UKCP responds to consultation on NICE depression guideline

UKCP has responded to the consultation on NICE’s guideline for the recognition and treatment of depression in adults.

In our response, we welcomed the significant steps forward taken in the latest draft of the guideline, particularly the new emphasis on patient choice and the removal of the stepped care model. If implemented alongside a workforce and service development strategy, we believe this could have a major impact on the availability of psychotherapeutic treatments, particularly the provision of alternatives to antidepressant medication and cognitive behavioural therapy, in the NHS and beyond.

We also welcomed NICE’s broader efforts to engage with the fundamental methodological concerns that we, as part of a coalition of 50 mental health organisations, have raised repeatedly during the guideline development process. These efforts, we believe, have led to a much-improved guideline compared to the previous draft.

However, we still have several serious concerns with the current draft guideline, and we raised these in full in our consultation response.

NICE continues to rank treatments, despite its new emphasis on patient choice, and its own evidence reviews revealing that all psychotherapeutic treatments in the guideline were found to be both clinically and cost-effective. This hierarchical system could fundamentally undermine the commitment to patient choice, as well as hampering the roll-out of alternative therapies through commissioning and workforce planning decisions.

We argued strongly in our response that, at a time when demand for mental health services has never been higher, NICE should remove these rankings and avoid creating needless barriers to access. We highlighted the vital role psychotherapists and psychotherapeutic counsellors could play in delivering much-needed support if the guideline gave commissioners and service providers greater flexibility in their decision-making.

We also highlighted in our response where NICE has failed to address methodological issues that we have consistently raised during the development of this guideline. These include:

• inconsistencies in the review of long-term follow-up data – where we know the lasting effects of psychotherapy stand out
• limited consideration of data on service user experience of treatments, meaning a limited influence of service user preferences on the recommendations
• the binary categorisation of depression into ‘less severe’ and ‘more severe’, which is not scientifically validated
• the failure of the guideline to take ‘partial recovery’ into account, even though the shift to a milder experience of depression can have a transformational effect on someone’s quality of life
• the use of network meta-analysis (NMA) as the primary method of determining both clinical effectiveness and cost effectiveness, despite serious questions about the validity of NMA as a method of analysis for mental health treatments
• the continued over-reliance on evidence from randomised control trials (RCTs), significantly limiting the scope of evidence included
• the exclusion of high-quality evidence for the efficacy of several therapeutic approaches, such as family and systemic therapies, humanistic and integrative therapies, creative therapies and, more generally, longer-term therapy models.

We await NICE’s response to our comments and the concerns raised, and hope these are reflected in the final guideline.

Many of our critiques of this guideline apply to other NICE mental health guidelines. The positive changes made to the depression guideline owe much to the joint campaigning work we have helped to lead over the past four years, that has seen our coalition grow to more than 50 organisations and secured the support of over 100 parliamentarians. In the coming months, we look forward to building on the momentum of this campaign as part of a wider call for a paradigm shift in the approach to evidence gathering and guideline development in mental health.