Stepped psychological and medication treatment

01Purpose and principlesWhat the treatment does and how it fits into care.

Begin with shared formulation and immediate needs. Explain whether the presentation lies within NICE's less severe or more severe group and what evidence supports that view. Discuss previous treatment, preference, language, neurodevelopmental needs, access, childcare, work, physical illness, pregnancy and overdose risk. Address sleep, pain, alcohol, housing and isolation in parallel. Treatment choice should not be determined by what has the shortest waiting list if another option is more acceptable and clinically appropriate.

For less severe depression, NICE prioritises less intrusive options. Active monitoring can be appropriate when symptoms may improve and risk is low, but it requires agreed follow-up rather than no care. Guided self-help can use structured behavioural activation, CBT or problem-solving material with practitioner support. Group exercise, group CBT or behavioural activation and mindfulness or meditation programmes are options in the guideline tables. If the person prefers an antidepressant after informed discussion, preference matters; the recommendation against routine initial use is not a ban.

For more severe depression, explain the range and sequence rather than presenting medication as compulsory. Individual CBT or behavioural activation, an antidepressant, and combined individual CBT plus antidepressant are prominent choices. Combination may address symptoms through complementary mechanisms but adds treatment burden. Couple therapy can be relevant when relationship difficulties contribute and both people wish to engage. Specialist options are required for psychosis, catatonia, high risk, complex comorbidity or failure of adequate routine treatment.

Medication selection balances prior benefit, likely adverse effects, withdrawal, interaction, physical comorbidity, pregnancy, sexual function, sedation, overdose toxicity and the person's priorities. SSRIs often offer a favourable balance, but not every SSRI is interchangeable. Explain that improvement may begin within four weeks, that early adverse effects can precede benefit and that abrupt stopping can cause withdrawal. Provide written information and a monitoring plan. Limit quantities when overdose risk is relevant without withholding effective care.

Review actively. At early follow-up, assess adherence, adverse effects, agitation, suicide risk, sleep, function and whether therapy is accessible. When there is no response after an adequate trial, check diagnosis, bipolarity, substances, physical illness, dose, duration, missed doses and therapeutic delivery. Options include switching psychological approach, switching antidepressant, increasing dose within licensed and tolerated limits or combining psychological and medication treatment. More complex pharmacological combinations and ECT require specialist-informed risk and monitoring.

Key points

Treat immediate risk, housing, pain, substance use, physical illness and safeguarding needs alongside depression rather than waiting for mood remission.
For less severe depression, discuss active monitoring, guided self-help, structured group physical activity, group behavioural activation or CBT and mindfulness-based options according to NICE and preference.
Do not routinely make antidepressants the initial offer for less severe depression unless the person understands options and prefers medication.
For more severe depression, discuss individual CBT, behavioural activation, antidepressant treatment and combination individual CBT plus an antidepressant as evidence-based choices.
SSRIs are generally well tolerated and often considered before other antidepressant classes, but prior response, adverse effects, overdose toxicity, interactions and preference determine selection.
Explain onset, common harms, withdrawal, adherence and duration; antidepressant benefit is commonly expected within about four weeks when treatment is effective.
Review usually within two weeks, or within one week for people aged 18 to 25 or when suicide risk is a particular concern, with further review based on need.
If response is absent or limited, assess delivery and barriers, then collaboratively increase psychological intensity, switch modality or antidepressant, or combine treatments.
Continue effective antidepressant treatment for at least six months after remission unless a reason to stop exists, then review relapse risk and taper gradually when ending.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Active monitoring candidate

Less severe symptoms, preserved safety and function and a clear review plan make supported monitoring reasonable when that matches preference.

Psychological-treatment preference

The person favours a structured therapy and can access a modality suited to severity, formulation, language and practical circumstances.

Medication preference

The person understands likely benefits, adverse effects, alternatives, withdrawal and monitoring and chooses an antidepressant even within less severe illness.

Combined-treatment need

More severe, persistent or recurrent symptoms and functional loss may justify complementary psychological and medication treatment after burden and preference discussion.

Urgent specialist pathway

Psychosis, catatonia, immediate suicide danger, severe self-neglect or complex resistance exceeds routine sequential community care.

Red flags requiring action

A person with less severe symptom count may still need urgent care when suicide risk, psychosis, safeguarding or physical compromise is present.
Antidepressants are not routinely offered as the initial treatment for less severe depression unless that is the person's informed preference.
Psychological treatment must be delivered at an adequate therapeutic dose by trained practitioners; a waiting-list entry is not an intervention.
Early agitation, akathisia, emergent suicidal thoughts, mania or severe adverse effects after medication initiation requires prompt review rather than automatic continuation.
Non-response should trigger review of diagnosis, adherence, dose, duration, social barriers, substances and comorbidity before the person is labelled resistant.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Severity, function and preference assessmentFirst step
Why
Choose an initial option aligned with clinical need, previous response, goals and treatment burden.
Interpretation and limitations
Questionnaire scores assist but do not decide. Risk, psychosis, capacity, access and physical illness can change the appropriate level.
02
Psychological-treatment suitability review
Why
Match formulation to CBT, behavioural activation, guided self-help, exercise, mindfulness or interpersonal and couple approaches.
Interpretation and limitations
Consider complexity, cognition, trauma, language, group acceptability and practical access; a referral alone does not provide therapeutic exposure.
03
Medication suitability review
Why
Assess previous response, interactions, overdose risk, comorbidity, reproductive context, adverse-effect priorities and withdrawal history.
Interpretation and limitations
Select and dose from current prescribing information. Class labels do not erase meaningful differences in cardiac, bleeding, sexual or sedative effects.
04
Early response and harm review
Why
Assess adherence, activation, suicidality, adverse effects, sleep, symptoms and function after starting treatment.
Interpretation and limitations
Early worsening or mania requires prompt action. Limited benefit before an adequate duration may not equal failure unless harm makes continuation unsuitable.
05
Non-response review
Why
Check diagnosis, delivery, dose, duration, adherence, substances, physical causes and social barriers before escalation.
Interpretation and limitations
Correct remediable problems and decide collaboratively whether to switch, intensify or combine, avoiding repeated ineffective continuation.

04Treatment approachPreparation, options, escalation and aftercare.

01Less severe careStart with acceptable low intrusionFirst stepSymptoms and impairment fall within less severe depression without an overriding urgent need.

1Explain active monitoring and guideline-listed psychological, behavioural and social options and identify the person's priorities and access barriers.
2Offer the least intrusive acceptable intervention, while prescribing an antidepressant when informed preference supports it rather than as routine default.
3EscalationSet an active review of symptoms, function and safety and escalate when deterioration or inadequate response changes the balance.

02More severe careOffer effective higher-intensity choicesSymptoms or functional impairment indicate more severe depression and urgent psychotic or medical danger is addressed.

1Discuss individual CBT, behavioural activation, antidepressant and combined CBT plus antidepressant with expected benefit, burden and availability.
2Select from preference, previous response, comorbidity, overdose risk and feasibility and ensure each treatment is delivered adequately.
3EscalationReview early for safety and within an adequate trial for benefit, escalating to specialist care for psychosis, complexity or sustained non-response.

03Inadequate responseVerify the trial before changing courseSymptoms and function have not improved sufficiently after an initial intervention.

1Recheck diagnosis, bipolarity, adherence, dose, duration, therapy attendance and quality, substances, physical illness and social obstacles.
2Agree whether to optimise, switch within or between modalities or combine psychological and medication care.
3Use specialist advice for medication combinations, lithium or antipsychotic augmentation and ECT, with explicit monitoring and stopping plans.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

An SSRI option often selected when medication is preferred because of broad experience and a generally favourable balance of tolerability and overdose safety.

Sertraline

For adult major depression, start 50 mg orally once daily; if needed, increase in 50 mg steps no more often than weekly to a maximum 200 mg daily.

Check interactions, bleeding risk, hyponatraemia, activation, sexual effects and serotonin toxicity; use particular caution in bipolarity, hepatic impairment, pregnancy and concurrent serotonergic medicines.

An alternative antidepressant when SSRI effects are unsuitable or when sedation and appetite effect may align with informed patient priorities.

Mirtazapine

Use 15 to 30 mg orally at night initially, then adjust by response and tolerability within the licensed 15 to 45 mg daily range.

Discuss somnolence, increased appetite, weight gain, dizziness and rare blood dyscrasia; sedation can impair driving, and switching or combination requires interaction and serotonin-risk review.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Review usually within two weeks of starting treatment and within one week for age 18 to 25 or a particular suicide concern, adjusting frequency to need.
At each early review assess self-harm, activation, akathisia, mania, adherence, adverse effects, sleep, substance use and real-world function.
Monitor psychological access and therapeutic delivery as carefully as medicine adherence, including language, digital, travel and childcare barriers.
Continue an effective antidepressant for at least six months after remission, then review recurrence risk, residual symptoms, preference and harms.
When stopping, taper in stages with smaller reductions at lower doses, monitoring withdrawal separately from relapse and slowing if symptoms are intolerable.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Stepped is not rigid

Urgency, preference, prior response and access can justify moving directly to a more intensive option rather than completing every lower step.

Waiting is an intervention only

Active monitoring requires a date, safety net and escalation route; an unreviewed waiting list does not meet that standard.

Therapy has dose

Sessions, practitioner competence, engagement and between-session practice affect whether a psychological trial was actually adequate.

Medication preference is valid

A person with less severe depression may reasonably choose an antidepressant after informed discussion even though it is not the routine initial offer.

Function may lag

Mood can improve before confidence, work or relationships recover, so rehabilitation and behavioural goals remain necessary after symptom response.

08Common pitfallsFrequent interpretation and management errors.

01
Offering an antidepressant automatically to every person with less severe depression.
02
Calling active monitoring when no follow-up date or safety net exists.
03
Presenting one therapy as the only evidence-based choice despite preference and access differences.
04
Judging psychological treatment ineffective before adequate delivery and engagement.
05
Increasing antidepressant dose without checking bipolarity, adherence, interactions and adverse effects.
06
Missing early suicidality, activation or akathisia because benefit has not yet emerged.
07
Stopping abruptly after remission or confusing withdrawal with immediate depressive relapse.