How should I approach the management of an adult with mild to moderate depression who prefers psychological therapy over medication?

For an adult with mild to moderate depression who prefers psychological therapy over medication, the management approach should prioritise their preference within a stepped-care framework ¹,³,⁴.

• Assessment and Shared Decision-Making:
  • First, confirm the severity of depression. Mild depression is defined as a PHQ-9 score less than 16, while moderate depression is a PHQ-9 score of 16 or more ¹.
  • Develop a treatment plan based on shared decision-making, taking into account the person's wishes, previous treatment experiences, and expectations ⁴. Discuss potential benefits, harms, waiting times, and how treatments will be delivered ⁴.
• Recommended Psychological Interventions:
  • For less severe depression, psychological therapies are recommended first-line, and antidepressant treatment is generally not offered first-line unless the person prefers it ⁴.
  • Effective and cost-effective first-line psychological options include:
    • Guided self-help: This is often recommended first-line for most people with less severe depression due to its accessibility, pragmatism, and cost-effectiveness ⁴.
    • Individual or group Cognitive Behavioural Therapy (CBT) ⁴.
    • Individual or group Behavioural Activation (BA) ⁴.
  • Other psychological interventions that may be considered, though potentially less cost-effective, include:
    • Counselling: This involves individual sessions focusing on emotional processing and developing coping mechanisms, often useful for people with psychosocial, relationship, or employment problems contributing to their depression ¹.
    • Short-term psychodynamic psychotherapy (STPP): This involves individual sessions focusing on recognising difficult feelings in relationships and identifying repeated patterns ¹. It may be useful for people with emotional and developmental difficulties in relationships ¹.
    • Interpersonal Psychotherapy (IPT): This may be helpful for people with depression associated with interpersonal difficulties, such as adjusting to relationship transitions or loss ¹.
• Stepped Care Approach:
  • The stepped-care model suggests delivering the least intrusive, most effective, and least resource-intensive treatments first ¹,³. If the person does not benefit from initial interventions, they can be "stepped up" to more intensive treatments ¹,³.
  • For persistent subthreshold depressive symptoms or mild to moderate depression, low-intensity psychosocial interventions and psychological interventions are appropriate for Step 2 ³. If there's an inadequate response, they may be stepped up to Step 3, which includes high-intensity psychological interventions ³.
• General Support and Monitoring:
  • Provide advice on the nature and course of depression, recovery, and sources of information and support (e.g., self-help materials, support groups) ⁴.
  • Advise on activities to improve well-being, such as physical activity and maintaining a healthy lifestyle ⁴.
  • Offer social support, including for family and carers ⁴.
  • If the person has a new episode of less severe depression and does not want treatment or feels symptoms are improving, offer active monitoring with the option to consider treatment at any time ⁴.
  • Routine outcome monitoring should be used to assess progress regularly, usually at each contact, using valid scales for symptoms or personal and social functioning ¹.