Map, guide and compass: the Draft NICE guidelines for depression

In his recent review of depression memoirs, Jeremy Clarke the psychoanalytic psychotherapist, and a member of the NICE panel on depression, concluded that lived experience is not the same kind of depression as that in clinical guidelines. If so that’s a problem.

However, we need to acknowledge that there is no single experience of what we call depression, no single cause, and no single effective treatment. Nor are people who suffer from the collection of symptoms we recognise as common to ‘depression’ all treated in the same place – although, in the UK, the vast majority primarily see their GP. Getting help for depression can seem like wading through a morass while your inner compass is disabled. Guidelines can provide a map of the options for helping you on your way.

            Nevertheless the new draft guidelines published last autumn after considerable delay, leave me, someone who has experienced depression, as Clarke notes, as a recurrent, sometimes disabling, often lifelong illness, curiously disappointed. Yes, the options for treatment, based on the best evidence are all there (though not quite all – I’ll come back to that later), but something else is missing. The sense that, for many people, those who aren’t among the 50% who do recover after brief treatment, that depression is a journey, and to help you on that you need a guide, who can help you to make the choices and decisions about which treatment you want to try from the wheel of options at a time in your life when you may be less able to make a decision than ever before. 

            For most people that guide will be their GP. But what if he or she isn’t interested in mental health and doesn’t know much about the options? Some doctors sadly are not. What if you haven’t established a trusting relationship with them? its harder than ever now with the pressure on primary care to have that kind of continuous relationship I had with my old GP over many years – the person who was the ‘keeper of my story.’ The short paragraph on ‘principles of care’ on the first page of the guidelines doesn’t acknowledge that. Without a guide, we fall back on ‘self-management’ but It’s extremely difficult to self-manage your own care when you are significantly depressed. You can easily get lost or even harmed by wrong choices that you make.

In my academic research and clinical work with an Improving Access to Psychological Therapies (IAPT) service in Salford over many years we showed how psychological well-being practitioners could act not only as therapists but also as guides, working closely with the GP, supervised by experienced mental health staff. We tried to help people get access to what might really be needed from the whole biopsychosocial spectrum of care, not simply psychological therapy because many of them had a wide range of life difficulties, physical illnesses and problems – not only ‘depression’. ‘Collaborative care’ as it’s known, has the best evidence base for treating depression in primary care, because it recognises that even if you know what helps people to recover from depression (the first 50 pages of the NICE guidance) they often don’t get it because when you are depressed you may not think you deserve treatment and you can easily disappear. Collaborative care has been adopted across the world, but not in the UK where (in England at least) the standalone IAPT model of providing mostly brief CBT, largely disengaged from primary care and the rest of the mental health service, has prevailed. Collaborative care gets a brief mention on page 51 yet collaborative care workers don’t just help you to navigate the system they help you to get the best out of it.

            A significant number of us spend many years on this journey, struggling to come to terms with the life events that predisposed, triggered or maintain our difficult moods. What happens when we run out of options? When our own inner compass refuses to start working again or has been seriously damaged by our early life experiences. When the brief therapies described here are exhausted and we ‘fall off the map’. 

            Working in a IAPT service you soon become familiar with the scenario of having nowhere suitable to refer a person with symptoms of chronic depression who requires referral for individual therapy to begin to resolve early trauma or psychological conflicts. Those for whom brief therapies, and those based on CBT, are not sufficient. I suspect that the NICE guidance considers these under the rubric of ‘depression in people with a diagnosis of personality disorder’ but why should people who fail to recover from depression have to accept that label, with its associated stigma, to receive care – even if it’s available? 

There is growing evidence for the effectiveness of longer term psychodynamic psychotherapy for chronic depression, however services that in the past could provide this have been eviscerated in the push for only brief interventions to meet IAPT targets. Both are needed. Some of us (myself amongst them) needed a skilled psychodynamic therapist over a much longer period to guide our way forwards again out of the morass, back into life and help re-set our inner compass. Acknowledgement of this is missing in the draft NICE guidelines for depression even though so many of us recognise it is true. Longer-term psychodynamic therapy is now almost impossible to obtain on the NHS and, if missed out again from the guidelines will continue to be so.

So, in my view, the map, as drawn, is incomplete and the journey through depression, whatever it is, is difficult to make for many of us without the help of a guide that we can trust. 

That is what my lived and professional experience tells me.

My memoir of recovering from depression: Finding True North: the healing power of place is out now.

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