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New British Guidelines Advise Physicians on Treatment of Depression and Anxiety

December 8, 2004

On December 6, 2004, the National Institute for Clinical Excellence (NICE) issued guidelines for the British National Health Service on the treatment and care of people with depression and anxiety. The guidelines take into account recent information from the British Medicines and Healthcare products Regulatory Agency (MHRA), the body that performs similar regulatory functions as the FDA.

The advice being communicated to health professionals in Great Britain focuses on the use of SSRIs in adults and concludes that the balance of risks and benefits of all SSRIs in adults remains positive. However, according to the guidelines, prescribers and consumers should be aware of the side effect profile of these medications and the need for monitoring patients being treated for depressive illness or anxiety disorders.

Depression Guideline

The guideline on depression recommends that for mild and moderate depression, psychological treatments specifically focused on depression, such as problem-solving therapy, cognitive behaviour therapy and counselling, can be as effective as drug treatments and should be offered as treatment options.

The guideline also recommends that:

  • Antidepressants should not be used for the initial treatment of mild depression, because the risk-benefit ratio is poor.
  • For patients with mild depression who do not want an intervention or who, in the opinion of the health care professional, may recover with no intervention, a further assessment should be arranged, normally within two (2) weeks (‘watchful waiting’).
  • When an antidepressant is prescribed for moderate or severe depression it should be a SSRI, because SSRIs are as effective as tricyclic antidepressants and their use is less likely to be discontinued because of side effects.
  • All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur due to stopping or missing doses or, occasionally, due to reducing the dose of the drug.
  • Screening should be conducted for all high risk groups – for example, those with a past history of depression, significant physical illnesses causing disability, or other mental health problems such as dementia.
  • For severe depression, psychological treatment, such as cognitive behavioral therapy (CBT) should be used in combination with anti-depressant medication.

Anxiety Guideline

The guideline on anxiety recommends that patients should be offered any of the following three types of intervention, taking into account patient preferences. In descending order of long term effectiveness, these interventions are:

  • Psychological therapy, such as CBT.
  • Medication, such as SSRIs licensed for generalized anxiety disorder.
  • Self help, such as the use of written materials based on CBT principles.

NAMI’s Views on the New Guidelines

  • The British guidelines do not say that anti-depressant medications should not be used. Rather, they emphasize that in cases of mild depression, other forms of therapy should be tried before medication. Decisions on treatment—whether through antidepressants, talk therapy or diet and exercise -- must ultimately be made by the doctor and the patient -- weighing potential benefits, risks, and alternatives. The choice of any medication for any illness must be made carefully, with informed consent.
  • Depression is the leading cause of disability around the world and needs thoughtful interventions. Suicide is an outcome strongly associated with depression. Mild depression can quickly turn into severe depression. Severe depression is not always easily recognized. In some cases, people with severe depression are able to pursue normal, daily routines, with the severity of the symptoms and the degree of functional impairment associated with these symptoms not readily apparent. In these cases, time may be of the essence. It may be appropriate to prescribe medications as the first response, followed only then by talk therapy and diet and exercise changes. Side effects and withdrawal effects can be effectively managed -- but lost lives are irretrievable.
  • It is important also to recognize that many people with depression self-medicate with alcohol or drugs. Co-occurring substance use or abuse complicates the treatment of depression and increases the risks of those with depression. Pharmacological treatment with anti-depressant medication is a far better alternative than self-medicating with alcohol or other drugs.
  • These guidelines should not serve as a reason for physicians in the United States to stop prescribing anti-depressant medications in appropriate cases, or for consumers to stop taking anti-depressant medications. As stated above, decisions about medications or alternative forms of treatment should be made carefully, through consultation between treating physicians and their patients.
  • It is important to note that the British announcement involves guidelines - not restriction or prohibition. There also are cultural and political distinctions between British and American health practice; medical practice under the British health service system is heavily regulated and relies less on individual clinical judgment than the American system.

For more information on this issue, please contact Joel Miller at