Step 3

This is for patients for whom Step 2 measures have not achieved an adequate response to two or more interventions, and for individuals who have moderate to severe depression, plus those with:

• Episodes of depression less than a year apart
• Current or historic signs that indicate the possibility of bipolar disorder
• Persistent suicidal thoughts
• Signs of self-neglect.

At this level, antidepressant medication is likely to be combined with high-intensity psychological interventions such as CBT. Referral to mental health specialists in secondary care may be necessary.

Step 4 

This is for patients with severe and complex disease. High intensity psychological interventions, combined treatments, higher risk medication, multiprofessional and in-patient care, which may involve electroconvulsive therapy, and crisis teams come in at this step.