Clare Taylor

Depression in adults, including those with a chronic physical health problem: summary of NICE guidance

Each year 6% of adults will experience an episode of depression, and over the course of a person’s lifetime more than 15% of the population will have an episode.1 2 3 4 Depression (as defined by the American Psychiatric Association5) is the leading cause of suicide and currently the fourth highest disease burden on society in terms of its treatment costs, its effect on families and carers, and its impact on productivity in the workplace. Depression can be disabling and distressing and for many people can become a chronic disorder, especially if inadequately treated. It is about two to three times more common in people with a chronic physical health problem than in people who are in good physical health.6 Chronic physical health problems can precipitate and exacerbate depression, but depression can also adversely affect outcomes of coexisting physical illnesses, including increased mortality. Furthermore, depression can be a risk factor for some physical illnesses, such as cardiovascular disease.7 This article summarises the most recent recommendations on depression from the National Institute for Health and Clinical Excellence (NICE): an updated guideline on the management and treatment of depression in adults8 and a new guideline on depression focusing on adults with a chronic physical health problem.9 In both guidelines diagnosis was based on the criteria of the Diagnostic and statistical manual of mental disorders , fourth edition (DSM-IV), which require the presence of at least five symptoms and of impaired function persisting for at least two weeks.5 NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, recommendations are based on the experience and opinion of the Guideline Development Group (GDG) of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. …

Recognition, intervention, and management of antisocial behaviour and conduct disorders in children and young people: summary of NICE-SCIE guidance

Antisocial behaviour and conduct disorders (including oppositional defiant disorder and conduct disorder) are the most common mental and behavioural problems in children and young people globally, with the frequency increasing in Western countries.1 In the United Kingdom 5% of mental and behavioural problems in children and young people (≤ 18 years) meet criteria for a conduct disorder, as do almost 40% of looked-after children, children who have been abused, and those on child protection or safeguarding registers.2 Conduct disorders are strongly associated with poor performance at school, social isolation, substance misuse, and involvement with the criminal justice system.3 A large proportion of children and young people with a conduct disorder will go on to be antisocial adults with impoverished and destructive lifestyles,3 especially if the conduct problems develop early,4 and a large minority will be diagnosed with antisocial personality disorder.5 Antisocial behaviour and conduct disorders often coexist with other mental health problems, place a heavy personal and economic burden on individuals and society,6 and involve a wide range of health, social care, educational, and criminal justice services. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on recognising and managing antisocial behaviour and conduct disorders in children and young people.7 The guideline was developed jointly with the Social Care Institute for Excellence (SCIE). NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Working safely and effectively Health and social care professionals working with children and young people who present with behaviour suggestive of a conduct disorder, …

Management of psychosis and schizophrenia in adults: summary of updated NICE guidance

Psychosis is relatively common, with schizophrenia being the most prevalent form of psychotic disorder, affecting about seven in 1000 adults, with onset typically occurring between the ages of 15 and 35.1 These disorders, which are characterised by distressing hallucinations and delusions, disturbed behaviour, and memory and motivation problems, present a major personal,2 social,3 clinical,4 and financial5 challenge. Moreover, poor physical health is strongly associated with schizophrenia, with men dying 20 years earlier than the general population and women dying 15 years earlier,6 7 mainly from illnesses such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease, HIV infection, hepatitis C, and tuberculosis.8 Difficulties in people with severe mental illness accessing general medical services in primary and secondary care contribute to reduced life expectancy.9 Although many people with psychosis and schizophrenia respond to antipsychotic drugs initially, around 80% relapse within five years, partly because they discontinue medication,10 which for many people has unacceptable side effects. However, although around 75% of people with schizophrenia recurrently relapse and have continued disability,10 there is a moderately good long term global outcome in over half.11 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on managing psychosis and schizophrenia in adults.12 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Care across all phases—physical health

Diagnosis, assessment, and management of harmful drinking and alcohol dependence: summary of NICE guidance

Alcohol dependence affects 4% of people aged between 16 and 65 years in England (6% of men and 2% of women),1 and over 26% of all adults (38% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or wellbeing. Yet currently only 6% of people who are alcohol dependent receive treatment.1 Alcohol dependence is characterised by withdrawal, craving, impaired control, and tolerance of alcohol and is associated with a higher rate of mental and physical illness and a wide range of social problems. Harmful drinking is a pattern of alcohol consumption that can lead to psychological problems such as depression, accidents, injuries, and physical health problems such as pancreatitis. Alcohol misuse is also an increasing problem in children and young people, with over 24 000 treated in the NHS for alcohol related problems in 2008 and 2009.2 Hospital admissions related to alcohol consumption increased by 81% between 2003 and 2009.3 Harmful drinking and alcohol dependence therefore represent a considerable burden to individuals, their families, and wider society. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis, assessment, and management of harmful drinking and alcohol dependence.4 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Identification and initial assessment

Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance

Social anxiety disorder is one of the most persistent and common of the anxiety disorders, with lifetime prevalence rates in Europe of 6.7% (range 3.9-13.7%).1 It often coexists with depression, substance use disorder, generalised anxiety disorder, panic disorder, and post-traumatic stress disorder.2 It can severely impair a person’s daily functioning by impeding the formation of relationships, reducing quality of life, and negatively affecting performance at work or school. Despite this, and the fact that effective treatments exist, only about half of people with this condition seek treatment, many after waiting 10-15 years.3 Although about 40% of those who develop the condition in childhood or adolescence recover before adulthood,4 for many the disorder persists into adulthood, with the chance of spontaneous recovery then limited compared with other mental health problems. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on recognising, assessing, and treating social anxiety disorder in children, young people, and adults.5 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Principles for working with all people with social anxiety disorder When the person arrives for the appointment, offer to meet them or alert them …

Borderline and antisocial personality disorders: summary of NICE guidance

Personality disorders are common, with an estimated prevalence in the community of 4.4%.1 They can significantly impair personal and social functioning, with considerable cost to health services, society, the criminal justice system, and the individual. Of the 10 classified types of personality disorder, borderline and antisocial personality disorder are the most prominent in forensic and general psychiatric settings. People with borderline personality disorder tend to have volatile relationships, an unstable self image, labile affects, and impulsiveness; they also frequently self harm. People with antisocial personality disorder characteristically break rules routinely; engage in criminal behaviour; and have a strong tendency to be reckless, irresponsible, and deceitful. People with both disorders often report a history of serious family problems, domestic violence, abuse, and inconsistent and often violent punishment in childhood. Separate guidelines were developed for these two disorders because of differences in diagnostic criteria and contact with services. People with borderline personality disorder tend to be “treatment seeking,” whereas the antisocial group are “treatment resisting,”2 and they are unlikely to come into contact with services except for the treatment of comorbid conditions or when legally mandated to attend treatment programmes.3 This article summarises the key recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of both borderline and antisocial personality disorder.2 3 Because about 50% of children with conduct disorder develop antisocial personality disorder, the guideline for this disorder includes preventive strategies—namely, interventions for conduct disorder in childhood and adolescence. NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### The role of psychological treatment

Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance

Psychosis, including schizophrenia, comprises a major group of psychiatric disorders characterised by hallucinations and/or delusions (psychotic symptoms) that alter perception, thoughts, affect, and behaviour, and which can considerably impair a child or young person’s development, relationships, and physical health. Schizophrenia is estimated to affect 1.6 to 1.9 per 100 000 in the child population,1 2 with prevalence increasing rapidly from age 14.3 Psychosis and schizophrenia in children (age 12 years and under) and young people (up to age 17 years) are leading causes of disability4 and are more severe and have worse prognosis than if onset is in adulthood, owing to disruption to social and cognitive development. Young people with schizophrenia tend to have a shorter life expectancy than the general population, largely because of suicide, injury, or cardiovascular disease,5 the last partly from antipsychotic medication. Children and young people with transient or attenuated psychotic symptoms are at increased risk of developing psychosis or schizophrenia,6 and delayed treatment can impair longer term outcomes,7 making early recognition and intervention crucial. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) guideline on psychosis and schizophrenia in children and young people.8 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### General principles of care Health and social care professionals working with children and young people with psychosis or schizophrenia should be trained and competent to work with children and young people with mental health problems of all levels of learning ability, cognitive capacity, emotional maturity, and development. [ Based on the …

Service user involvement in clinical guideline development and implementation: Learning from mental health service users in the UK

Abstract The participation of service users and the public in the development of clinical guidelines is increasingly valued in international guideline programmes. This paper extends the findings of Harding et al.s (2010) exploration of the views of service users who participated in developing NICE mental health guidelines. This analysis considered the relative value of personal versus professional knowledge and experience, the barriers to service users contributing effectively in guideline development, the unspoken ‘rules’ concerning decision making, and issues of power and group dynamics. We combine these insights with observations from research in guideline development and with advances in the recovery movement and in the shared decision-making clinical model to suggest areas of improvement in guideline development, notably: translating evidence to recommendations, optimizing the acceptability of treatment recommendations to service users, and reconciling different types of knowledge.

Identification and care pathways for common mental health disorders: summary of NICE guidance.

At any one time, as many as 15% of people in the United Kingdom1 experience common mental health problems such as depression and anxiety disorders, including generalised anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. These may cause considerable impairment and disability, with high costs for both the person and society. Most people who are diagnosed with a common mental health disorder (about 80%) are treated in primary care2; however, there is widespread under-recognition of depression and anxiety disorders.3 4 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) to improve identification of common mental health disorders, access to services, and pathways to care.5 The guideline also adopted or adapted treatment recommendations from existing NICE guidance on depression,6 7 generalised anxiety disorder and panic disorder,8 post-traumatic stress disorder,9 obsessive-compulsive disorder,10 and antenatal and postnatal mental health11 and organised them into a common stepped care framework. NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com. ### Identification of common mental health disorders If a person answers “yes” to either of the above questions consider depression and follow …

Quality, bias and service user experience in healthcare: 10 years of mental health guidelines at the UK National Collaborating Centre for Mental Health

Abstract The guideline programme developed by the National Collaborating Centre for Mental Health (NCCMH) for the National Institute for Health and Clinical Excellence (NICE) is probably the most comprehensive and methodologically advanced mental health guideline programme in the world, covering most adults and children with mental health problems and addressing a broad range of pharmacological and psychological/psychosocial interventions. As the success of the NICE programme gains momentum, its influence in the National Health Service (NHS) grows. If guidelines contain systematic bias the effects will be widespread. Over the last 10 years the NCCMH has recognized imperfections and patterns of bias in the way that evidence is generated and included in guidelines, including psychological/psychosocial interventions and drug treatments. The pharmaceutical industry remains a major source of bias through selective reporting and publishing, and represents a threat to ensuring the evidence underpinning guidelines and clinical decision-making is as complete and reliable as possible. The inclusion of service users into guideline development at the NCCMH has developed in parallel to the identification and understanding of evidential bias, and is now becoming an important focus for high-quality guidelines which are becoming increasingly person-centred. For mental health this is as radical as the integration of psychological/psychosocial treatments into what has, for many years, been a largely medical domain. The future role of service users in monitoring their own experience of care and ensuring that trusts are accountable to them is now a real possibility and is likely to have an impact upon the traditional power relations in mental health and the stigma usually associated with psychiatric problems.