In July, NICE announced the publication of its long-awaited revised guideline on the treatment and management of depression in adults, and that it would consult on this guideline until early September. Working with the BPC’s research and evidence base group, and following consultation with a number of eminent clinicians and researchers in the past few months, the BPC has now sent in its consultation response. The BPC, in common with other psychological therapy professional bodies, has long tried to tackle NICE’s recommendations on psychological therapies because they have historically been based only on particular forms of evidence (such as randomised controlled trials), leading to recommendations with limited clinical utility but which nonetheless are hugely influential. In effect, although this is changing a little, commissioners, budget holders and politicians still overwhelmingly defer to the recommendations of NICE. As there is now good evidence for the efficacy of psychoanalytic psychotherapy, our priority is to ensure that psychoanalytic psychotherapy is fairly evaluated as a treatment by NICE and that patients are able to access this well-evidenced treatment.
We have expressed serious concern and reservations about a wide number of points in the revised guideline and in particular, about the methodology which was used to develop the guideline and its recommendations. Our concerns include:
1. That the guideline development group did not pay any attention to long-term follow-up data, including from the Tavistock Adult Depression Study, which demonstrated for example that at 2-year follow-up after treatment, 44% of people who had recieved long-term psychoanalytic psychotherapy no longer met diagnistic criteria for major depressive disorders compared to 10% of patients in a control group recieiving treatment-as-usual. We beieve that a treatment which demonstrates considerable effect at long-term follow-up is stronger than one which does not, and that a treatment which has little effect after a treatment ends is surely a weaker treatment than one which has a longer-lasting effect on a patient. We therefore suggest that NICE takes into due consideration all follow-up data on the effect of treatments for patients/service users, and takes this data into consideration when makings its recommendations.
2. That Treatment-Resistant Depression and Chronic Depression have been (artificially) separated as categories of depression. Past guidelines emphasised the myriad types of depression that are chronic and resistant to treatment, and which are often linked with co-morbid mental health disorders. Given that the draft guidelines emphasise the difficulty in, and problems of, classifying depression, we do not understand why a decision has now been taken to separate Treatment Resistant Depression and Chronic Depression. This also goes against the recommendations of the European Psychiatric Association and the American Psychiatric Association which both recommend a common persistent depression category. We have recommended NICE does not seperate these two types of depression.
3. That the recommendations are based on a narrow interpretation of what constitutes evidence. The guideline development group only examined randomised controlled trials (RCTs) and meta-analyses. This means that the recommendations are not necessarily in the best interests of patients, being based on a privileging of treatments which lend themselves to RCTs (CBT for example) but which have limited clinical utility. The RCTS considered were largely only of patients with a diagnosis of depression only, where there is much evidence, in addition to clinical experience, that depression is frequently comorbid with other illnesses, such as anxiety. The guideline development group also did not take into account real-world evidence, such as that from the IAPT datset concerning the effectiveness of psychodynamic psychotherapy and CBT. The dataset shows that both types of treatment have a recovery rate of 45.9%, with psychodynamic psychotherapy achieving this with 5.7 sessions on average, as opposed to 5.8 sessions on average for CBT.
The final guideline will be published in January. We are aware that a number of professional bodies, mental health charities and individual academics and clinicians have similar concerns around the draft guideline and we are looking into a number of options with regard to next steps. Given the prevalence of depression in this country, and the impact NICE guidelines have on treatments widely available, we are concerned that the final recommendations are based on sound methodology and accurately reflect what works for people experiencing depression.