- Naomi Moller, Professor of Psychology and Psychotherapy at the Open University, President of the UK Chapter of the Society for Psychotherapy Research
- Dr Felicitas Rost, Research Lead, Tavistock and Portman NHS Foundation Trust, Lead for a coalition of stakeholders raising concerns about the NICE guideline for depression, Past President of the Society for Psychotherapy Research
Mental health guidelines might not be – at first glance – a topic that should inspire brouhaha, but the fight over the NICE Guideline for Depression in Adults has been long-running and noisy. The core claim is that the methodologies used to derive the guideline are flawed, which naturally casts doubts on NICE’s conclusions. If you can get past that, there is also the allegation that critical recommendations in the current (third) draft guideline are not supported by NICE’s own analyses. Brouhaha indeed.
While NICE ponders the feedback from yet another consultation on the guideline draft, it is worth reviewing the arguments.
What is NICE?
The National Institute for Health and Care Excellence (NICE) is an independent, but government-funded, body responsible for developing NHS health guidelines in England, with Wales and Northern Ireland often borrowing from the findings (Scotland has its own equivalent body). Drawing on existing research and conducting its own analyses, NICE aims to develop evidence-based guidelines that improve patient care. Hence the 2009 NICE Guideline for Depression in Adults: Recognition and Management aimed to “improve care for people with depression by promoting improved recognition and treatment.” Experience with NICE suggests that the organisation wants to be perceived as expert, competent, unflappable, impartial and – yes – right.
Brouhaha # 1: Delayed once – and again – and again
NICE guidelines are periodically updated in order to incorporate new research evidence. Part of the process involves a stakeholder consultation, in which individuals and organisations comment on the draft guideline. Following the consultation period, the draft may or may not be modified before the guideline is formally published. The 2009 depression guideline update process was launched in 2014, with the initial draft first released for public consultation in 2017 – and then again in 2018, and then again in 2021. Three rounds of public/stakeholder consultation are unprecedented for NICE, as is the fact that the guideline development team has now been asked three times to draw conclusions from the re-run analyses. To get an inkling of how unprecedented this is, think about Her Majesty the Queen Elizabeth jumping out a helicopter at the (then) age of 85. Yes, that sense of disbelief.
Brouhaha # 2: A broad swathe of stakeholders remain unconvinced
The delays in the publication of the depression guideline are (we modestly think) attributable to the 100 MPs and Peers and 50-organisation-strong coalition of mental health charities, service user groups, professional societies and psychotherapy researchers who have banded together to raise serious concerns about the guideline methodology and, consequently, its conclusions. In addition to
the three consultation periods and (so far) three drafts of the guideline, NICE has also stepped outside its own guideline development process by twice meeting with this coalition, presumably in an attempt to understand and resolve the concerns raised. In the first consultation meeting, a NICE spokesperson (male) sought to reassure (patronise) the coalition leader (female) that NICE really is an expert in research methodology. So – came the reply – am I. Reassurances since that NICE has met the coalitions concerns have been similarly unconvincing.
Brouhaha #3: NICE conclusions are not nice
The most recent draft guideline came with a very nice diagram to help patients, and their doctors, choose the best treatment for them. The new emphasis on client choice in this third draft guideline is welcome, given the solid evidence that offering therapy clients options about their treatment improves their outcomes (Swift, Callahan, Cooper & Parkin, 2018; Lindhiem, Bennett, Trentacosta & McLear, 2014). However, this diagram also included a hierarchy: Clients should be encouraged to choose treatment A; if they dislike A they could choose B; if they dislike B they could choose C (etc.). As argued by the coalition in response to the guideline, the problem with this is that NICE’s own network meta-analysis did not actually provide evidence that the treatments are differentially effective in any clinically meaningful way. Sometimes NICE will make recommendations from a pool of treatments that are more or less equivalent in terms of clinical effectiveness on the basis that one treatment is more cost effective. However, the guideline economic analyses – by admission of the independent researcher team that conducted them – showed high levels of uncertainty related to the relative effectiveness and cost effectiveness of all the interventions, including a high degree of uncertainty about estimates of cost. In other words, while the draft guideline recommendations imply that some treatments for depression in adults are better economically and clinically than others, the analyses do not actually evidence this.
Finazzi, E., & MacBeth, A. (2021). Service users experience of psychological interventions in primary care settings: A qualitative meta‐synthesis. Clinical Psychology & Psychotherapy.
Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: a meta-analysis. Clinical psychology review, 34(6), 506-517.
Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.