RAG rating

n/a

Document type

Clinical pathways

Place

Hertfordshire and West Essex ICB

Output type

Clinical Pathways

Pathway

Depression Care Pathway

Depression

The depression treatment pathway is divided into four levels based on severity and response to treatment.

LEVEL 1 – Recognizing and Assessing Depression

• Ask key questions to identify depression:
• Do you feel down, depressed, or hopeless?
• Have you lost interest or pleasure in doing things?
• If the patient has a chronic physical illness, ask additional questions:
• Do you feel worthless?
• Do you have trouble concentrating?
• Have you had thoughts of death?
• If there is an immediate risk of harm (to self or others), refer urgently to specialist mental health services.
• Provide links and contact details for suicide prevention support (still in development).

LEVEL 2 – New Episode of Less Severe Depression

• Use a Multi-Disciplinary Team (MDT) to support care.
• Offer treatment options, choosing from the following:
• Therapies: Group or individual Cognitive Behavioural Therapy (CBT) or Behavioural Activation (BA).
• Lifestyle approaches: Group exercise, mindfulness, and meditation.
• Other therapies: Interpersonal psychotherapy (IPT), short-term psychodynamic therapy (STPP), and counselling.
• Medication: Selective Serotonin Reuptake Inhibitors (SSRIs).
• Couples therapy: If relationship problems contribute to depression.
• Antidepressants are not the first choice unless the patient prefers them.
• Respect the patient’s choice to decline treatment.

LEVEL 3 – More Severe Depression or Limited Response to Initial Treatment

• Use MDT support to guide care.
• Treatment options include:
• A combination of CBT and antidepressants.
• Individual therapy: CBT, BA, interpersonal psychotherapy (IPT), problem-solving therapy, or STPP.
• Medication: Antidepressants, including SSRIs.
• Self-help approaches: Guided self-help, group exercise.
• Couples therapy for relationship-related issues.
• If there is no improvement within 4–6 weeks, consider:
• Trying a different therapy.
• Adding an SSRI to therapy.
• Offering antidepressants alone.
• Including group exercise in the treatment plan.
• Discuss the risks of long-term antidepressant use versus relapse risk.

LEVEL 4 – Chronic, Psychotic, and Personality Disorder-Related Depression

• Use MDT support for complex cases.
• Treatment for chronic depression:
• Cognitive Behavioural Therapy (CBT).
• Antidepressants: SSRIs, Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), or Tricyclic Antidepressants (TCAs).
• Combination therapy: CBT plus an SSRI or TCA.
• Treatment for depression with personality disorder:
• A combination of antidepressants and psychological therapy (CBT, BA, IPT, or STPP).
• Treatment for psychotic depression:
• Refer to a specialist mental health service.
• A combination of an antidepressant and an antipsychotic (e.g., olanzapine or quetiapine).
• Regular monitoring for hallucinations or unusual thoughts.
• Caution with TCAs, as they can be dangerous in overdose. Lofepramine is the safest option.

Additional Considerations

• Shared decision-making is encouraged.
• Community resources and support should be included in the care plan.
• Neuromodulation treatments (e.g., brain stimulation) may be available for specific cases.
• Advanced care decisions should be documented as per guidance.