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Depression in Adults


This guideline applies to adults.

 

Introduction

Depression is a common condition but is often over-diagnosed. It is essential to appreciate that not every patient who presents with distress or low mood will be experiencing depression.

It is a treatable condition, with effective evidence-based treatments, including medication, psychological therapy and social interventions.


 

Red flags

  • Risk to self, including:
    • imminent or high-risk of suicide
    • severe self-neglect, including poor oral intake
  • Risk to others
     
  • Psychosis

 


Investigations prior to referral

Consider blood tests if appropriate, including FBC UE TFT LFT Glucose CRP Ferritin B12 Folate


 

Management Optimisation

In the absence of red flags, manage as below:

Key principles:

  • Take a shared decision-making and stepped care approach.
  • Avoid rushing to make a diagnosis.
  • Inspire hope and emphasise the effectiveness of treatments.
  • Address any underlying issues/factors and manage co-morbidities, where co-existent:
    • anxiety, the priority should be to treat the depression.
    • dementia, consider psychological therapies. Avoid the routine use of antidepressants.
  • Signpost to self-help wellbeing resources and encourage self-care i.e. physical activity, good sleep, healthy eating, connecting, daily routine, alcohol reduction, recreational drug avoidance, mindfulness/relaxation, goal setting, try to do something enjoyable every day.
  • Consider implications on fitness to drive.
  • Closely safety-net and provide mental health crisis contact numbers.
  • Consider using a validated depression questionnaire.

 

Less severe depression (“stopped seeing friends”):

1. Consider watchful waiting for 2-4 weeks.

2. Discuss first-line treatment options as per NICE visual aid (less severe depression).

3. Consider offering psychological therapy (via Talking Therapies).

4. Do not routinely offer antidepressant medication as first-line treatment – there is no evidence of benefit compared to placebo.

5. Consider offering (usually SSRI) if:

  • PMHx: more severe depression.
  • Subthreshold depression for at least 2 years.
  • No response to psychological therapy or self-help wellbeing resources.
  • Mild depression complicating long-term physical conditions.

6. Organise follow-up in general practice – arrange initial review, usually within 2-4 weeks, and ensure follow-up if patient DNAs1. Decide ongoing frequency of review based on patient preference, co-morbidities and response to treatments.

7. If not improving as expected, re-consider the diagnosis and/or manage as per more severe depression.

 

More severe depression (“stopped going to work or getting out of bed”):

1. Discuss first-line treatment options are per NICE visual aid (more severe depression).

2. Offer both psychological therapy (via Talking Therapies) and antidepressant medication(usually SSRI) – a patient may need to be effectively established on medication before gaining benefit, or engaging with, psychological interventions.  

3. Organise follow-up using clinical acumen to decide on review interval. A reasonable approach is to follow-up:

  • patients at increased risk of suicide, especially those under 30yrs on SSRI or SNRI, within 1 week and frequently thereafter until risk subsides.
  • all others, at 2-4 weeks1 (bearing in mind antidepressants may take 6 weeks to have an effect). Decide ongoing frequency of review based on patient preference, co-morbidities and response to treatments.
  • ensure DNAs are actively followed up.       

4. Up-titrate antidepressant medication (usually SSRI) to maximum dose. If intolerable side effects or poor response considering switching to an alternative antidepressant, see NICE CKS: Depression – Switching Antidepressants (June 2024).

 

 

Advice and Guidance

Consider seeking specialist advice or referral to specialist services if ongoing symptoms despite having trialled maximum doses of at least 2 antidepressants for a reasonable period of time.

See the guideline on Specialist Mental Health Advice (routine or urgent)for further information.


 

Referral

Same-day advice/assessment:

In presence of red flag features, contact the 24/7 Healthcare Professionals Line and Crisis Hub

 

Urgent or routine CMHT referral:

Consider seeking specialist advice or referral to specialist services if ongoing symptoms despite having trialled maximum doses of at least 2 antidepressants for a reasonable period of time.

 

For information on referral criteria, information required, and referral process see guideline on Single Point of Access (SPoA) for CMHT

 

 

Supporting Information

For patients:

 

For professionals:

 

References

  1. NICE CKS: Depression (February 2025)

 

Page Review Information 

Review date

20 March 2025

Next review date

20 March 2027

Clinical editor

Dr Laura Vines

Contributors

Dr Jeremy Sandbrook, Consultant Psychiatrist CFT