Depression

Prevalence of depression in children and young people is approximately 1-2% for pre-pubertal children, rising in early teens (more steeply for girls than boys) to 4-5% for mid-teens (8). The rates of raised depressive symptoms (or subthreshold depression) is much higher in adolescence with estimated 34% prevalence (9)

Depression is common in adults. The exact prevalence of depression varies depending on social situation, age, presence of comorbidities and the severity of depression experienced. In people aged 18-44 years, depression is the leading cause of disability and premature death, with a worldwide prevalence of 4.4%, and a UK prevalence of 4.5% (3). According to the Scottish Health Survey 2022, the proportion of adults in Scotland with two or more symptoms of depression was 13% for all adults, which is an increase in prevalence from an earlier survey in 2010/11 (prevalence was 7% among men(10) and 9% among women). Lower prevalence of symptoms of depression was recorded among people aged 75 and over at 7%, prevalence for 65-74 age group was 9% (11).  More than 50% of people experiencing a major depressive episode recover within 6 months, and nearly 75% within a year (3). In the longer-term, the proportion of people who recover drops to approximately 60% at 2 years, 40% at 4 years, and 30% at 6 years ⁽³⁾. With treatment, the majority of depressive episodes last about 3–6 months (3). All treatments including talking therapies as well as prescribed medication offer a range of benefits and costs in terms of side effects and the best options for an individual should be discussed openly, allowing individuals to understand and consider their own treatment decisions.

There are challenges in estimating prevalence rates of depression in people with intellectual disability, as studies vary in methodology and the application of diagnostic criteria.  Mental health presentations may also differ compared to those without intellectual disability.  Reported prevalence of depression in people with intellectual disability varies with a range of 3- 15% in adults across all levels of intellectual disability (12) and estimates of 4% in adults with mild intellectual disability (13) prevalence of depression in children and young people with all levels of intellectual disability is 2% (12).

This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with depression. This information is also for people diagnosed with depression, their families, and carers.

This topic introduction page covers evidence-based psychological interventions used to treat depression in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered. Depression commonly presents with other conditions, e.g. anxiety, substance use, PTSD and physical illness. The Matrix pages related to these topics may also be relevant.

Exclusions for topic: This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found in NICE guidance (2),(3).

There are a range of psychological interventions that could be included in the treatment tables for depression. However, in order to be consistent with a focus on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist, psychological interventions for the treatment of depression with low strength evidence and low levels of efficacy have not been included.

Evidence of overview for children and young people (CYP)

High quality evidence demonstrates that psychological interventions are effective for depression in children and young people (14). A stepped approach to care can be adopted in the management of CYP with depression. This approach takes into consideration the different needs of CYP with depression and the responses needed from health and social care services (2). However, decisions on the psychological intervention offered can also be guided by several factors, including severity of depression, patient and family’s capacity to access care, their clinical needs, developmental level and child and parent preferences (2). Options are listed in relation to new presentations of less severe depression (mild, subthreshold or dysthymia), more severe depression (moderate to severe) and chronic or comorbid depression.

Less severe depression

Children and young people with mild depression (without significant comorbid problems or active suicidal ideas or plans) can be offered digital/computerised formats of cognitive–behavioural therapy (CBT), group CBT, group interpersonal psychotherapy (IPT) or group non-directive supportive therapy as first line recommendation (2). As mentioned above, choice of intervention should be guided by several factors and delivered in line with the principles for delivering-effective-psychological-therapies-and-interventions-to-children-and-young-people. Individual CBT and attachment-based family therapy are also recommended as alternative interventions. In a stepped care model these would be applied if needs were not met by the digital or group recommendations.  The ability and wish to engage with computerised CBT, group or individual treatment approaches will vary with age and preference.

More severe depression

Children and young people with moderate to severe depression can be offered interventions adapted to developmental level. In 5- to 11-year-olds family-based IPT, family therapy (family-focused treatment for childhood depression and systems integrated family therapy), psychodynamic psychotherapy and individual CBT are recommended. In 12 to 18 year olds individual CBT is recommended as a first line intervention.  If individual CBT is unsuitable for the adolescent due to clinical needs, personal choice or circumstances then IPT for adolescents, family therapy (attachment based or systemic), psychodynamic psychotherapy, behavioural activation or brief psychosocial intervention can be alternatives.

The evidence for psychological interventions in younger children is based on fewer trials than in adolescents. There is a risk of bias in many trials on which the evidence is based with one meta-analysis finding 20% meeting all quality criteria in an analysis of 40 studies (14). More studies involve CBT and IPT than the other treatment options.  Group delivery format is more common in trials than individual treatment.

CBT can be delivered in several formats (including individual, group and face-to-face) with medium-large effect sizes (15),(16). Specific CBT intervention components - including cognitive work and behavioural activation can improve outcomes (15), as well taking into account the individual contextual and developmental needs (2). These factors can be considered when decisions are made regarding the content and context of delivery.

IPT can be delivered in group and individual format and a meta-analysis examining changes in depression symptoms post intervention revealed a large significant improvement in depression symptoms following IPT for adolescents (17),(18).

Lastly, NICE guidance for the management of depression in CYP includes recommendations for family therapies - family-focused treatment for childhood depression (FFT-CD) (2), (19),(20) and systems integrated family therapy in 5–11-year-olds as a first line option. In 12–18-year-olds family therapies are an alternative recommendation (attachment based or systemic) (2),(21) These recommendations have been based on a smaller number of trials.

One moderate quality RCT reported similar outcomes of Attachment-Based Family Therapy (ABFT) when compared to Family Enhanced Non-Directive Supportive Therapy (FE-NST) for reducing adolescents’ suicide ideation and depressive symptoms (21) and a meta-analyses which compared ABFT with other approaches found similar effects across family therapy approaches, and no statistically significant effect of family therapy approaches over other approaches such as IPT or CBT (22).

Treatment choices should be based on individual circumstances, clinical history and presentation, presence of co-existing neurodevelopmental disorders, learning disabilities or comorbidities, as well as patient and carer preferences (23). Interventions delivered should be adapted to developmental level as needed (23). Not all treatment options may be currently available in every setting. Family/caregiver involvement can improve treatment outcomes for CYP with depression and practitioners should involve the family where appropriate. However, the circumstances and form of involvement that are most associated with engagement and improvement are not yet fully determined (24).

Chronic or comorbid depression

Adolescents experiencing chronic or comorbid depression may benefit from combined treatment with psychological therapies and antidepressants (2). Monitoring to establish the benefits of both elements can be clinical helpful and the need for medication should be reviewed as per prescribing guidelines. Comorbid problems, such as anxiety, are common and the relevant Matrix topics should be consulted as appropriate.

 

Overview of evidence for adults

A collaborative approach to care should be considered in the management of people with depression. Pathways provided should promote access to care, choice, coordination and continuity of care, and facilitate integrated care delivery across services (3).

A range of treatments have proven efficacy, including pharmacological and other interventions such as exercise, which go beyond the scope of this guidance (see NICE, 2022 for a full review). The psychological intervention offered can depend on several factors including severity of depression, the patient’s capacity to access care, their clinical needs, and preferences (3). Options are listed in relation to new presentations of less severe depression (mild or subthreshold); new episodes of more severe depression (moderate and severe range) and for chronic depressive symptoms.

It should be noted that estimates of response rates across psychological interventions are around 40% (25) and response to interventions should be monitored and an alternative approach offered if required. Additionally, psychological therapy can be combined with an antidepressant medication.

Interventions are listed in an order reflecting their clinical and cost-effectiveness for differing presentations of depression.

Less severe depression:

Individuals with less severe depression whose needs and preferences match with a psychological intervention can be offered: Guided self-help, Group cognitive behavioural therapy (CBT), Group behavioural activation (BA), Individual CBT, Individual BA, Group mindfulness (such as mindfulness based cognitive therapy), Interpersonal psychotherapy (IPT), Person Centred Experiential Counselling for Depression (PCECfD), Short-term psychodynamic psychotherapy (short-term PP).

More severe depression:

Individuals with more severe depression whose needs and preferences match with a psychological intervention can be offered: Individual CBT (with or without antidepressant medication), Individual BA, Individual problem solving, Person Centred Experiential Counselling for Depression (PCECfD), Short-term psychodynamic psychotherapy (short-term PP), IPT or Guided self-help.

Guided self-help varies in format from books to digital formats, such as apps and online programmes. There is evidence of greater effects and stronger adherence when delivered with support from an appropriately trained health care professional (26),(27), (28), (29),(30),(31),(32). Guided self-help interventions for the treatment of new episodes of less severe and more severe depression should involve printed or digital self-help materials based on CBT, structured BA, problem-solving or psychoeducation materials and should involve support from a trained facilitator who encourages progress (3)^. It usually consists of 6-8 regular structured sessions. Guided self-help can have comparable effects in the treatment of depression as face-to-face treatments with a low to moderate effect on symptoms (33).

Groups can be a cost-effective option for treatment of less severe depression.  CBT, BA and Mindfulness based groups are recommended (3) with small-large impacts on symptoms. The group delivery should be provided by a practitioner who has therapy-specific training and competence, preferably supported by second practitioner.  Groups should typically include 8 regular sessions. Clinicians might consider the required balance of number of sessions. Higher numbers of sessions provide access to additional content and may aid group cohesion. However, longer courses may cause increased drop-out. Research is required to discover the best balance of length and duration as how this relates to individual patient choice.

Individual CBT, BA, IPT, short-term PP and Person-Centred Experiential Counselling for Depression (PCECfD), are recommended for new episodes of depression across different levels of severity. In addition, Individual problem-solving can be considered for more severe depression. They should be delivered by a practitioner with therapy-specific training and competence and should follow an empirically validated protocol or treatment manual specifically for depression. Duration typically consists of 8-16 regular sessions and there is evidence that weekly or bi-weekly can have stronger effects (27) (16). These approaches have a well-established evidence base. There are some differences in effect sizes between interventions and trials (CBT – medium-high; BA- medium to high; problem solving therapy medium-high; IPT – medium (33) short-term PP -small; non-directive supportive therapy – medium (27),(16) and these can be taken into account alongside other factors, such as preference and availability.

Behavioural Couples Therapy (BCT) can be considered for a subgroup of adults with less or more severe depression who have problems in the relationship with their partner(3). These include adults for whom their relationship problem(s) could potentially be contributing to their depression, or partner involvement could assist with their treatment (3). BCT typically involves 15-20 sessions. The evidence for this approach is more limited than for the other interventions (3),(34) and this is included as an alternative recommendation in the evidence table.

Overview of evidence for older adults

A series of reviews suggest that psychological interventions are also effective in late-life depression (35) (36),(37) and evidence is especially well established for CBT and problem-solving therapy(35) and there is some evidence supporting efficacy for lower intensity interventions like guided self-help (38). The evidence is less well established for older people with depression who reside in long-term care where it is suggested that CBT, behavioural therapy and reminiscence therapy may reduce depressive symptoms and improve quality of life and psychological well-being in the short term (39). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Psychological Therapies and Interventions for Older People for further information on factors relevant to practice. 

Chronic or comorbid depression:

People may present with chronic depressive symptoms that may have not sought treatment for depression previously or may require further line treatment due to limited response to treatment or relapse. NICE guidelines recommend offering CBT (with or without an SSRI) to people who have not had previous treatment. CBT is effective for treatment resistant depression that has not responded to antidepressants (40). The CBT should have a focus on the chronic depressive symptoms and address key maintaining factors, i.e. avoidance, interpersonal problems, and rumination. If people have received previous treatment, or are currently not responding to therapy, then NICE recommend switching to another psychological therapy.

Large scale reviews of psychotherapies for depression include trials of chronic and treatment resistant depression and generally suggest that a combination of psychotherapy and medication is more effective than either alone (41), (27).  These reviews, and others focusing on chronic depression include: CBT that focuses on chronic depression symptoms, including CBASP, specifically developed to treat chronic depression (42), (43),(44) IPT, and Mindfulness-based Cognitive Therapy (MBCT). MBCT can be considered for individuals with recurrent depressive disorder who are at high risk of relapse as a relapse prevention intervention. Meta-analytic studies have previously found MBCT to be most beneficial for relapse prevention in individuals who have experienced at least 3 previous depression episodes (45)(46). However, more recent work indicates a similar benefit in increasing time to relapse compared with treatment as usual however many previous episodes of depression there have been (47).  MBCT also shows statistically significant improvement in suicidal ideation compared with treatment as usual (48). Effects seem to persist for at least six months after treatment (49). A smaller systematic review of 14 trials investigated the impact of psychological therapies on functioning and quality of life in persistent depression (50) found the impact highest for MBCT, IPT and psychodynamic psychotherapy with more variable findings in the impact of CBASP on functioning and QOL. 

It is also common for people to experience depression in the context of other mental or physical health problems. The Matrix guidance for anxiety disorders, PTSD, substance use, personality disorder, mental health problems in the perinatal period and physical health topics should be considered as required. Collaborative care can be particularly helpful for older people with depression, those with significant physical health problems, social isolation or people with chronic depression not responding to usual specialist care (3).

Patients with severe depressive illness may experience psychotic symptoms.  Psychological treatments can be offered after improvement in acute psychotic symptoms and can be combined with antidepressant medication and antipsychotic medication (3).

Overview of evidence for people with learning disabilities

Large scale trials of psychological interventions in general populations tend to exclude people with learning disabilities, therefore there is limited evidence for mental health interventions with this group.  For people with learning disabilities and mental health difficulties, (51) recommend that general guidelines for psychological interventions should be considered, with appropriate adaptations for people with learning disabilities.  More information relating to adapting therapy can be found on Delivering effective psychological therapies and interventions to people with Intellectual/Learning Disabilities (content under development).

For the treatment of depression NICE recommends CBT with appropriate adaptations for people with mild learning disabilities.  A meta-analysis (52) CBT for adults with intellectual disability found a significant effect of controlled trials for depression, although most studies involve people with mild learning disabilities. The Mental Ill Health report from SLDO (2022) (1) conducted a rapid review to build on NICE.  For people with mild or moderate learning disabilities, one RCT demonstrated efficacy for both Beat It (an adapted behavioural activation intervention) and Step Up (guided self-help) for depressive symptoms (53). Both interventions involve a supporter for the person with a learning disability. The evidence in people with severe and profound learning disabilities related to depression is too underdeveloped to result in recommendations for standalone psychological interventions.

Overview of evidence for harms and adverse effects

Like pharmaceutical treatments, psychological therapies also have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically in trials of psychological interventions for depression. Risks might include dependency on the therapist, risks of therapist abuse, or feeling worse as a result of assessment, or treatment awakening areas of distress before learning the skills to self-manage this.  

One area that has been examined is the risk of deterioration in adult patients receiving psychological therapy for depression. This has been examined in a meta-analysis of 18 studies (54). This is a small proportion of all psychotherapy trials, and the majority do not report deterioration rates, thus the conclusions drawn should be considered with caution. The findings indicate that psychological treatments may reduce the risk of deterioration with a 61% lower chance to deteriorate than patients in control groups. However, clinicians should still be aware of the risk of deterioration during therapy (4-10% across studies).

Recommendation	Who for?	Intervention	Type of Psychological Practice	Evidence	Efficacy
First line	Children and young people (5-18) with mild depression	Digital cognitive–behavioural therapy (CBT)(2), (55)(56)(57)(58)	Skilled/enhanced/specialist	A	low- medium
		Group CBT (2),(59),(27)	Enhanced/specialist		Medium -high
		Group non-directive supportive therapy (NDST) (2)	Enhanced		N/A
		Group interpersonal psychotherapy (IPT). (59)(2)(55) (17) (18)	Specialist		Medium-high
Alternative (if indicated by need or insufficient response to first line options)	Children and young people (5-18) with mild depression	Attachment-based family therapy (ABFT)(2),(21),(22)	Specialist	A	low-medium
		Individual CBT. (2),(15),(55),(14)	Specialist		Medium- high
	Young people (12-18) with mild depression	Behavioural Activation for adolescents (4), (60)	Enhanced/Specialist	B	low
First line	Children (5-11) with moderate to severe depression	Family-based IPT(2)	Specialist	A	low-medium(14)
		Family therapy (family-focused treatment for childhood depression and systems integrated family therapy) (2),(19),(22)
		Psychodynamic psychotherapy(2)
		Individual CBT(2)
First line	Young people (12-18) with moderate to severe depression	Individual CBT (2) (14)(15)	Specialist	A
First line	CYP with mild to moderate learning disabilities and depression	CBT (or specific components of CBT) with appropriate adaptations to needs based on formulation(51)	Specialist	C	N/A
		Parent training programmes specifically designed for parents or carers of children with learning disabilities to help prevent or treat mental health problems in the child, and to support carer wellbeing (51)	Enhanced/specialist	B	N/A
Alternative	Young people (12-18) with moderate to severe depression	IPT for adolescents (2),(17)	Enhanced/specialist	A	High low-medium
		Family therapy (attachment based or systemic) (2),(21),(22)
		Psychodynamic psychotherapy (2)
		Brief psychosocial intervention (2)
		Behavioural Activation (4), (60)		B
First line	CYP with chronic depression or co-occurring mental health difficulties	Therapy combined with antidepressants (2)	Enhanced/specialist	A	Low-high

Recommendation	Who for?	Intervention	Type of psychological intervention	Evidence	Efficacy
First line	Adults presenting with a new episode of less severe depression	Guided Self-help (3), (25),(28), (61)	Skilled/Enhanced	A	Low -high
		Group CBT (3),(62)(27)	Enhanced/Specialist
		Group BA(63) (62),	Enhanced/Specialist
		Individual CBT (25), (16), (64)	Specialist
		Individual BA (16),(62), (65),(63)	Enhanced/Specialist
		Group mindfulness (such as mindfulness based cognitive therapy) (3)	Enhanced/Specialist
		Interpersonal psychotherapy (33)(3),(5)	Specialist
		Person Centred Experiential Counselling for Depression (PCECfD) (3)	Enhanced/Specialist
		Short-term PP (3),(66),(67)	Specialist
First line	Adults presenting with a new episode of more severe depression	Individual CBT (with antidepressant medication) (27), (16)	Specialist	A	Low-high
		Individual CBT (without antidepressants) (25)	Specialist
		Individual BA (16),(62), (65),(63)	Enhanced/Specialist
		Individual problem solving(3)(68)	Enhanced/Specialist
		Person Centred Experiential Counselling for Depression (PCECfD), (3)	Enhanced/Specialist
		Short-term PP (3),(66),(67)	Specialist
		IPT (3),(33)	Specialist
		Guided self help (25),(3),(61)	Skilled/Enhanced
Alternative	Adults with depression and a partner willing to participate in treatment	Behavioural couples therapy (3),(34)	Enhanced/Specialist	A	N/A
First line	Adults with chronic depression	As above for severe depression Combination psychological therapy and medication	Enhanced/Specialist	A	Low-high
Alternative	Adults with chronic depression	MBCT (47),(49),(48) Group DBT (69) CBASP (42),(44)	Enhanced/Specialist	A	Low-high
First line	Adults with mild to moderate learning disability and depression	CBT (with appropriate adaptations to needs based on formulation) (52),(51)	Specialist	A	N/A
Alternative	Adults with mild to moderate learning disability and depression	Adapted Behavioural Activation (Beat It) Guided self-help (Step Up) (53)	Enhanced/Specialist	B	N/A
Co-occurring problems and depression		Collaborative or multi-disciplinary care (3).  This is common, please see other tables as appropriate.

With thanks to Professor Chris Williams and SAM-H for their feedback and comments.

Technical group: Fiona Duffy, Alisdair Forrest, Patricia Graham, Allyson McDougall, Marina McLoughlin, Suzanne Mills, Leeanne Nicklas, Marie Claire Shankland, Fiona Switzer, Massimo Tarsia, Amanda Whyte.

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