UK: Guardian: "NHS to give therapy for depression before medication under new guidelines"

"Millions of people with mild depression in England should be offered therapy, exercise, mindfulness or meditation before antidepressants, according to the first new NHS guidelines in more than a decade.

Under draft guidance, the National Institute for Health and Care Excellence (Nice) recommends the “menu of treatment options” be offered to patients by health professionals before medication is considered.

Currently, those with mild depression are offered antidepressants or a high-intensity psychological intervention, such as cognitive behavioural therapy (CBT). The shake-up forms part of the first new recommendations to identify, treat and manage depression in adults since 2009."

https://www.theguardian.com/society...ession-before-medication-under-new-guidelines

 

I suspect this might actually be a good thing. I think there is a much too hasty dash to medicate depression.

Of course in severe situations, medication might be well advised, but I suspect for many, early medication of milder depressive issues just complicates matters.

 

I'm tempted to think less incentive to hand out anti-depressants is a good thing, but if the alternative is six months on a waiting list for CBT...perhaps not!

 

Interesting that CBT is described as “high intensity psychological intervention”, which seems to clarify that it would have the potential to harm if inappropriately applied.

 

Perhaps more people could become interested in the reporting of harms from non-pharmacological interventions. Depression generally is a very relatable issue for many people and they can see themselves wanting to access such services.

ETA: And to have some protection against potential harms or serious issues arising.

 

If the evidence is sound then the recommendation should follow the evidence, the challenge is putting that into practice. The NHS is short of trained personnel across the board, swapping a low cost prescribing regime for a higher cost, high personnel demand regime doesn't seem achievable in the near or even medium term.

Advising mildly depressed patients to take up sport or an active hobby may be sound, but it assumes motivation, access to resources and available free time, which is OK for certain demographics but a no prescribe rule may lead to short term mild depression becoming long term moderate depression and higher levels of self prescribing in patients who either can't achieve lifestyle change or access non anti depressant treatments.

 

Originally CBT is a hardcore psychiatric treatment, used for things like severe depression, OCD, eating disorders, hypochondria/severe health anxiety, severe phobia's and sexual disorders. Not a low-treshold psychological method like a regular talking therapy. (And it's still strange to me that people see it that way.)

It takes two intense psychiatric treatments,

• Cognitive Therapy -heavily influencing thoughts and cognitions based on what the therapist decides is acceptable or "disfunctional", and
• Behaviour Therapy -manipulating behaviour via well-established Operant Conditioning principles

and combines them.

Apart from if it works or not, I think this stuff should come with a reporting scheme, guardrails, safety belts ànd optional helmets because of it being so intense and powerful, with high risks for the patient's mental health if mistakes are made. The original handbook had some safety measures installed that make sense, but the authors themselves seem rather easy about them, and I doubt that they are really used much in practise.


I'm not at home with it, but I also thought CBT for depression was also debated, that there's no consensus in psychology and psychiatry that it is a useful treatment?
But if it does help, then it might indeed be a good idea to start with that, especially if the depression is mild, before antidepressants are prescribed.

 

Anecdotally I have a friend who told me he was very harmed by it and that he now strongly believes CBT "doesn't work" for mental health issues either. He now pays for a proper therapist after spending years in a CBT-based "therapeutic" situation which he now thinks of as abusive and exploitative. He feels slightly ashamed to have gone along with it and to have taken part in some absurd things they suggested he do e.g. strange role-play games.

It's one of the main reasons he feels empathy on this ME/CFS situation (and believes me when I talk about it, unlike most people). Interestingly, he told me that there was a huge emphasis on the physical part of his mental health condition, which he found confusing, frustrating, and irrelevant. The message was "this is physical" whereas he just wanted to talk about his issues. I always thought this was an interesting take as I'm so used to thinking of it from the other end of "biopsychosocial" ME/CFS end, where there is an inappropriate focus in the other direction.

He has thankfully improved after paying for a regular talking therapist. I have often thought that such people might be allies, although it's horrible that many people with mental health issues are also going through quite extreme psychological harms as well. (What was described sounded potentially extremely psychologically damaging and unethical). As the term "CBT" is used in different ways it's hard to keep track of in order to protect patients, or monitor for alleged efficacy. It's difficult with the all-too-familiar methodological problems in the literature.

 

With more and more conditions being treated as psychogenic, and doctors being told not to treat anyone with medicines, I foresee a huge increase in the number of people being left untreated for invisible diseases. I imagine that number is already quite high, and that many of the ignored are female or children.

 

Not a criticism Arvo but I seemed to pick up somewhere that they'd identified genes re eating disorders.

Seems to be a bit counterintuitive that CBT overrides your genes.

I'd be content with a well conducted study which shows it woks though.

 

It sounds as if instead of either drugs or 'proper CBT' the idea is just to suggest stuff, including 'sort-of therapy', gym and meditation. People who are depressed know that they could go to the gym or meditate but they have lost the drive to do so. I can't see then point of parcelling this up into 'a menu of treatment options', like those mini pats of butter at the checkout.

It sounds like blather, like everything else, to me.

 

This was discussed on BBC radio2 today. Interesting that most people who said it had been very helpful talked about 'counselling', as opposed to CBT which seemed to have more mixed responses.

 

It’s a difficult one. If drugs are not the first option, and serious CBT isn’t either, then what is the first option?

Do people respond to the idea of “Doctor’s orders” to take a 10 min walk outside each day? Or is that discarded as easily as the general advice of friends? So what then should be offered?

I suspect general counselling to help with life problems (eg debt, unsustainable working hours, etc.) might be a good first step, but it seems counselling of this nature is now seen (in medical circles) as less useful than CBT, so it is perhaps as hard to access as any other therapy.

@Sly Saint - Just seen your post. Yes. I think CBT has become over-rated, and good old life-counselling is often more useful. (And truth be told, many folk with strong family or social support, will be accessing this help over the traditional cuppa at the kitchen table. It is the folk who are more socially isolated who might need access to more formal counselling, but I suspect they are also the ones least likely to be offered the help.)

 

The obvious choice, as you suggest, is old fashioned counselling. It used to be done by GPs and by psychiatrists - no need to call it anything more fancy.

But like butter in a dish, counselling has been replaced by the little packages at the checkout.

Counselling by someone other than family and friends is probably useful for a lot of people. Having someone neutral and experienced to talk to rather than parents or ex-partners may be very important. Unfortunately, if that person sees themselves as delivering 'talking therapy' based on some crackpot psychological theory that has never been subjected to proper testing the result may be a disaster.

 

I don't teach anyone anything when I say that but, when a person is in depression, most of the time, he (or she) first and foremost needs to be listened to and heard in what they personally experience in their life. It has nothing to do with a recipe learned in advance and made for everyone. And yes, sometimes it is easier to confide in someone outside of our context of life.

But choosing the right person or the right professional to be accompanied, everything is there isn't it?

The too many stories of abuse by TCC therapists that I have heard in the UK make me say, beyond any doubt, that you are so right to demand a system to assess and denounce the harms of these therapies to your government.

 

I think I had real depression once which fit the usual description as mood disorder fairly well. Then I experienced despair as my life was falling apart due to ME/CFS and I was being blamed for it rather than being understood and helped. This was an injustice.

In the second case, I'm sure it would have been terrible to apply any sort of therapy that didn't involve a lot of attentive listening and trust building.

The first depression was a biological thing. The second was adverse life events plus unfavorable social context and a lack of maturity to handle such terribly difficult situations well.

 

I'm sorry but the idea that millions of people, in the UK alone, live with mild depression needing "cognitive rehabilitation" or therapy is absurd. It's a complete misunderstanding and/or misinterpretation of the underlying data.

It's equally absurd that no one seems to question the validity of this interpretation, in a field that is plagued with that very problem in every nook and cranny. The default reflex in medicine to mindless slap psychological labels on everything has lead medicine completely astray. All because medicine simply can't deal with the fact that they still have more to understand than they have so far. Reeks of immaturity.

 

How awful that your friend feels ashamed when it was sold to him as something that works. (And that he had a bad experience.) It's normal that he went along with it. Despite what is claimed, the patient-therapist relationship is an unequal one, which the therapist has to keep an eye on. You think you're in good hands, and are expected to trust the therapist, so of course you go along with things because you think the therapist is the expert who knows that this will work.
I recently saw a Twitter thread with a lot of women who were criticising CBT from their experiences with it for trauma, saying it made everything worse. Because it is based on the notion of the client having distorted cognitions that need to be "fixed", it also harmed by encouraging people to accept an abusive relationship, or missing things like how someone's life situation was bad, or someone being neurodivergant, having ADHD, or hypothyroidism etc, which was the actual problem that could not be "treated" with CBT.

I'm glad to hear your friend has found actual help and is doing better!