Common mental health disorders in primary care

overview

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/common-mental-health-disorders-in-primary-
care
NICE Pathway last updated: 04 December 2018

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Common mental health disorders in adults

No additional information

2 Identification and assessment

See Common mental health disorders in primary care / Identifying and assessing common
mental health disorders

3 Principles for treatment and referral

See Common mental health disorders in primary care / Principles for treatment and referral in
common mental health disorders

4 Managing specific mental health disorders

A stepped-care model is used to organise the provision of services and to help people with
common mental health disorders, their families, carers and healthcare professionals to choose
the most effective interventions. For more information on the stepped care model, see stepped
care model: a combined summary for common mental health disorders [See page 5].

5 Developing local care pathways

See Common mental health disorders in primary care / Developing local care pathways for
common mental health disorders

6 See what NICE says on antenatal and postnatal mental health

See Antenatal and postnatal mental health

7 See what NICE says on depression

See Depression

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8 See what NICE says on generalised anxiety disorder

See Generalised anxiety disorder

9 See what NICE says on obsessive-compulsive disorder and body

dysmorphic disorder

See Obsessive-compulsive disorder and body dysmorphic disorder

10 See what NICE says on panic disorder

See Panic disorder

11 See what NICE says on post-traumatic stress disorder

See Post-traumatic stress disorder

12 See what NICE says on social anxiety disorder

See Social anxiety disorder

13 Experience of care

Use these recommendations with NICE's recommendations on:

patient experience in adult NHS services

service user experience in adult mental health services.

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Stepped-care model: a combined summary for common mental health

disorders

Focus of the intervention Nature of the intervention

Depression: CBT, IPT, behavioural activation,

behavioural couples therapy, antidepressants,
combined interventions, collaborative care (for
people with depression and a chronic physical
health problem), self-help groups, counselling,
short-term psychodynamic psychotherapy
(discuss with the person the uncertainty of the
effectiveness of counselling and
psychodynamic psychotherapy in treating
depression).
Step 3: Persistent subthreshold depressive
symptoms or mild to moderate depression
GAD: CBT, applied relaxation, drug treatment,
that has not responded to a low-intensity
combined interventions, self-help groups.
intervention; initial presentation of moderate
or severe depression; GAD with marked
functional impairment or that has not Panic disorder: CBT, antidepressants, self-
responded to a low-intensity intervention; help groups.
moderate to severe panic disorder; OCD
with moderate or severe functional OCD: CBT (including ERP), antidepressants,
impairment; PTSD. combined interventions and case management,
self-help groups.

PTSD: Trauma-focused CBT, EMDR, drug

treatment.

All disorders: Support groups, befriending,

rehabilitation programmes, educational and
employment support services; referral for
further assessment and interventions.

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Depression: Individual facilitated self-help,

computerised CBT, structured physical activity,
group-based peer support (self-help)
programmes (for people with depression and a
chronic physical health problem), non-directive
counselling delivered at home (for women
during pregnancy or the postnatal period),
antidepressants, self-help groups.

Step 2: Persistent subthreshold depressive

GAD and panic disorder: Individual non-
symptoms or mild to moderate depression;
facilitated and facilitated self-help,
GAD; mild to moderate panic disorder; mild
psychoeducational groups, self-help groups.
to moderate OCD; PTSD (including people
with mild to moderate PTSD).
OCD: Individual or group CBT (including ERP),
self-help groups.

PTSD: Trauma-focused CBT or EMDR.

All disorders: Support groups, educational

and employment support services; referral for
further assessment and interventions.

Step 1: All disorders – known and All disorders: Identification, assessment,

suspected presentations of common mental psychoeducation, active monitoring; referral for
health disorders. further assessment and interventions.

CBT

cognitive behavioural therapy

EMDR

eye movement desensitisation and reprocessing

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ERP

exposure and response prevention

GAD

generalised anxiety disorder

Distress Thermometer

a single-item question screen to identify distress by asking the person to mark on a scale of 0 to
10 how distressed they have been during the past week

GAD-2

2-item generalised anxiety disorder scale

HADS

hospital anxiety and depression scale

GAD-7

7-item generalised anxiety disorder scale

IAPT

improving access to psychological therapies

IPT

interpersonal therapy

Mild

when applied to common mental health disorders, mild generally refers to relatively few core
symptoms (although sufficient to achieve a diagnosis), a limited duration and little impact on
day-to-day functioning

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OCD

obsessive compulsive disorder

PHQ-9

9-item patient health questionnaire

PTSD

post-traumatic stress disorder

Sources

Common mental health disorders: identification and pathways to care (2011) NICE guideline
CG123

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

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Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

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their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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