For many people, depression is a distressing and debilitating (but also resolving) problem from which complete recovery is possible. For others, it is prolonged and disabling, running its course over many years. Depression of this type has profound effects on subjective health and wellbeing, relationships, and everyday functioning and activity.

The evidence for what helps people experiencing severe and long-term depression is thin, with current NICE guidelines on the recognition and management of depression in adults making the case for new research to improve the treatment and care of this group.

This new paper by Richard Morriss and colleagues, reported in The Lancet Psychiatry, is one response to this call.

Methods

People taking part in this large, multicentre, trial were recruited through secondary mental health services in three English NHS Trusts and were known to have persistent, moderate or severe, unipolar depression. The mean length of time since first receiving a diagnosis of depression was over 16 years, and on entry to the study each participant had an equal chance of being randomised to one of two groups.

In the first, patients received ‘specialist depression services’ (SDS), and in the second, treatment as usual (TAU). Distinguishing SDS from TAU is important. Here is a summary of the defining characteristics of SDS extracted from the detailed description given by Morriss et al.:

• Pharmacological and psychological treatments, as recommended by NICE, provided as a specialty service within specialist mental health care;
• A collaborative care approach involving close working between psychiatrists (with specialist interests in depression) and trained and experienced CBT therapists over a period of one year, followed by a careful transfer of care over an additional three months to either usual specialist mental health or primary care services;
• Proactive and individually tailored, specialist, medication management supported during periods of medication change by weekly or fortnightly review;
• Collaborative pharmacotherapy discussions involving all parties: psychiatrists, CBT therapists and service users;
• Individual weekly CBT sessions for up to 10 months, tapering towards the conclusion of treatment;
• Therapy being tailored to incorporate compassion-focused, vocational and occupational approaches, mindfulness and relapse prevention as necessary.

In contrast, TAU meant routine community mental health care: medications prescribed by psychiatrists, possible shared reviews with primary care colleagues, psychosocial interventions from nurses or others but with ‘little evidence […] of joint reviews of progress and regular professional meetings being used’, and ‘Responses to medication and treatment [were] reviewed only by the provider of the treatment’.

Participants’ health and functioning was assessed using the Hamilton Depression Rating Scale (HDRS) and the Global Assessment of Function (GAF), with scores recorded at baseline and at six monthly intervals thereafter. One of the research team’s reported aims was to treat people with long term, disabling, depression over an extended period, and to follow up participants for as long as 36 months. That’s an impressive, and unusual, commitment which is challenged by the likelihood of increasing numbers of people dropping out as time progresses. In this first paper, outcomes at up to 18 months are reported, along with the costs of providing SDS. Future papers reporting longer term outcomes are promised.

Results

• A total of 307 people were referred to the study, of whom 187 received either SDS or TAU. From these, 144 were assessed at 6 months’ follow-up, 134 at one year and 110 at 18 months.
• At six and 12 month follow-up, no significant differences between the SDS and TAU groups could be detected on either the HDRS or the GAF.
• However, at the 18 month follow-up, depression in the SDS group measured using the HDRS had improved significantly compared to depression in the group receiving usual care, although no significant improvements were found in functioning amongst the SDS group.
• It will be interesting indeed to see how outcomes compare for people in both groups at the two and three year follow-up points.
• For the economic analysis, the mean cost of staff time for the delivery of the SDS was £2,298 per patient.

Conclusions

A specialist depression service which:

1. integrates expert medication management with
2. CBT and other supportive therapies as appropriate and which
3. is delivered through a collaborative approach

might improve clinical outcomes for people with long-term, moderate to severe, depression.

What is not clear is what part, or parts, of the SDS approach contributed to the significant improvement in depression detected at 18 months (but not before). We will also need to wait to see how far improvements at 18 months are sustained at two and three year follow-up.

Links

Primary paper

Morriss R, Garland A, Nixon N, Guo B, James M, Kaylor-Hughes C, Moore R, Ramana R, Sampson C, Sweeney T, Dalgleish T. (2016) Efficacy and cost-effectiveness of a specialist depression service versus usual specialist mental health care to manage persistent depression: a randomised controlled trial, The Lancet Psychiatry, Available online 3 August 2016, ISSN 2215-0366. http://dx.doi.org/10.1016/S2215-0366(16)30143-2.

Other references

NICE (2009) Depression in adults: recognition and management. NICE CG90.