Depression in adults according to NICE NG222: the treatment decision tree, step by step

What depression covers here

The guideline defines depression by the absence of positive affect, low mood and associated emotional, cognitive, physical and behavioural symptoms, and refers to ICD-11 or DSM-5 for detail. Severity is a continuum made of three elements: symptoms, duration, and impact on personal and social functioning. PEB summary, not a quotation.

What specialist care should include (1.12.1)

• a risk assessment;
• an assessment of needs;
• a programme of coordinated multidisciplinary care;
• access to psychological treatments, after improvement of acute psychotic symptoms.

Discuss the options and, for people who have capacity, reach a shared decision. PEB summary of a list.

The same threshold, written twice

Page 7 presents it as an example: thresholds on validated scales were used as an indicator of severity, and a PHQ-9 score of 16 is given “for example”. Page 86, in Terms used in this guideline, the same threshold becomes a definition, “was defined as”. The page 7 sentence also lacks a comparison sign before 16, in the PDF and on the NICE web page alike. The tree quotes the definition and shows the gap.

Not the usual PHQ-9 bands

The PEB page on the PHQ-9 gives the authors’ conventional bands at 5, 10, 15 and 20, and a screening threshold of 10. The 16 used by NG222 is neither: it is this guideline’s own line between its two levels. The PHQ-9 on PEB (in French).

What the discussion provides (1.3.3)

• information on the treatments NICE recommends, their benefits and harms, waiting times and expected outcomes;
• a choice of treatment, of format (individual or group, in person or remotely) and of place;
• the option of attending with a family member or friend;
• the option of choosing the gender of the professional, keeping a professional already known, or changing if the relationship does not work.

Section 1.3.1 also asks what the person thinks contributed to the depression, their previous episodes and treatments, and what they hope to gain. PEB summary of lists.

Table 2, in the order NICE gives

Combination of individual cognitive behavioural therapy (CBT) and an antidepressant ; Individual CBT ; Individual behavioural activation (BA) ; Antidepressant medication ; Individual problem-solving ; Counselling ; Short-term psychodynamic psychotherapy (STPP) ; Interpersonal psychotherapy (IPT) ; Guided self-help ; Group exercise.

1.6.1 states that all these treatments can be used first line. The table title gives the order as the committee’s interpretation of clinical and cost effectiveness and of implementation factors: it is not a ranking of evidence.

What the table says about antidepressants

SSRIs are described as generally well tolerated, with a good safety profile, to be considered as the first choice for most people; TCAs are dangerous in overdose, lofepramine having the best safety profile. A first review usually within 2 weeks, at 1 week for a new prescription between 18 and 25 years or when there is a particular concern about suicide. Typically taken for at least 6 months, with regular reviews. For guided self-help and group exercise, the table asks to weigh first the advantages of options with more therapist contact. PEB summary of table 2.

Table 1, in the order NICE gives

Guided self-help ; Group cognitive behavioural therapy (CBT) ; Group behavioural activation (BA) ; Individual CBT ; Individual BA ; Group exercise ; Group mindfulness and meditation ; Interpersonal psychotherapy (IPT) ; Selective serotonin reuptake inhibitors (SSRIs) ; Counselling ; Short-term psychodynamic psychotherapy (STPP).

1.5.2 asks to take into account that all these treatments can be used first line, but to consider first the least intrusive and least resource intensive, guided self-help, and to recognise the right to decline treatment. The rationale places guided self-help first “for pragmatic reasons”; the rest of the order follows the committee’s consensus on average effectiveness and cost effectiveness (page 97).

Guided self-help, as table 1 describes it

Printed or digital materials built on structured CBT, structured behavioural activation, problem-solving or psychoeducation, with support from a trained practitioner, usually 6 to 8 structured regular sessions. PEB summary.

The rest of 1.4.3, and the antidepressant timetable

1.4.3 also asks to monitor concordance, side effects and harms, and suicidal ideation, particularly in the early weeks, and to consider routine outcome monitoring with validated sessional measures, for example the PHQ-9. For antidepressants, 1.4.11 sets the first review usually within 2 weeks, or 1 week after starting for a new prescription between 18 and 25 years or when there is a particular concern about suicide, and says the effect, if the drug is going to work, usually shows within 4 weeks. PEB summary.

The rest of 1.12.5, and how to stop

Whether and when to stop the antipsychotic is decided by specialist services or in consultation with them. 1.4.37: antipsychotics are stopped only in or with advice from specialist services, gradually over at least 4 weeks and in proportion to the length of treatment.

Why Not routinely

The refusal carries its exception in its own text: the second sentence names the only situation in which to offer medication. It targets antidepressant medication as a class, not SSRIs alone. NICE amended it in October 2025 to clarify its advice on first-line treatment for less severe depression (Update information, page 110).

What the committee adds

If an antidepressant is used at this level of severity, the committee advised that SSRIs would be preferred, because of their safety and tolerability (rationale, page 97). Table 1 lists SSRIs ninth of eleven options.

What 1.5.1 asks for

• discuss the presenting problems, underlying vulnerabilities and risk factors, and the person’s concerns;
• make sure the person knows they can change their mind, and how to seek help;
• provide information on the nature and course of depression;
• arrange a further assessment, normally within 2 to 4 weeks;
• make contact, with repeated attempts if necessary, if the person does not attend.

PEB summary of a list.

What to discuss (1.9.1)

• personal, social or environmental factors, or physical or other mental health conditions, that might explain why the treatment is not working;
• problems adhering to the plan, for example stopping or reducing medication because of side effects, or missing sessions.

If any of these apply, reach a shared decision on how to address them, including the help other agencies may give. PEB summary of a list.

Three recommendations, three starting points

1.9.4 after psychological therapy alone, 1.9.5 after an antidepressant alone, 1.9.6 after a combination. Each asks to discuss the options and reach a shared decision. 1.9.7 adds that vortioxetine is recommended in a separate NICE technology appraisal, TA367, after no or limited response to at least 2 antidepressants within the current episode; TA367 is not in the PEB corpus.

The options of 1.9.5

• adding a group exercise intervention;
• switching to a psychological therapy, among the options for more severe depression;
• increasing the dose within the licensed range if well tolerated, knowing that higher doses may not be more effective and can increase side effects, with frequent follow-up;
• switching to another drug of the same class, or of a different class (an SSRI, an SNRI, or in secondary care a TCA or an MAOI), with cross-tapering if needed, any MAOI switch in or with advice from secondary care, and TCAs dangerous in overdose;
• changing to a combination of psychological therapy (for example CBT, IPT or STPP) and medication.

PEB summary of a list.

Why this card carries the trunk

1.9.8 and 1.9.9 continue this situation only: they concern a person whose depression “has had no response or a limited response to antidepressant medication”.

The three options of 1.9.6

• switching to another psychological therapy;
• increasing the dose or switching to another antidepressant, as in 1.9.5;
• adding in another medication, as in 1.9.9.

The three options of 1.9.4

• switching to an alternative psychological treatment;
• adding an SSRI to the psychological therapy;
• switching to an SSRI alone.

After a discussion that includes what other treatments the person has found helpful in the past.

The three alternative conditions

• the person chooses ECT based on their past experience of ECT and what has worked for them;
• a rapid response is needed, for example when the depression is life-threatening because the person is not eating or drinking;
• other treatments have been unsuccessful.

Life-threatening depression is the example of the second condition, not a fourth condition. PEB summary of a list.

The options of 1.9.9

• adding an antidepressant from a different class, for example mirtazapine or trazodone with an SSRI;
• combining an antidepressant with a second-generation antipsychotic (for example aripiprazole, olanzapine, quetiapine or risperidone) or with lithium;
• augmenting with ECT, lamotrigine or liothyronine.

Some combinations are dangerous and to be avoided, for example an SSRI, SNRI or TCA with an MAOI. With an antipsychotic, its effects on depression, including loss of interest and motivation, are to be reviewed carefully. In June 2022 some antipsychotics, lamotrigine and liothyronine were off-label for this use. PEB summary of a list.