The Tavistock’s view of depression and what the draft NICE guidelines may be missing
20 September 2017
For 2016's National Depression Awareness Week I gave an account, along with my colleague Dr David Bell, Consultant Psychiatrist in Psychotherapy, of the way many of the experienced clinicians and researchers here at the Tavistock conceptualise depression and the implications this has for how we believe we need to approach this long term condition. We are not alone in this conceptualisation. You can read that article here.
Depression is a term that covers a multitude of human problems. For most sufferers, the difficulties express themselves in a different way; but the degree of suffering should not be underestimated. Many make attempts to take their own lives and the condition can limit lives considerably. Depression is often associated with feeling a deep sense of pointlessness, having difficulty in sustaining any feeling of pleasure or enjoyment, and people with depression view themselves very negatively. They have great difficulty in forming relationships, or the relationships they have become easily contaminated with the feelings of pointlessness.
Whereas an infectious illness starts at a definable point and has a course limited to weeks and months, depression is different; increasingly we have come to recognise that depression is not best thought of as an acute illness but as a long term condition. This summer NICE published its draft guidelines “Depression in adults: treatment and management”. Last week we submitted our response to these. This was not an easy task. The draft guidelines are lengthy with a selective review of the research into some treatments (both psychotherapeutic and pharmacological) for depression.
Some might say that what we encounter at the Tavistock is the more severe and complex end of the caseload and that our view is skewed by this. We worked on our response with colleagues across different clinical services and academia to inform our comments and suggestions with the latest clinical outcome data and research. But fundamentally, it is this view of depression as a condition which needs to be managed, much like diabetes or asthma, rather than an infection with a clearly discernible beginning, middle and end or cause, intervention and cure, which underlines our belief that patients deserve more than is currently being proposed.
Many people who are depressed recognise that they have been so for very many years – sometimes since childhood or adolescence. Although they may have managed to have relationships, work, etc., they are rarely without the feeling of the depressive shadow threatening to overwhelm them at any moment and when it does, they soon give up on things and retreat from normal life. Even when things are going well, they are very often continually anxious that the pleasure will soon dissipate and the shadow will overwhelm them again.
It is thus more appropriate here, and in fact in the majority of cases, to understand the depression as part of what a person is, part of their personality. The depression, in this sense, is an authentic expression of their lives and its contents, and the negative thoughts and feelings need to be seen and respected as very important meaningful communications. For this reason, approaches that overemphasise the value of medication such as antidepressants and underemphasise the need for a person to understand this important part of their nature, may well increase the feelings of alienation and leave the individual feeling very short-changed. While medication may have a role to play, in many cases this is limited. And although some individuals will benefit from relatively brief courses of psychological treatment, we have found that many require considerably more help.
Central to our approach at the
Tavistock is the understanding of depression as a meaningful communication
about the person’s life history and current circumstances. All individuals
referred to the Trust’s Adult services will have a number of in-depth
consultations to understand the nature of their difficulties. Where
psychotherapy is a realistic option, individuals will often receive a course of
treatment lasting 12 months, sometimes 18 months, sometimes even longer.
A recent study carried out by senior clinicians and researchers at the Tavistock was published in the journal World Psychiatry, in 2016. The Tavistock Adult Depression Study, now widely-quoted, found that many patients – all of whom had struggled with longstanding depression and had not been helped by other (often briefer) therapies – showed real benefit after more than a year of treatment. The study also demonstrated that the benefit of this therapy often continued increasing after the treatment had ended. Thus the therapy had helped the person onto a developmental trajectory which continued beyond the clinical sessions. The study also showed that many individuals had been depressed for much of their lives. Sadly this was overlooked in the review of the evidence.
So while some briefer therapies may sometimes help with certain symptoms, especially with patients with relatively mild, recently diagnosed depression, a longer therapy, focusing on guilt, loss, attachments, relationships, and a propensity to lose the capacity to value good things in one’s life, is often the only route to a more longstanding understanding and recovery.
The draft guidelines continue to give much emphasis to cognitive behavioral therapy (CBT) with almost no place in the guidelines for other modalities of psychotherapy, even when the evidence base is strong for both long term and short term psychoanalytic psychotherapy, and when patient choice is often pro-psychoanalytic psychotherapy. Psychological treatments generally have more widespread acceptance than medication from service users, with a recent meta-analysis suggesting a three-fold preference for psychological treatment. It is also increasingly recognised that individuals wish to have a choice of psychological treatment options, and that the provision of such choice may improve treatment engagement and outcome.
The ‘Increasing Access to Psychological Therapies’ service (IAPT), established in 2008, represented a major expansion in access to talking treatments. However within a tightly defined model focused primarily on CBT it has faced challenges in being able to respond adequately to the breadth of needs experienced by patients presenting with depression.
Dr Susan McPherson, Senior Lecturer at the University of Essex, has also just published a blog, Guidelines for Depression: More Gourmet Nights from NICE. It argues for a radically different way of approaching depression and its sufferers who, like many with long-term conditions, are often experts in themselves.
Along with other organisations in our field, the Tavistock and Portman NHS Foundation Trust has responded formally to the draft guidelines highlighting these issues. We have argued for the need for a much greater emphasis on patient choice and for a clearer recognition of those patients who experience severe and chronic depression for whom a short programme of CBT is unlikely to be successful.
Depression is one of the most significant health issues facing western societies in the 21st century. In recommending clinical best practice NICE in this area needs to demonstrate a broad approach, grounded in the full range of available evidence, respecting patient choice and recognising the range in the type and severity of symptoms with which patients present. In depression one size does not definitely fit all.
By Dr Julian Stern, Director of Adult and Forensic Services
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The Tavistock Adult Depression Study (TADS) is the first randomized controlled trial in the NHS to establish if long term psychoanalytic...