NICE NG222 2022: depression in adults treatment and management

Official guidelineDepression in adults: treatment and management (NG222). NICE, 2022.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults aged 18 and over with a new episode or recurrence of depression, including those with chronic physical health problems, managed in primary and secondary care.

Key recommendations

For less severe depression, offer a choice of options first-line, including guided self-help, group cognitive behavioural therapy, group behavioural activation, individual CBT or behavioural activation, group exercise, mindfulness or meditation, or antidepressant medication if preferred, rather than defaulting to watchful waiting alone.
Antidepressants are not routinely recommended as first-line treatment for less severe depression unless this is the patient's preference.
For more severe depression, offer a choice of an antidepressant alone, a high-intensity psychological intervention alone (such as CBT or IPT), or a combination of both.
Discuss patient preference regarding medication versus psychological therapy, taking into account previous treatment response, side effect profile, and concurrent physical health conditions.
When starting an antidepressant, SSRIs are generally preferred due to a favourable balance of efficacy, tolerability, safety and cost.
Review patients around 2 weeks after starting an antidepressant (earlier in younger people or those at higher risk of suicide), then regularly thereafter to assess response and side effects.
Continue antidepressant treatment for at least 6 months after remission to reduce risk of relapse before considering tapering.
When stopping antidepressants, taper the dose gradually in a manner tailored to the individual drug and patient to minimise withdrawal symptoms, recognising these can be more prolonged than previously thought.
For depression that has not responded adequately to initial treatment, consider switching antidepressant class, augmenting medication, adding or switching to psychological therapy, or referral to specialist mental health services.
Consider the person's wider circumstances, including social support, employment, and physical health comorbidities, as part of a holistic management plan.

What is new in this edition

Replaced the previous stepped-care model based on mild/moderate/severe categorisation with a 'less severe' versus 'more severe' framework.
Moved away from a strict treatment hierarchy toward presenting multiple first-line options for shared decision-making.
Greater emphasis on individualised, gradual tapering of antidepressants and recognition of potentially prolonged discontinuation symptoms.
Reduced default emphasis on antidepressants as automatic first-line for less severe depression.

Practice points for students

Think 'less severe vs more severe' rather than the old mild/moderate/severe staging when discussing NG222 in exams.
Shared decision-making and patient preference are central; there is no single mandated first-line treatment for less severe depression.
Always warn patients about possible discontinuation symptoms and taper gradually rather than stopping abruptly.
For more severe depression, combination therapy is one of the first-line choices, alongside antidepressant alone or psychological therapy alone, depending on patient preference.
Continue antidepressants for at least 6 months post-remission before considering discontinuation.

Condition

Major depressive disorder