This guideline has been developed to advise on common mental health disorders. The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, people with a common mental health disorder, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with a common mental health disorder, while also emphasising the importance of the experience of care for them and their families and carers (see Appendix 1 for more details on the scope of the guideline).
Although the evidence base is rapidly expanding there are a number of major gaps, and future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence. In the meantime, it is hoped that the guideline will assist clinicians, and people with a common mental health disorder and their families and carers, by identifying the merits of particular approaches where the evidence from research and clinical experience exists.
1.1. NATIONAL CLINICAL GUIDELINES
1.1.1. What are clinical guidelines?
Clinical practice guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate the evidence relating to the specific condition in question. Where evidence is lacking, the guidelines incorporate statements and recommendations based upon the consensus statements developed by the Guideline Development Group (GDG).
Clinical guidelines are intended to improve the process and outcomes of health-care in a number of different ways They can:
provide up-to-date evidence-based recommendations for the management of conditions and disorders by healthcare professionals
be used as the basis to set standards to assess the practice of healthcare professionals
form the basis for education and training of healthcare professionals
assist patients and carers in making informed decisions about their treatment and care
improve communication between healthcare professionals, patients and carers
help to identify priority areas for further research.
1.1.2. Uses and limitation of clinical guidelines
Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high-quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals with a common mental health disorder.
Although the quality of research in this field is variable, the methodology used here reflects current international understanding on the appropriate practice for guideline development (Appraisal of Guidelines for Research and Evaluation Instrument [AGREE]; www.agreecollaboration.org; AGREE Collaboration, 2003), ensuring the collection and selection of the best research evidence available and the systematic generation of treatment recommendations applicable to the majority of people with a common mental health disorder. However, there will always be some people for whom and situations in which clinical guideline recommendations are not readily applicable. This guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with a common mental health disorder and their family or carer.
In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations of the clinical guidelines. While national guidelines are concerned with clinical and cost effectiveness, issues of affordability and implementation costs are to be determined by the National Health Service (NHS).
In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In addition and of particular relevance in mental health, evidence-based treatments are often delivered within the context of an overall treatment programme, including a range of activities the purpose of which may be to help engage the person and provide an appropriate context for the delivery of specific interventions. It is important to maintain and enhance the service context in which these interventions are delivered otherwise the specific benefits of effective interventions will be lost. Indeed, the importance of organising care in order to support and encourage a good therapeutic relationship is at times as important as the specific treatments offered.
1.1.3. Why develop national guidelines?
The National Institute for Health and Clinical Excellence (NICE) was established as a Special Health Authority for England and Wales in 1999, with a remit to provide a single source of authoritative and reliable guidance for service users, professionals and the public. NICE guidance aims to improve standards of care, diminish unacceptable variations in the provision and quality of care across the NHS and ensure that the health service is patient-centred. All guidance is developed in a transparent and collaborative manner using the best available evidence and involving all relevant stakeholders.
NICE generates guidance in a number of different ways, three of which are relevant here. First, national guidance is produced by the Technology Appraisal Committee to give robust advice about a particular treatment, intervention, procedure or other health technology. Second, NICE commissions public health intervention guidance focused on types of activity (interventions) that help to reduce people's risk of developing a disease or condition, or help to promote or maintain a healthy lifestyle. Third, NICE commissions the production of national clinical practice guidelines focused upon the overall treatment and management of a specific condition. To enable this latter development, NICE has established four National Collaborating Centres in conjunction with a range of professional organisations involved in healthcare.
1.1.4. The National Collaborating Centre for Mental Health
This guideline has been commissioned by NICE and developed within the National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration of the professional organisations involved in the field of mental health, national service user and carer organisations, a number of academic institutions and NICE. The NCCMH is funded by NICE and is led by a partnership between the Royal College of Psychiatrists and the British Psychological Society's Centre for Outcomes Research and Effectiveness, based at University College London.
1.1.5. From national clinical guidelines to local protocols
Once a national guideline has been published and disseminated, local healthcare groups will be expected to produce a plan and identify resources for implementation along with appropriate timetables. Subsequently, a multidisciplinary group involving commissioners of healthcare, primary care and specialist mental health professionals, and service users and their carers should undertake the translation of the implementation plan locally, taking into account both the recommendations set out in this guideline and the priorities set in the National Service Framework for Mental Health (Department of Health, 1999) and related documentation. The nature and pace of the local plan will reflect local healthcare needs and the nature of existing services; full implementation may take considerable time, especially where substantial training needs are identified.
1.1.6. Auditing the implementation of clinical guidelines
This guideline identifies key areas of clinical practice and service delivery for local and national audit. Although the generation of audit standards is an important and necessary step in the implementation of this guidance, a more broadly-based implementation strategy will be developed. Nevertheless, it should be noted that the Care Quality Commission will monitor the extent to which Primary Care Trusts, trusts responsible for mental health and social care, and Health Authorities have implemented these guidelines.
1.2. THE NATIONAL COMMON MENTAL HEALTH DISORDERS GUIDELINE
1.2.1. Who has developed this guideline?
The GDG was convened by the NCCMH and supported by funding from NICE. The GDG included two people with a common mental health disorder, a carer and professionals from psychiatry, clinical psychology, general practice and nursing.
Staff from the NCCMH provided leadership and support throughout the process of guideline development, undertaking systematic searches, information retrieval, appraisal and systematic review of the evidence. Members of the GDG received training in the process of guideline development from NCCMH staff, and the service users and carer received training and support from the NICE Patient and Public Involvement Programme. The NICE Guidelines Technical Adviser provided advice and assistance regarding aspects of the guideline development process.
All GDG members made formal declarations of interests at the outset, which were updated at every GDG meeting. The GDG met a total of nine times throughout the process of guideline development. It met as a whole, but key topics were led by a national expert in the relevant topic. The GDG was supported by the NCCMH technical team, with additional expert advice from special advisers where needed. The group oversaw the production and synthesis of research evidence before presentation. All statements and recommendations in this guideline have been generated and agreed by the whole GDG.
1.2.2. For whom is this guideline intended?
This guideline will be relevant for adults with common mental health disorders including depression and anxiety disorders. It covers the care provided by primary, community and secondary care, and other healthcare professionals who have direct contact with and make decisions concerning the care of adults with common mental health disorders.
The guideline will also be relevant to the work, but will not cover the practice, of those in:
The experience of people with a common mental health disorder can affect the whole family and often the community. The guideline recognises the role of both in the treatment and support of people with common mental health disorders.
1.2.3. Specific aims of this guideline
The guideline makes recommendations for identification and pathways to care for people with common mental health disorders. It aims to:
review aspects of service delivery critical to the effective provision of clinical interventions for common mental health disorders
review aspects of service delivery critical to effective implementation of existing NICE guidelines covering these disorders
evaluate models of service delivery designed to promote access to services
evaluate the role of methods for identification and assessment
develop treatment and referral advice for common mental health disorders through adaptation and adoption of recommendations from existing NICE guidelines
evaluate the role of systems for organising and developing local care pathways for these disorders
consider the experience of care from the perspective of people with a common mental health disorder, and their families and carers
promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales.
1.2.4. The structure of this guideline
The guideline is divided into chapters, each covering a set of related topics. The first three chapters provide a summary of the clinical practice and research recommendations, a general introduction to guidelines and the topic, and to the methods used to develop this guideline. Chapter 4 to Chapter 7 provide the evidence that underpins the recommendations.
Each evidence chapter begins with a general introduction to the topic that sets the recommendations in context. Depending on the nature of the evidence, narrative reviews or meta-analyses were conducted, and the structure of the chapters varies accordingly. Where appropriate, details about current practice, the evidence base and any research limitations are provided. Clinical summaries are then used to summarise the evidence presented. Health economic evidence is then presented (where appropriate), followed by a section (‘From evidence to recommendations’) that draws together the clinical and health economic evidence, and provides a rationale for the recommendations. On the CD-ROM, Appendix 14 provides further details about clinical study characteristics.
