THE National Institute for Health and Care Excellence (Nice) has published its draft guidelines on the treatment of depression — the first change in 12 years. 

In this it differentiates between what it calls mild, moderate and severe depression, with a so-called “menu” of treatment options available, to tempt healthcare providers and patients away from anti-depressants. 

It would be hard to argue against increasing choice. But still there are a few points that remain a concern, such as how decisions are made as to what group a patient belongs to, along with the pressure on services. More widely, why are the terms reactive and clinical not being used and why are these changes being made now?

Under these guidelines, the question of whether someone has mild, moderate or severe depression will have to be decided by what is vaguely described as “the healthcare professional.” This is likely to be a GP. 

Therapies on offer from the Improving Access to Psychological Therapies (Iapt) framework could be group cognitive behavioural therapy (CBT), group mindfulness, meditation self-help, exercise or counselling.  

Only those with severe depression should be offered anti-depressants, but CBT and counselling should be offered as well.

If we put the pandemic to one side, there was already a crisis in general practice. With the pandemic this pressure has grown expediently, with a poll by the Medical and Dental Defence Union of Scotland finding that more than half of GPs were thinking of leaving the profession or retiring early. 

Likewise, the demand for mental health support has been increasing before and during the pandemic, and there has been a loss of 25 per cent of mental health beds since 2010. 

This has severely damaged the ability of services to meet this increased need and act in a timely and safe manner.

The impact on cuts to services, the loss of experienced staff and hospital beds has meant that Iapt services are not delivered how they are meant to be, especially in terms of providing timely and safe support.

Clinical psychologist Dr Ruth Ann Harpur says: “Iapt services can provide very good therapies for people with mild to moderate depression, which is what they were designed to do, but the pressure on services means there is often a long wait to see someone.”

That long wait means what could at first be described as mild depression becomes more severe, yet during this period of waiting many don’t get any support.

Sharon was referred to Iapt for CBT by her crisis team, but it took four months before her appointment came through. During that wait she got no support, causing a marked deterioration in her mental health.

Like Sharon, Cassie experienced a deterioration in her mental health after she waited for a year to finally start the six sessions of group dialectical behaviour therapy (DBT). 

During this time all she had was limited phone support, but she soon found out that this didn’t offer help at all. 

During the year she developed anorexia and made serious and life-threatening attempts on her life. 

Reflecting on this time, Cassie says: “They couldn’t even tell me how long the wait would be, as they simply didn’t have enough staff to deliver the therapy.”

Many patients under the Iapt framework are put into groups for CBT and DBT. This is often seen as a cost-saving measure. 

Simon had been waiting months for group CBT, and eventually was put into a group that was already established. In it there were two very strong characters who dominated proceedings in a very threatening manner. 

This not only had an impact on others like Simon but also the facilitator of the group who couldn’t handle what was happening.

Harpur says: “This account highlights the need to screen patients for groups and have very skilled facilitators with specialist training and supervision for group interventions.

“They are not a cheap way of seeing more people — they’re a different form of therapy that requires a particular set of skills and support for therapists.”

For Simon, the experience with the group caused a deterioration in his mood, which included feeing suicidal at times. But he soon realised he would face an even longer wait to get any specialist support.

“Under these proposals, for those determined as being severely depressed the picture is different,” says Harpur. 

“There may be little provision for people whose depression leads to suicidal feelings or self-harm with even longer waits for more specialist therapists within secondary care.”

Although these guidelines stress the move away from anti-depressants Harpur says such medication is the only immediate option for most patients with severe depression who face long waits for specialist services in the secondary sector.

But what happens if the GP or community mental health team (CMHT) doesn’t think a patient is depressed, or feel that they are not in need of additional support? 

This happened to Elaine who was severely depressed following the suicide of a close friend. As she worked full-time, the CMHT didn’t believe she could be depressed. 

This was coupled with all the therapy only being offered during working hours. She was told that if she “went off sick” things might be different, but Elaine felt her job was the only thing keeping her alive.

What is worrying is this account is far from unique, with many people falling through the cracks. That includes some patients who are crying out for help. 

In these cases, there seems to be an assumption that if you say you feel depressed and suicidal or attempt suicide, you are probably not depressed or suicidal and instead have “capacity.”

Running through these draft guidelines is the theme of “personal responsibility.” It reads very much like blaming the patient. That they are the problem, rather than someone with mental health problems.

Elaine says: “When in a severe depression, you’re not thinking straight. Intense thoughts of harm are overriding the functional, rational part of the brain. Thoughts are distorted. Taking personal responsibility is difficult when this overwhelmed. There’s a need to have someone step in and provide support and safety.”

That support and safety is what is lacking in so much of mental healthcare but this new document from Nice seems to have other motives, rather than just reducing the use of anti-depressants.

The main change seems to be the use of terms mild, moderate and severe to describe depression. This then downgrades depression, with only a third of cases classed as severe.   

That’s a big change from the usual description of reactive and clinical depression, where it was just the cause that differentiated the types of depression recognising that both could be equally severe.

Instead, throughout the document depression is treated as if it is a difficult emotion. This fits in with some of the arguments that are currently ongoing about what depression is and what it isn’t and how it should be treated. 

This was discussed in the controversial report Understanding Depression, published by the British Psychological Society. This document argues that depression should be thought of as “an experience rather than a disease.”

If this is the plan — to split the depressed into these groups, with the emphasis on CBT and other psychological methods that put the onus on the patient to get themselves better — then it is a gamble fraught with danger, especially when patients are waiting months and months for therapy, with their condition deteriorating but left unsupervised and unsupported.

RF Hunt is an author and freelance journalist.