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SIGN guidance on non-pharmaceutical management of depression

The Scottish Intecollegiate Guidelines Network (SIGN) published their guidance on "Non-pharmaceutical management of depression" today.  SIGN comment:  "Depression Alliance Scotland proposed the development of this guideline based on feedback from service users who were seeking information about interventions other than prescribed antidepressants which could be helpful in managing their depression.  The Scottish Integrated Care Pathway (ICP) for depression sets standards for appropriate care and treatment of people with depression. It states that for those who choose a non-pharmacological approach, or for whom medication is not effective, there should be the offer of a brief depression-focused psychological intervention.  There is a need for accessible and robust evidence based information about the alternatives to prescribed antidepressants to be available to both GPs and service users."

They go on to say:  "This guideline provides an assessment of, and presents the evidence base for, the efficacy of non-pharmaceutical therapies, encompassing psychological therapies, structured exercise and lifestyle interventions, and a range of alternative and complementary treatments, many of which are not routinely available within the NHS.  This guideline will be of particular interest to those developing mental health services, health care professionals in primary and secondary care (eg GPs, community psychiatric nurses, clinical psychologists and psychiatrists) and patients with depression and their carers.  It may also be helpful to voluntary organisations and exercise professionals working in exercise referral schemes, public or private fitness centres, and physical activity promotion."

The guidance is freely accessible/downloadable as the full 44 page "Non-pharmaceutical management of depression in adults: a national clinical guideline", as a brief 2 page "Quick reference guide" and as a 32 page "Treating depression without using prescribed medication: booklet for patients and carers".

How good is this guidance?  It's good.  Of course there are areas one can criticise, but overall it's excellent.  A big thank you to the group of clinicians, researchers and members of the general public, who volunteered and worked for years to put this guideline together.  The obvious comparison is the recent English/Welsh "Updated NICE guidelines on treating depression".  SIGN's effort is welcome because it steers clear of the much written about subject of antidepressant medication and concentrates on the crucially important area of non-pharmaceutical management.

What are the key points?  Well SIGN's "A grade" recommendations (grading reflects the strength of the underlying research evidence) are for various forms of psychotherapy - behavioural activation (BA), cognitive behavioural psychotherapy (CBT), and interpersonal psychotherapy (IPT).  For self-help, SIGN give an A grade to guided self-help based on BA or CBT (including via computer programmes).  Their still strong "B grade" recommendations (good underlying research backing, but not as extensive as for A grades) are for problem solving therapy and short term psychodynamic psychotherapy.  There's a B grade recommendation too for group mindfulness-based cognitive therapy (MBCT) to reduce risk of relapse for people who have already suffered three or more episodes of depression.  Interestingly and encouragingly, there's a further B grade recommendation for forms of structured exercise.

SIGN also make a series of "best practice" points about appropriate training of psychotherapists, appropriate styles of self-help group, the potential value of couples-focused therapy, and the importance of healthy lifestyle.  Sadly, SIGN have fallen into line with the typical establishment position on St John's wort, suggesting that health professionals should not recommend its use because of concerns about standardisation of dose and interactions with other medications.  In the original draft guideline, SIGN gave St John's wort an A grade recommendation.  I wrote extensively about this in "Draft SIGN non-pharmacological depression treatments guideline, 3rd post: herbs & supplements"The points I made are still valid.  In fact, in a burst of enthusiasm, I wrote nine blog posts about the original SIGN draft guideline.  Several of these commentaries still seem worth reading - for example the already mentioned post on St John's wort, and another on the "Therapeutic alliance in the treatment of depression".  Overall though, a big thumbs up for this guideline, for all who contributed to it, and for Ruth Lang, retired Information and Support Officer for the charity Depression Alliance Scotland, who inspired and initiated the whole process.


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