Download Guidelines for Initiating Psychological Therapy in Moderate to

Guidelines for Psychological Therapy in Moderate to Severe Depression
DEPRESSION ICP
Suitability
Depression-focused psychological therapy is appropriate if the individual concerned:
 is psychologically minded (i.e. they demonstrate some insight and selfawareness)
 is motivated to change
 has a personal preference for psychological therapy
 has had limited success with antidepressant drug therapy
Choice of psychological therapy:
At least one session should be spent on assessment for suitability for psychological
therapy. It is expected that the first treatment offered would be based on CBT, but
consideration should be given to behavioural interventions and problem solving,
especially for those for whom written tasks would be difficult.
The principal is matched care – the least input required to achieve a good outcome.
Thus the psychological therapist should, in collaboration with the user, consider
guided self-help as well as 1:1 or group therapy. The frequency, duration and number
of sessions will be determined by patient need. It is expected that within primary care
the average number of contacts will be 6.
Outcomes
If there is no response after 4 sessions the therapist should review with supervisor and
consider a second opinion/change of approach. This may include consideration of
medication if this has not already been tried.
Partial response after 6 sessions may lead to further sessions after discussion with
supervisor.
Non-response or minimal response after 6 to 8 sessions, consider referral to secondary
care after discussion with supervisor.
Other presenting factors
It is likely that some users will present with other problems as well as low mood. A
history of sexual abuse and PTSD are to be dealt with by Psychological Therapist in
the first instance. Significant complexity would be discussed at supervision and
referral onwards would be arranged if required.
Social Factors Should be addressed through signposting – with referral to the Doing
Well Advisor if required.
Laura Mitchell Assistant Psychologist
NHS BORDERS
Michael Henderson Consultant Clinical Psychologist
Algorithm for Depression-Focused Psychological Therapy
Note: Input above line most likely to be the main intervention and occurring in a
primary care setting. More severe/treatment resistant presentations (in shaded area)
would be seen as part of a secondary care (MDT) treatment plan.
Moderate →
severe
depression
DEPRESSED
MOOD
Mild depression/low mood:
appropriate self-help and
signposting matched to need is
usually more beneficial before
trying psychological therapy
Unsuccessful
antidepressant drug
therapy OR personal
preference
Assessment for Psychological Therapy
Consider:
 Patient preference
 Severity/level of need
 Other psychological/social factors
 Past response to psychological therapy
Self-Help and Signposting interventions
appropriate to identified need. This could lead
to the uptake of the following interventions:
-Individually tailored exercise plan.
-Targeted signposting to local or national
statutory or voluntary organisations.
-Level 2/3 self-help material (Doing Well)
- Guided CBT self-help. (Manual or Web)
Lower
level
severity/
needs
Moderate
level
severity/
needs
Self-help
not
appropriate
/effective
Brief Psychological Therapy
 Usually 6-8 sessions over 1012 weeks
TREATMENT INEFFECTIVE
 Re-consider:
o severity/level of needs
o changing or combining modes of
treatment (e.g. antidepressant drugs)
o therapeutic alliance
o type of therapy
o patient motivation, etc.
Longer-Term specialist
Psychological Therapy
 Usually 16-20 sessions over
6-9 months within a team
setting
Laura Mitchell Assistant Psychologist
NHS BORDERS
Treatment
Resistant/Recurrent/Chronic
Depression
 Agree longer term care plan for
therapy e.g. see every 6 months
 Include maintenance
treatment/booster sessions
Michael Henderson Consultant Clinical Psychologist