NICE recommends staged withdrawal of antidepressants

Adults with depression who want to stop taking antidepressants should have the dose of their medication reduced in stages to reduce the likelihood and severity of withdrawal symptoms | via National Institute for Health and Care Excellence (NICE).

A new draft quality standard, which sets out priority areas for quality improvement for the care of adults with depression, includes a statement to help adults who want to come off the medication permanently. The independent advisory committee, which includes experts in treating adults with depression, has recommended the staged withdrawal of antidepressants.

The committee said primary care and mental health professionals should follow the NICE guideline recommendations on stopping antidepressant medication, including agreeing with their patient whether it is right for them to stop taking the medication and if so, the speed and duration of withdrawal from it. Reducing the dose of an antidepressant in stages over time, known as ‘tapering’, helps to reduce withdrawal effects and long-term dependence on the medication.

Any withdrawal symptoms need to have been resolved, or to be tolerable, before making the next dose reduction the committee has said.

Full detail: Adults with depression who want to quit antidepressants should be given support on how to do it safely over time, says NICE

See also: Draft quality standard for depression in adults | NICE

Depression in adults: treatment and management

National Institute for Health and Care Excellence | Depression in adults: treatment and management | NICE guideline [NG222]

This guideline covers identifying, treating and managing depression in people aged 18 and over. It recommends treatments for first episodes of depression and further-line treatments, and provides advice on preventing relapse, and managing chronic depression, psychotic depression and depression with a coexisting diagnosis of personality disorder.

This guideline updates and replaces NICE guideline CG90 (October 2009). This guideline was previously called depression in adults: recognition and management.

Full detail: Depression in adults: treatment and management

NICE have also created a series of visual summaries to explain the treatment and management of depression in adults:

• Discussing first-line treatments for less severe depression
• Discussing first-line treatments for more severe depression
• Preventing relapse
• Further-line treatment
• Treatment options for chronic depression, depression with personality disorder or psychotic depression
• The matched care model

The healthiness and sustainability of national and global food based dietary guidelines: modelling study

Objective To analyse the health and environmental implications of adopting national food based dietary guidelines (FBDGs) at a national level and compared with global health and environmental targets.

Design Modelling study.

Setting 85 countries.

Participants Population of 85 countries.

Main outcome measures A graded coding method was developed and used to extract quantitative recommendations from 85 FBDGs. The health and environmental impacts of these guidelines were assessed by using a comparative risk assessment of deaths from chronic diseases and a set of country specific environmental footprints for greenhouse gas emissions, freshwater use, cropland use, and fertiliser application. For comparison, the impacts of adopting the global dietary recommendations of the World Health Organization and the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems were also analysed. Each guideline’s health and sustainability implications were assessed by modelling its adoption at both the national level and globally, and comparing the impacts to global health and environmental targets, including the Action Agenda on Non-Communicable Diseases, the Paris Climate Agreement, the Aichi biodiversity targets related to land use, and the sustainable development goals and planetary boundaries related to freshwater use and fertiliser application.

Results Adoption of national FBDGs was associated with reductions in premature mortality of 15% on average (95% uncertainty interval 13% to 16%) and mixed changes in environmental resource demand, including a reduction in greenhouse gas emissions of 13% on average (regional range −34% to 35%). When universally adopted globally, most of the national guidelines (83, 98%) were not compatible with at least one of the global health and environmental targets. About a third of the FBDGs (29, 34%) were incompatible with the agenda on non-communicable diseases, and most (57 to 74, 67% to 87%) were incompatible with the Paris Climate Agreement and other environmental targets. In comparison, adoption of the WHO recommendations was associated with similar health and environmental changes, whereas adoption of the EAT-Lancet recommendations was associated with 34% greater reductions in premature mortality, more than three times greater reductions in greenhouse gas emissions, and general attainment of the global health and environmental targets. As an example, the FBDGs of the UK, US, and China were incompatible with the climate change, land use, freshwater, and nitrogen targets, and adopting guidelines in line with the EAT-Lancet recommendation could increase the number of avoided deaths from 78 000 (74 000 to 81 000) to 104 000 (96 000 to 112 000) in the UK, from 480 000 (445 000 to 516 000) to 585 000 (523 000 to 646 000) in the USA, and from 1 149 000 (1 095 000 to 1 204 000) to 1 802 000 (1 664 000 to 1 941 000) in China.

Conclusions This analysis suggests that national guidelines could be both healthier and more sustainable. Providing clearer advice on limiting in most contexts the consumption of animal source foods, in particular beef and dairy, was found to have the greatest potential for increasing the environmental sustainability of dietary guidelines, whereas increasing the intake of whole grains, fruits and vegetables, nuts and seeds, and legumes, reducing the intake of red and processed meat, and highlighting the importance of attaining balanced energy intake and weight levels were associated with most of the additional health benefits. The health results were based on observational data and assuming a causal relation between dietary risk factors and health outcomes. The certainty of evidence for these relations is mostly graded as moderate in existing meta-analyses.

Reference: BMJ 2020;370:m2322 

Covid-19: Children with conditions managed in primary care may not need to shield

Most children who are managed in a primary care setting for conditions such as asthma, diabetes, epilepsy, and kidney disease may not need to continue to shield and could return to school once they reopen, says new guidance from the Royal College of Paediatrics and Child Health.1

The guidelines set out two groups of shielding patients, with group A being told to continue to shield and group B advised to review whether they need to shield after a conversation between the child, family, and clinician. This update after a review by the college concluded that “not all those children and young people who are currently advised to shield need to continue to do so.”

Full article: BMJ 2020;369:m2374

COVID-19: toolkit for GPs and GP practices. BMA Guidance

Comprehensive guidance for GPs, partners and practice managers to manage employment and contractual issues and service provision during the coronavirus pandemic.

Primary Care–Based Interventions to Prevent Illicit Drug Use in Children, Adolescents, and Young Adults

Importance  In 2017, an estimated 7.9% of persons aged 12 to 17 years reported illicit drug use in the past month, and an estimated 50% of adolescents in the US had used an illicit drug by the time they graduated from high school. Young adults aged 18 to 25 years have a higher rate of current illicit drug use, with an estimated 23.2% currently using illicit drugs. Illicit drug use is associated with many negative health, social, and economic consequences and is a significant contributor to 3 of the leading causes of death among young persons (aged 10-24 years): unintentional injuries including motor vehicle crashes, suicide, and homicide.

Objective  To update its 2014 recommendation, the USPSTF commissioned a review of the evidence on the potential benefits and harms of interventions to prevent illicit drug use in children, adolescents, and young adults.

Population  This recommendation applies to children (11 years and younger), adolescents (aged 12-17 years), and young adults (aged 18-25 years), including pregnant persons.

Evidence Assessment  Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care–based interventions to prevent illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed.

Recommendation  The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent illicit drug use, including nonmedical use of prescription drugs, in children, adolescents, and young adults. (I statement)

Reference: JAMA. 2020;323(20):2060-2066.

Covid-19 and pregnancy

Guideline: Coronavirus (COVID-19) Infection in pregnancy

Published by the Royal College of Obstetricians and Gynaecologists (RCOG), with input from the Royal College of Midwives, the Royal College of Paediatrics and Child Health (RCPH), the Royal College of Anaesthetists, and the Obstetric Anaesthetists’ Association.

This summary is based on version 8 of the guideline, published on 17 April 2020 (https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdf)

Full article: BMJ 2020;369:m1672

Toward Universal Deployable Guidelines for the Care of Patients With COVID-19

Guidelines are developed for various reasons, including the emergence of new, potentially practice-changing evidence or a perceived need for guidance in times of uncertainty. The COVID-19 pandemic presents an almost unparalleled example of the latter, prompting the Surviving Sepsis Campaign (SSC) Task Force to rapidly produce Guidelines on the Management of Critically Ill Adults With Coronavirus Disease 2019 (COVID-19).¹ These guidelines are adapted from the well-known 2016 SSC guidelines,² and highlights are excerpted in this issue of JAMA.³ In a brief amount of time, the authors have produced an impressively thorough and expansive set of guidelines, organized as more than 50 recommendations under 4 domains. The intended goal is to reduce unwanted practice variation and provide a focused and informed distillation of the existing evidence in a manner that will be practical for, and accessible to, clinicians in a wide variety of settings around the world. Because COVID-19 is a new disease, the SSC Task Force relied on the expert interpretation of available evidence from analogous conditions, such as sepsis, when generating its recommendation. The intent of the guideline committee is to update the guidelines as evidence specific to the care of patients with COVID-19 emerges.

Full text: JAMA. 2020;323(18):1786-1787.

Managing COVID-19 symptoms (including at the end of life) in the community: summary of NICE guidelines

What you need to know

• Put treatment escalation plans in place for patients with COVID-19 because they may deteriorate rapidly and need urgent hospital admission

• Encourage patients with cough to avoid lying on their back and, for those with a cough that is distressing, to consider short term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution

• Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises, and coordinated breathing training

Full text: BMJ 2020;369:m1461

COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community

NICE | April 2020| COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community

The guideline on managing symptoms provides advice to health professionals on the management of cough, fever, breathlessness and anxiety, delirium and agitation in those with COVID-19.  It includes approaches for managing these symptoms such as considering the use of paracetamol in people with fever.

People are advised to first treat a mild cough with simple measures and should also avoid lying on their back as this can make coughing, which helps clear the lungs, more difficult. If the cough is more severe and distressing, codeine linctus, codeine phosphate tablets or morphine sulfate oral solution could be considered for short-term use.

Further guidelines will be announced in due course but are likely to include: COPD; Cystic fibrosis and dermatological conditions in people receiving immunotherapy. NICE will publish new guidelines each based on the priorities for patients and the NHS.

COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community