03 - References

References

336 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Official guidance on the treatment of depression: a summary of the NICE guidelines1 ■ ■Depression severity is categorised as less severe (includes subthreshold and mild depression) and more severe (includes moderate to severe depression). The severity of depression is determined by the combined influence of factors such as symptom severity, duration and the impact on personal and social functioning. ■ ■Antidepressants are not recommended as a first-­line treatment in less severe depression. Other options such as counselling, guided self-­help, cognitive behavioural therapy (CBT), behavioural activation, mindfulness, meditation, short-­term psychodynamic psychotherapy, interpersonal psychotherapy or exercise are preferred. ■ ■Antidepressants are recommended for the treatment of more severe depression and for dysthymia. ■ ■When an antidepressant is prescribed, a generic selective serotonin reuptake inhibitor (SSRI) is recommended. ■ ■All patients should be informed about the withdrawal (discontinuation) effects of antidepressants and how they can be minimised or avoided. ■ ■For treatment-­resistant depression, recommended strategies include implanted VNS, augmentation with lithium or an antipsychotic, or the addition of a second antidepressant (see section in this chapter). ■ ■Patients with a recurrent episode or at high risk should be treated for at least 2 years. ■ ■The use of electroconvulsive therapy (ECT) is supported for severe and treatment-­ resistant depression if patient prefers it and has responded in the past or when a rapid response is needed. Nasal esketamine is a licensed treatment for treatment-­resistant MDD,5 but is not yet approved by NICE in the UK. It is widely used elsewhere. This chapter concentrates on the use of antidepressants and offers advice on drug choice, dosing, switching strategies and sequencing of treatments. The near exclusion of other non-­drug treatment modalities does not imply any lack of confidence in their efficacy but simply reflects the need (in a prescribing guideline) to concentrate on medicines-­related subjects. References

1. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NICE guideline [NG222]. 2022 (last updated May 2024, last checked May 2024); https://www.nice.org.uk/guidance/ng222.
2. George MS, et al. Vagus nerve stimulation for the treatment of depression and other neuropsychiatric disorders. Expert Rev Neurother 2007; 7:63–74.
3. Hsu CW, et al. Comparing different non-­invasive brain stimulation interventions for bipolar depression treatment: a network meta-­analysis of randomized controlled trials. Neurosci Biobehav Rev 2024; 156:105483.
4. Loo CK, et al. A review of the efficacy of transcranial magnetic stimulation (TMS) treatment for depression, and current and future strategies to optimize efficacy. J Affect Disord 2005; 88:255–267.
5. Jannsen-­Cilag Ltd. Summary of Product Characteristics. Spravato 28 mg nasal spray, solution (esketamine hydrochloride). 2024 (last checked May 2024); https://www.medicines.org.uk/emc/product/10977/smpc.