Mental health policy and practice across Europe: an overview

The treatment of mental disorders 139
wherever professionals are involved, their role is to take these concepts into
consideration.
NICE guideline on the treatment of depression
The National Institute for Health and Clinical Excellence (NICE) in England
and Wales has commissioned a series of guidelines in which the methods of
evidence-based medicine are used to formulate policies for health care workers
in both generalist and specialist settings. The guideline on depression (National
Collaborating Centre for Mental Health 2005) illustrates many of the points
discussed in this chapter. Although depressive illnesses of all grades of severity
are treated in primary care in the United Kingdom, it is generally the case that
less severely depressed people are treated in primary care rather than in specialist
care. It is also true to say that as the severity of depression increases, there is a
lower prevalence: so, there are far more people with mild depression than
moderate depression, and so on. In terms of available human resources, there
are not enough trained staff to provide psychotherapy to everyone who might
benefit from it. The NICE guideline makes detailed recommendations not
only about drug treatments and psychological treatments, but also on the best
service arrangements; the three-tier model advocated in this chapter is therefore
echoed in the document.
In view of staffing and service constraints, the guideline uses a ‘stepped care’
approach, in which each step up the hierarchy indicates a need for a more
specialized (and usually much more expensive) treatment. Having provided, in
the first step, detailed guidance on how GPs can improve their detection rates
for depression, the guideline moves to the second step, which is the best-practice
management of mild depression (just diagnosable on ICD-10 criteria, with four
symptoms, in addition to entry symptoms). This is done in primary care, by GPs
or practice nurses. There is no difference between active antidepressant drug
and placebo in mild depression, so primary care staff are advised to use other
treatment interventions, such as self-help, physical exercise, ‘watchful waiting’
and problem-solving. To the extent that drugs have any role here, it is not as
antidepressants but as aids to the restoration of sleep and as daytime sedatives.
Computerized cognitive-behaviour therapy has also been shown to be effective
in mild depression. However, antidepressants may have a place if mild depression
persists after treatment of a more severe episode, or where the individual
has a past history of depression.
The third step is the management of moderate depression, defined as five or
six additional symptoms, and severe depression defined as seven or more additional
symptoms. Here, antidepressants have been shown to be effective, and
are recommended on the basis of their relatively low toxicity, low cost, generally
low discontinuation syndrome and tolerability – as there is no evidence that
any one antidepressant is more effective than another. SSRIs (selective serotonin
reuptake inhibitors) are recommended in view of these considerations. Examples
of recommended antidepressants are citalopram and fluoxetine; or sertraline
if heart disease is present. Simple psychological interventions like problemsolving
by primary care staff may be effective, but are somewhat more expensive