Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience

Figures & data

Table I. Summary of NICE's recommendations for the psychological treatment of depression and anxiety disorders.

Place in stepped-care service	Disorder	Recommended intervention
Step 3: High-intensity service (Primarily weekly, face-to-face, one-to-one sessions with a suitably trained therapist. In some disorders, such as depression, CBT can also be delivered effectively to small groups of patients. Behavioural couples therapy naturally involves the therapist, the depressed client and his/her partner)	Depression: moderate to severe	CBT or IPT^a, each with medication
	Depression: mild to moderate	CBT or IPT^a Behavioural activation (BA)^a,b Behavioural couples therapy (if the patient has a partner, the relationship is considered to be contributing to the maintenance of the depression, and both parties wish to work together in therapy) Counselling^a or short-term psychodynamic therapy^a (consider if patient has declined CBT, IPT, BA, or behavioural couples therapy)
	Panic disorder	CBT
	Generalized anxiety disorder (GAD)	CBT
	Post-traumatic stress disorder (PTSD)	CBT, EMDR
	Social phobia	CBT, EMDR
	Obsessive - compulsive disorder (OCD)	CBT
Step 2: Low-intensity service (Less intensive clinician input than the high intensity service. Patients are typically encouraged to work through some form of self-help programme with frequent, brief guidance and encouragement from a PWP who acts as a coach)	Depression	Guided self-help based on CBT, cCBT, behavioural activation, structured physical activity
	Panic disorder	Self-help based on CBT, cCBT
	GAD	Self-help based on CBT, psycho-educational groups, computerized CBT
	PTSD	n/a^c
	Social phobia	n/a
	OCD	Guided self-help based on CBT
Step 1: Primary care	Moderate to severe depression with a chronic physical health problem	Collaborative care (consider if depression has not responded to initial course of high intensity intervention and/or medication)

PWP, Psychological wellbeing practitioner; CBT, cognitive behavioural therapy; cCBT, computerized cognitive behavioural therapy; IPT, interpersonal therapy; EMDR, eye movement desensitization reprocessing therapy (considered by many to be a form of CBT); Behavioural activation is a variant of CBT; Active monitoring includes careful monitoring of symptoms, psycho-education about the disorder and sleep hygiene advice.

NICE has not yet issued guidance on the treatment of social phobia. However, there is a substantial body of evidence supporting the effectiveness of high-intensity CBT. Low intensity versions of CBT are being developed by several groups around the world and it seems likely that they will play a useful role in the future.

^aNICE's recent (NICE, 2009a, 2009b) updates on the treatment of depression come in two parts: recommendations for the treatment of ‘depression’ and recommendations for the treatment of ‘depression in adults with a chronic physical health problem’. The two guidelines are very similar. However, it should be noted that the ‘depression with a physical health problem’ guideline does not recommend IPT, behavioural activation, counselling or brief dynamic therapy as high-intensity interventions.

^bAlthough the recent update of the NICE guideline for depression (NICE, 2009a) recommends behavioural activation for the treatment of mild to moderate depression, it notes that the evidence base is not as strong as for CBT or IPT.

^cNICE does not recommend any low-intensity interventions for PTSD and recommends that you do NOT offer psychological debriefing.

Figure 1. Improvement in PHQ-9 and GAD-7 scores between initial assessment (pre-) and last available session (post-) in people who either completed both the pre- and post-treatment CORE-OM or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site. Figure derived from Clark et al. (2009).

Table II. Key IAPT reference documents (available at http://www.iapt.nhs.uk) with publication dates in parentheses, when relevant.

IAPT Implementation Plan: National Guidelines for Regional Delivery (February 2008)
IAPT Implementation Plan: Curriculum for High-Intensity Workers
IAPT Implementation Plan: Curriculum for Low-Intensity Workers
IAPT Impact Assessment (February 2008)
IAPT Equality Impact Assessment (February 2008)
IAPT Supervision Guidance
IAPT Commissioning Toolkit (April 2008)
Realising the Benefits: IAPT at Full Roll-Out (February 2010)
The Operating Framework for the NHS in England 2011/12
No Health Without Mental Health (February 2011)
Talking Therapies: A Four Year Plan (February 2011)
Which Talking Therapy for Depression? (March 2011)
Commissioning Talking Therapies for 2011/12 (March 2011)
IAPT Data Handbook 2 (June 2011)

NICE (2009a). Depression: Treatment and Management of Depression in Adults. Clinical Guideline 90. London: National Institute for Health and Clinical Excellence. Available at www.nice.org.uk>.

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NICE (2009b). Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. Clinical Guideline 91. London: National Institute for Health and Clinical Excellence. Available at www.nice.org.uk.

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Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R. & Wright, B. (2009) Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 47, 910–920.

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