Referral criteria from primary care - depression

NICE referral criteria (1):

1) If a person with depression presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services.

2) If a person with depression is assessed to be at risk of suicide:

• do not withhold treatment for depression on the basis of their suicide risk
• take into account toxicity in overdose if an antidepressant is prescribed, or the person is taking other medication, and if necessary limit the amount of medicine available
• consider increasing the level of support provided, such as more frequent in-person, video call or telephone contact
• consider referral to specialist mental health services

3) For people with no or limited response to treatment for chronic depressive symptoms* that significantly impair personal and social functioning who have not responded to the treatments recommended in the sections on further-line treatment and chronic depressive symptoms*, offer a referral to specialist mental health services for advice and further treatment

4) If a person with depression wants to try a combination treatment and is willing to accept the possibility of an increased side-effect burden, consider referral to a specialist mental health setting or consulting a specialist. Treatment options include:

• adding an additional antidepressant medication from a different class (for example, adding mirtazapine or trazodone to an SSRI)
• combining an antidepressant medication with a second-generation antipsychotic (for example, aripiprazole, olanzapine, quetiapine or risperidone) or lithium
• augmenting antidepressants with electroconvulsive therapy, lamotrigine, or triiodothyronine (liothyronine)

• be aware that some combinations of classes of antidepressants are potentially dangerous and should be avoided (for example, a SSRI, SNRI or TCA with a MAOI), and that when using an antipsychotic the effects of this on depression, including loss of interest and motivation, should be carefully reviewed

5) For people with depression and a diagnosis of personality disorder, consider referral to a specialist personality disorder treatment programme.

6) Offer referral to specialist mental health services for people with depression with psychotic symptoms, where the treatment should include:

• a risk assessment
• an assessment of needs
• a programme of coordinated multidisciplinary care
• access to psychological treatments, after improvement of acute psychotic symptoms

7) Specialist referral

• refer people with more severe depression** or chronic depressive symptoms*, to specialist mental health services for coordinated multidisciplinary care if:
  • their depression significantly impairs personal and social functioning and
  • they have not benefitted from previous treatments, and either
    • have multiple complicating problems, for example unemployment, poor housing or financial problems or
    • have significant coexisting mental and physical health conditions

* people with chronic depressive symptoms includes those who continually meet criteria for the diagnosis of a major depressive episode for at least 2 years, or have persistent sub-threshold symptoms for at least 2 years, or who have persistent low mood with or without concurrent episodes of major depression for at least 2 years

• people with depressive symptoms may also have a number of social and personal difficulties that contribute to the maintenance of their chronic depressive symptoms

**more severe depression encompasses moderate and severe depression, and in this guideline was defined as depression scoring 16 or more on the PHQ-9 scale

Reference:

1. NICE (June 2022). Depression in adults: treatment and management