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Effectively Treating Pathological Self-Criticism in Depressed & Dysthymic Clients
Effectively Treating Pathological Self-Criticism in Depressed and Dysthymic Clients

Section 23
The NICE Guideline for Treating Depression

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What the guideline is suggesting
Both the depression and anxiety guidelines are very clear that the bulk of treatment for these conditions should be in primary care. This, of course, is where most treatment currently does take place. The anxiety guideline views referral to specialist mental health facilities as very much a second-line option for people who have not responded to two distinct types of treatment within primary care — any two of cognitive behavioural therapy (CBT), self-help or medication. In practice, community mental health teams (CMHTs) and other specialist teams should thus see relatively few people with anxiety, these being mostly patients with severe agoraphobia or serious additional problems on top of their anxiety.

The NICE depression guideline is a longer document than that on anxiety, and is more prescriptive and detailed. However, it is similar in stating that most help should be offered within primary care, specialist services again being reserved for patients with severe and complex problems. It contains detailed recommendations about medication and the use of electro-convulsive therapy (ECT), but it also gives a central role to various psychological interventions. These can be summarised as follows:

  • Primary care should be the main setting for the treatment of mild to moderate depression, where problem-solving therapy, counselling, advice on physical exercise, and brief or guided self-help CBT might all be offered. Antidepressant medication should not normally be offered to patients with milder depression.
  • For moderate to severe depression, and for patients who have not responded to other treatments, therapist-delivered CBT, interpersonal psychotherapy (IPT) and couple-focused therapy are all viable options, though with the best evidence for CBT.
  • For patients with severe or chronic depression, a combination of antidepressant medication and CBT should be offered. In principle, this could be delivered in the primary care setting, but in practice many of these patients are likely to be referred to specialist mental health services.

Concerning antidepressant medication, which has been the subject of controversy in recent months, the guideline discourages its use for less severe presentations of depression, but it does recommend that selective serotonin re-uptake inhibitors (SSRIs) be used as the first-line treatment of choice for moderate to severe depression, in preference, on grounds of tolerability, to older antidepressants, such as the tricyclics (TCAs), and, on grounds of cost, to psychological treatments. To balance what some readers may think is an inappropriate recommendation, the depression guideline, again like the anxiety guideline, is clear that patients can opt specifically to have psychological treatments in preference to medication. Given this choice, it is easy to imagine that many patients will opt against taking medication, which is increasingly perceived as having problematic side effects.

The role of the counsellor in relation to the guideline
In its description of recommended interventions for mild or moderate depression, the NICE guideline makes specific mention of counselling as one of a range of acceptable alternatives, along with problem-solving and brief CBT. It is recommended that such counselling takes place over 10 to 12 weeks and involves six to eight sessions. This of course is similar to what is offered already in many primary care settings. The guideline also states that patient preference should be taken into account when deciding on interventions.

Defining counselling for the purposes of the guideline was a tricky issue. Should it be taken to mean specifically 'person-centred' counselling, or should we define counselling simply as 'what counsellors do'? It is not always clear even in research studies whether counselling has been very clearly defined, though there are several recent UK studies that suggest promising results for some forms of counselling of patients in primary care, including those suffering with depression. The guideline development group chose to define counselling in terms of a person-centred approach, though we had quite a discussion about this! In practice it seems likely that many counsellors would probably use an eclectic mix of person-centred counselling, CBT and problem-solving as part of a package of care for a depressed client. Fortunately, these different approaches are all endorsed in the guideline!

Of course, counsellors do not exclusively practise counselling, however broadly we define this. Within the guideline are several activities that are recommended as intervention options, though it is not specified which members of the primary care team would be best placed to perform them. For instance, an option in mild depression is guided self help based on CBT. This is more than simply giving a person a book, or — as we do in Cardiff — a book prescription. Instead, it implies an active process in which a healthcare professional sits down alongside the patient and tries to engage him or her in the process of reading, or accessing via a personal computer, some form of CRT manual. It is important that the patient's progress — or otherwise — is then reviewed. Would counsellors wish to do this? Befriending is mentioned as a possible additional intervention in the care of people with chronic depression. Although this might seem rather low-tech to some counsellors and psychotherapists, perhaps others would view it as a worthwhile activity?

Also in the guideline is a mention of how primary care practices can enhance their overall care of depressed patients. There is reference to telephone support, primarily — though not necessarily solely — in relation to antidepressant medication. Something as simple and quick as a phone call can, it seems, be really helpful in enhancing patient adherence to treatment plans, whether or not these involve medication. Is this a suitable job for counsellors in primary care? It was considered possible, though it is not explicitly stated in the guideline, that graduate mental health workers could take on these roles. Certainly that could be the case in England, but it is impossible here in Wales, since we do not have these staff. Currently my team is working on a proposal for enhanced funding of our trust-wide primary care counselling scheme, on the assumption that some of our counsellors may opt to undertake these extra tasks. We are also basing our argument on the likelihood that there will simply be an increase in the overall demand for counselling by depressed patients, which — if this guideline is taken seriously-should be met.

In the area of more severe depression, there are specific recommendations about 'structured psychological interventions of longer duration', namely CBT, IPT and couple-focused therapy. However, the guideline does not specify where, or by whom, these should be delivered. In our own service it is probable that these will be viewed as jobs for CMHT psychologists, but there is no particular reason why they should not be carried out by appropriately trained counsellors in primary care. Clearly, though, this type of psychological intervention would be different from that offered to patients with milder presentations of depression: we are talking here about 16 to 20 sessions over perhaps nine to 12 months, with some patients receiving additional maintenance sessions. Incidentally, though there is a strong sense in the guideline of CBT being the favoured option, it would be wrong to think that this reflects clear evidence of superiority of CBT over the other two treatments in head-to-head trials. It is rather the case that there is simply more evidence collected by proponents of CBT.

In conclusion
It seems clear that the implementation of the NICE guideline on depression will mean more, not less, work for counsellors in primary care. Some of this extra work will be the core business of (person-centred) counselling. Those counsellors who are trained to deliver CBT, IPT or couple-focused therapy will be able to help provide interventions for more seriously depressed patients. There are some new tasks being introduced in primary care which could be tarried out by a range of staff, but which some counsellors would probably enjoy taking on. Overall, although there are lengthy sections in the guideline on the specifics of prescribing (or not prescribing) various antidepressant medications and ECT, it is clear that its overall thrust is to reorientate treatment in a more psychological direction. One aim is to ensure that referral to secondary care takes place only where there are clear indications for this, not simply because there is no other option. The guideline is very clear that we will need to develop alternative options, and that counsellors can have a key role in this process.

- Hughes, Ian; NICE in practice: Some thoughts on delivering the new guideline on depression; Counselling & Psychotherapy Journal; Apr 2005; Vol. 16; Issue 3.

Personal Reflection Exercise #9
The preceding section contained information regarding the NICE guideline for treating depression.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Andrews, L. A., Hayes, A. M., Abel, A., & Kuyken, W. (2020). Sudden gains and patterns of symptom change in cognitive–behavioral therapy for treatment-resistant depression. Journal of Consulting and Clinical Psychology, 88(2), 106–118.

Birk, J. L., Kronish, I. M., Moise, N., Falzon, L., Yoon, S., & Davidson, K. W. (2019). Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases. Health Psychology, 38(9), 802–811.

Dunkley, D. M., Starrs, C. J., Gouveia, L., & Moroz, M. (2020). Self-critical perfectionism and lower daily perceived control predict depressive and anxious symptoms over four years. Journal of Counseling Psychology. Advance online publication.

Online Continuing Education QUESTION 23
What are the NICE guidelines, as they relate to depression? Record the letter of the correct answer the CEU Test.

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