based peer support (self-help) programme. Managers and commissioners will need to consider resourcing such a programme to accommodate people whose physical health problem previously deterred them from undertaking a low-intensity intervention. This is likely to lead to an increase in costs.
Step 3: persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression The duration of delivery of high-intensity psychological interventions has been specified in CG90 and CG91 but a recommendation has been added to indicate that this can be flexible to meet the needs of individual patients. It is thought that in some cases access to high-intensity interventions has been limited as a result of recommendations in CG23. However, the opinion of clinical experts was divided on this point, so any costs or savings resulting from recommendations in CG90 and CG91 are likely to be based on local practice. Step 4: complex and severe depression Recommendation in CG90 has been updated to allow practitioners to consider ECT for people with moderate depression that has not responded to multiple drug treatments and psychological treatment. However, ECT is not recommended for routine use in people with moderate depression.

23. Discussion
How are diagnostic or problem identification tools used in primary care? What audit activity reviews their use?
How do our care pathways compare with the NICE guidance?
What methods are used to review service user treatment outcomes?
How can we address cases where there is persistent subthreshold CMHD symptoms?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Additional question:
What is our agreed approach for the diagnosis of anxiety, depression or other common mental health disorders?
How can we tailor assessments to ensure they are culturally sensitive and accessible?
What evidence do we have of effective collaboration between health and social care providers in our care pathway?

24. Find out more Visit www.nice.org.uk/guidance/CG123 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
baseline assessment
Resource for primary care
online educational tools
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information 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 or and quote reference numbers N2541 (quick reference guide) and/or N2542 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report and template allows people to estimate the local costs and savings involved.
Baseline assessment – for monitoring local practice.
Resource for primary care
Online educational tools from NICE and BMJ Learning:
- Anxiety disorders in adults - Depression in adults - Depression in adults with a chronic health problem The modules are free to access, though registration is required.

25. Presenter notes
The previous slide marks the end of the presentation; slides from this point on are for use by the presenter. For information, the stepped-care table on slide 16 contains action buttons that link to more detailed content (which is stored within slides 25-28). Action buttons only operate when the presentation is in slide show view. The presenter will need to click on a hyperlink to access the further detail.

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27. Stepped care: depression
Step 2 interventions
Individual facilitated self-help
Computerised CBT Structured physical activity
Group-based peer support (self-help) programmes
Non-directive counselling delivered at home* Antidepressants
Self-help groups * for women during pregnancy or the postnatal period
Step 3 interventions
CBT IPT Behavioural activation Behavioural couples therapy Counselling Short-term psychodynamic psychotherapy Antidepressants Combined interventions
Collaborative care (if chronic physical health problem) Befriending Rehabilitation programmes Self-help groups
Back to stepped care table

28. Stepped care: GAD and panic disorder
Step 2 interventions GAD and Panic disorder
Individual non-facilitated self-help
Facilitated self-help
Psychoeducational groups
Self-help groups
Step 3 interventions GAD
CBT Applied relaxation Drug treatment Combined interventions Self-help groups
Step 3 interventions Panic disorder
CBT Antidepressants Self-help groups
Back to stepped care table

29. Stepped care: obsessive-compulsive disorder
Step 2 interventions
Individual CBT
Group CBT (including ERP)
Self-help groups
Step 3 interventions
CBT (including ERP)
Antidepressants
Combined interventions and case management
Back to stepped care table

30. Stepped care: post-traumatic stress disorder
Step 2 interventions
Trauma-focused CBT
EMDR
Step 3 interventions
Drug treatment
Back to stepped care table