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National Collaborating Centre for Mental Health (UK). Depression in Children and Young People: Identification and Management in Primary, Community and Secondary Care. Leicester (UK): British Psychological Society; 2005. (NICE Clinical Guidelines, No. 28.)

Cover of Depression in Children and Young People

Depression in Children and Young People: Identification and Management in Primary, Community and Secondary Care.

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8Service configurations

8.1. Implications for service configuration

8.1.1. Introduction

The recommendations in this guideline have been devised to take account of the four-tier model of service organisation and are consistent with the National Service Framework (NSF) for Children, and therefore will not require an organisational framework outside of the main structures proposed by the NSF. However, the guidance is likely to have significant implications for service capacity. Depression in children and young people is currently a poorly recognised and under-reported disorder; as the number of children and young people with depression receiving treatment and help increases, so will the workload.

It is important to note that, consistent with current government policy regarding all children's services, the recommendations will have specific implications for healthcare professionals throughout all four tiers, but will also have relevance for non-healthcare professionals involved in the care of children and young people, including some voluntary organisations. This chapter will describe how services for children and young people are organised, highlight some of the problems in the current organisation of services for young people with depression and outline a ‘stepped care’ model used to structure the care pathway for this guideline. As better functional integration of children's services is a key to both the NSF and this guideline, this chapter will specify referral criteria for the movement of depressed children and young people between tiers, and identify methods of monitoring progress for patients and services.

In addition, the second part will review the current role and the evidence underpinning the use of inpatient units in the treatment of children and young people with depression.

8.1.2. Organisation of services

Interventions for children with depression may be provided by specialist CAMHS, but many children are significantly helped by non-specialist health, social work or education services. In order to recognise the different levels of interventions for many child mental health problems, CAMHS has increasingly been considered to have four main levels, or tiers, of delivery (NHS Health Advisory Service, 1995; see Appendix O). The National Service Framework for Children's Services (Department of Health, 2004), supported by priorities for the CAMHS grant, has defined the key service components for a comprehensive CAMHS that each Primary Care Trust should ensure is in place in each area by 2006. Such comprehensive services should have, at each tier, appropriately trained staff and services which can prevent, identify, and either treat or contribute to the treatment of depression in children and young people. There should also be CAMHS for children with disabilities across all tiers. Where the source of depression may lie with the facts and consequences of their disability, disabled children who suffer from moderate/severe depression should be offered treatment from these specialist CAMHS for children with disabilities. Less severely depressed children with disabilities, where the depression is not necessarily a consequence of their disability, can be seen in mainstream services. Where some of the interventions proposed such as complex talking therapies, are not feasible to deliver for some disabled children (deaf children for example), then modifications of these interventions should be provided by specialist CAMHS teams for children with disabilities. This may be extremely challenging for services.

Tier 1 services include services that have primary or direct contact with youth, primarily for reasons other than mental health. These services include primary care/general practice, counselling and psychotherapy, general paediatrics, social services, health visitors and schools. Although their primary task is not working with child mental health problems, they are the first point of contact with the child/family with mental health problems.

Tier 1 services should be able to draw on specialist CAMHS personnel who can consult and advise them about working with children and young people in their care who either have, or are at risk of developing, a mental health problem. For some children, additional input from an adult they already know may be more acceptable and effective than referral to specialist services. At this level, an important role is to understand the risks for depression amongst the children in their care, but also to detect those at high risk or those who have succumbed to depression.

Tier 2 services refer to those specialist CAMHS professionals working in a community-based setting alongside tier 1 workers, and therefore work in primary care, schools and other relevant community settings such as social services. Tier 2 staff usually work as a part of a team, with tier 1 staff, built around the individual child. In this position, tier 2 CAMHS professionals can provide fairly rapid assessment and treatment to children within tier 1 settings, as well as consultation/support to tier 1 workers. This is an important means by which less severely depressed children with lower levels of complexity can access help and treatment in a less stigmatising community-based setting. They will also be able to help identify those children needing referral to more specialist services. Often tier 2 professionals are also organised into multidisciplinary teams, with good links to tier 3 services, thereby facilitating a more seamless transition across tiers. It should be noted that sometimes, tier 2 services are provided by the voluntary sector (for example, some but not all adolescent counselling and psychotherapy services).

Tier 3 services comprise multidisciplinary teams of specialist CAMHS professionals working in (secondary care) specialist CAMHS facilities (e.g. Child and Family Consultation Services or Hospital Liaison Teams). The National Service Framework for Children's Services states that all PCT areas should have at least one comprehensive tier 3 multidisciplinary CAMHS team. They should provide specialist co-ordinated assessments and interventions, and should be able to offer the full range of appropriate psychological and pharmacological treatments.

Outreach services should also be available to those young people who are too depressed or housebound to access tier 3 services based in secondary care facilities, or to work in conjunction with outpatient treatment plans (e.g. monitoring of medication). Emergency services, with 24-hour availability should also be in place in all localities.

Importantly, tier 3 professionals can also provide consultation and training to tier 1 workers and refer when necessary to tier 4 services.

Tier 4 services are highly specialised tertiary CAMHS that provide multidisciplinary services for very severe depression (and other serious mental health problems), or for those who need very intensive treatment or supervision. These services vary in how they are organised. Some are acute adolescent or children's inpatient units, day hospitals and specialist treatment centres. Referrals to tier 4 units only come from tier 3 CAMHS professionals, usually a consultant child and adolescent psychiatrist, and patients are discharged back to tier 3 services or outreach services after admission.

Finally, protocols with adult mental health services need to be in place to ensure the smooth transition of young people to adult services when they turn 18. Such protocols need to ensure that access criteria to adult services are consistent with young people who have been previously treated by CAMHS. Adult services also need protocols in place for young people admitted to adult wards, which should include liaison with and involvement of CAMHS.

8.1.3. Problems in the current organisation of services for young people with depression

In the developed countries there is a low spend on mental health services in general compared with other medical services, despite the WHO highlighting the high priority for mental illness services worldwide (World Health Organization, 2001). Within the general mental health budget child mental health services often struggle to find new monies for development. Recently, however, there has been a significant increase in funding for CAMHS, both directly to PCTs and through the CAMHS grant.

Alternative sources of funding in England and Wales can be identified in other public sector services including social services, education and the home office. The emphasis for non-health funds is social care, diminishing the rates of anti-social behaviour in the community and ameliorating the effects of deprivation. Service development for non-health organisations is focused currently on community-based interventions for at risk families, provision of parenting programmes to those with young (generally under 7 years) children, and support for schools through enhancement of the child worker system aimed at behaviourally disturbed children. Although there is an increasing interest in trying to increase CAMHS access to schools – indeed the CAMHS grant can now be used to set up services in tier 2 (including schools and primary care) – the focus of developments in these areas is away from the needs of young people with depression. This is made all the more problematic because, currently, there is a moderate to low priority within NHS commissioning groups to increase funding to tier 3 outpatient services focused on current psychiatric illness in young people.

The structure of CAMHS is highly variable, at least partly as a result of successive restructuring exercises. For example, CAMHS can be found in primary care trust services, as well as mental health trusts, and some CAMHS have had their services split and inserted into non-NHS organisations. Primary care mental health professionals for children and young people may be employed within PCTs, outside of the tier 3 CAMHS, although with a strong liaison to these colleagues. These arrangements have led to some confusion: currently, ‘specialist CAMHS’ hospital or clinic-based outpatient and inpatient services are seen as ‘mental health’, whereas services involving liaison to other resources, such as schools, child protection, prevention and advisory services, are seen as ‘community’. In addition, locality-based priorities have increased the plethora of differentiated service provision, but again with an emphasis on a reduction in antisocial behaviour, improving parenting skills and enhancing child protection. It is perhaps these problems that have, at least in part, led to the development of an NSF for children's services. Indeed, the NSF for children emphasises a more comprehensive and functionally integrated approach, with a target for all local services to increase access to CAMHS by 10% year on year (Department of Health, 2004).

8.1.4. A ‘stepped care’ approach to organising services

The current arrangement of CAMHS into four tiers lends itself to a ‘stepped care’ approach. A stepped care model for service delivery starts with service provision being close to a person's home and place of work or education. At this level, patients have the more common and usually milder problems amenable to simpler interventions; the professionals at this level will be operating within primary and community sites. At this level assessment skills are needed for detection, and monitoring progress. When more complex problems present that require skills beyond this level, referral to the next step will be needed, based upon clear and agreed referral criteria. Sometimes interventions will be tried at the lowest step that prove unsuccessful, or the patient's condition becomes worse, then referral should follow, again based upon agreed referral criteria. The higher steps involve increasing specialisation and will be required for the more complex and difficult problems, or for those at higher risk, or where treatment has failed at lower levels.

For CAMHS, the tiered model is, effectively a ‘stepped care’ approach. However, because the lower tiers (1 and 2) vary geographically, in terms of the services provided and the types of professionals and interventions available in some areas, interventions delivered at tier 2 will be delivered by tier 3, or even tier 1, in another area. This has been accommodated in the care pathway developed for this guideline, and is simply illustrated in Figure 11.

Figure 11. The stepped care model.

Figure 11

The stepped care model.

8.1.5. Integrated working across tiers

There are a number of ways that integrated working can be enhanced. In any event, clear protocols for communication between tiers, the provision of training by specialist services for those based in lower tiers and joint planning will be needed. Moreover, it is accepted that, given the different ways in which services are organised, each locality may need to ensure integration in different ways. Some important issues are highlighted below.

8.1.5.1. Liaison and direct input to secondary education

CAMHS tier 2 or 3 staff will be expected to provide training for tier 1 staff. For depression in children and young people, as part of a targeted detection approach, it is recommended that this is particularly focused on pastoral support staff in secondary schools and educational services for young people excluded or non-attending mainstream provision i.e. pupil referral units, home education provision and so on. Depending on local protocols, this training may be inclusive of school nurses, school counsellors, special educational needs co-ordinators and whoever is involved in the identification of troubled young people in the school setting. In addition, it may be appropriate for tier 2 CAMHS to deliver individual or group interventions in the school setting and to provide advice to school staff about young people who may need to be referred to a tier 3 CAMHS team. In order to deliver this service, we recommend that each secondary school and secondary pupil referral unit should have a primary mental health worker (or CAMHS link worker) as part of tier 2 provision within the locality.

8.1.5.2. Links with other services for high-risk groups

CAMHS provision to services for looked after children and abused children should develop systems for the detection and treatment of depression in this population. Individuals in young offenders' institutions represent a further high-risk group. Refugees and other ‘very high-risk groups’ detailed in section 4.3.5 require special service provision as do children with disabilities where the depression is arising from this source.

8.1.6. Specialist teams for depression in children and young people?

In order for a tier 3 team to achieve these outputs and to deliver effective and informed psychological therapies, it is essential for a number of clinicians within the service to develop a special interest in mood disorders in children and young people. The exact structure governing how a team will organise themselves with respect to this requirement will vary. In some services it may be appropriate for a team to develop a specialist mood disorders team, whereas in other services a more integrated model of service may be more appropriate. Attention will need to be given to the service interface between management of self-harm, suicide attempts and depression, particularly with respect to the management of children and young people presenting with self-harm at local accident and emergency units.

8.1.7. Referral advice across tiers

To aid in the functional integration of CAMHS using this stepped care model, the following referral advice have been developed by the GDG.

Factors for referral to tier 1

  • Exposure to a single uncomplicated undesirable event in the absence of other risk factors for depression
  • Exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm
  • Exposure to a recent undesirable life event in the context of multiple-risk histories for depression in one or more family members (parents or children) providing that there is no evidence of depression and/or self-harm
  • Uncomplicated mild depression.

Factors for referral to CAMHS tiers 2 and 3

  • Depression with 2 or more other risks for depression
  • Depression with multiple risk histories in another family member (parent or siblings)
  • Mild depression which has not responded to interventions in tier 1 after 2 to 3 months
  • Moderate or severe depression (including psychotic depression)
  • Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression
  • Unexplained self-neglect of at least 1 month's duration that could be harmful to the physical health of the child/young person
  • Actively suicidal ideas or plans in the child/ young person.

Factors for referral to CAMHS tier 4

  • High recurrent risk of acts of self-harm or suicide
  • Significant, ongoing self-neglect (for example, poor personal hygiene, or significant reduction in eating that could be harmful to the physical health of the child/young person)
  • Intensity of assessment/treatment and/or level of supervision that is not available in tiers 2/3.

8.1.8. Transfer to adult services

There is considerable geographical variation in the arrangements for transfer of a young person from CAMHS to adult services in England and Wales. This has, in part, resulted from locally negotiated rules regarding the referral process and issues of responsibility in an ever-changing environment. In many areas, existing agreements between CAMHS and adults services work well for all parties; this guidance is most likely to be of use to those areas where agreements are not yet in place.

When a young person reaches 17/18 years of age and is receiving treatment and care from CAMHS, CAMHS should normally continue to provide care in accordance with this guideline until discharge is considered appropriate. There may be occasions where it is felt that earlier referral may be appropriate and in these circumstances agreement should be made between CAMHS and adult services on an individual case basis. When a young person reaches 18 years of age and is receiving treatment for a second or subsequent episode of depression, the CAMHS should again normally continue to provide care in accordance with this guideline.

CAMHS and adult services should work co-operatively using the care programme approach (as is good practice for transferring across any services), to ensure smooth transfer to the adult service. This approach is especially important for young people with recurrent depression or those with severe and/or psychotic depressions, as these groups are often impaired by symptoms and in addition, their sense of autonomy may be damaged. It is important therefore that on discharge from CAMHS, young people with a history of recurrent severe or psychotic depression, are adequately prepared for transfer and provided with good information about the treatment they may receive under the care of an adult service. Referral to adult services is not normally required for young people recovering from a single uncomplicated episode of mild to moderate depression.

8.1.9. Summary

CAMHS has four main levels, including services that have primary contact with child and young people and their families/carers, specialist services working in the community, multidisciplinary teams working in secondary care and highly specialised tertiary services.

Problems in the current organisation of services include service development for non-health organisations (e.g. schools), variability of services across the country with varying locality-based priorities, confusion about the specific definitions of the tiers (particularly tier 2 or 3).

The tier system lends itself to a stepped care approach with specific foci and actions linked to particular tiers along the care pathway for depression in children and young people. Integrated working across tiers may be enhanced through direct input into secondary education and links with non-mental health services for high-risk groups. Specialist teams within tier 3 for depression in children and young people may enhance the quality of services.

When a young person becomes 18 years of age while receiving treatment and care from CAMHS, CAMHS should continue to provide care in accordance with this guideline. CAMHS and adult services should work co-operatively using the care programme approach to ensure smooth transfer to adult services for those with recurrent depressions. They should prepare young people for transfer and provide good information about treatment for adults, and about local services.

8.2. Inpatient units in the treatment of depression

8.2.1. Introduction

Children and young people with depression are rarely admitted to specialist psychiatric inpatient units, with only approximately 400 admissions per annum in England and Wales (O'Herlihy et al., in press). Often, when admission is considered necessary, there will be no alternative due to the level of risk, use of mental health legislation or a lack of alternative intensive treatments or supervision available in the community.

The research evidence for the efficacy of inpatient treatment is extremely limited for most, if not all, psychiatric problems across the age range, including young people with depression. A systematic review of the literature revealed no randomised controlled trials specifically looking at admission as a treatment modality for depression in children and young people. There are a number of studies using less rigorous research design methods looking at outcomes for this group, but many of these were carried out in the United States where services are configured differently. Most studies using inpatient samples of depressed young people are designed to explore the impact of interventions other than the effect of admission.

The provision of inpatient units for children and young people within England and Wales is variable (O'Herlihy et al., 2003). Some inpatient services offer acute admission facilities; some longer-stay therapeutic treatment environments and others attempt to offer both. There are also units that specialise in treating specific disorders, such as anorexia nervosa, but none that specialise solely in the treatment of depression.

Of considerable concern, is the finding in one study in the North West of England, which suggested that for young people with a principal diagnosis of mood disorder, more are admitted to other hospital wards, including adult mental health wards and paediatric wards, than to specialist psychiatric inpatient units for young people (Gowers et al., 2001).

For the purposes of this section, inpatient treatment will refer to specialist child and adolescent psychiatric inpatient provision.

8.2.2. Current practice

8.2.2.1. Indications for admission

Garralda (1986) and Wolkind and Gent (1987) in UK studies, not specific to depression, found criteria for admission included failure of outpatient treatment, difficulties with assessment or diagnosis, family difficulties and the need for 24-hour observation or care. Wrate et al., (1994) in a UK multi-centre prospective study looked at reasons for admission in 276 young people admitted to specialised adolescent psychiatric units. The reasons given were: to provide a detailed psychiatric assessment (51%); to establish better therapeutic control of a case (36%); to provide a therapeutic peer group experience (36%); to obtain improved control over the adolescent's behaviour (26%); to relieve outpatient colleagues from a treatment failure (20%); to assess or facilitate future placement needs (19%); to provide relief to exhausted parents (18%); to achieve psychological separation between parents and the patient (17%); and to provide an outpatient with schooling otherwise unavailable (9%).

Further surveys of criteria for admission to inpatient units have been carried out in the US (Costello et al., 1991; Pottick et al., 1995). Again, the studies were not specific to depression and generally replicate the UK findings, but also include factors specific to the US, such as the presence of insurance cover (Pottick et al., 1995). Costello et al. (1991) developed a checklist of criteria which had good predictive value when determining whether or not a child needed admission. However, admission rates in the US are much higher than the UK, one study suggesting by approximately five times (Maskey, 1998). Clearly, caution is needed in applying such findings to settings in England and Wales.

Admission criteria in the UK continue to vary between individual inpatient units, but generally now fall into three broad categories (see Cotgrove, 2001; Green, 2002).

  1. High risk: admission may be indicated when there are high levels of risk to the child/young person, secondary to suicidal thoughts or behaviours or self-neglect, beyond the capacity of the family and community-based services to manage.
  2. Intensive treatment: when the intensity of treatment needed is not available from other services. This is more commonly the case when depression is associated with other psychosocial difficulties, and/or comorbid disorder resulting in difficulties pervading all aspects of the child/young person's life.
  3. Intensive assessment: an inpatient unit can offer 24-hours-a-day assessment and supervision by a multidisciplinary team to gather information to guide further management. This may involve observing the child/young person's behaviour and their interaction with others, observing the effects of a specific intervention, such as the use of medication, or allowing time for a range of investigations to be carried out, such as cognitive assessments or physical investigations. The admission can also allow for the assessment of the child/young person's difficulties out of the context of their home or school. For example, a young person may appear severely depressed in the context of a problematic home environment or associated with bullying at school, but their mood may lift significantly when admitted. This information can be helpful in guiding future management whether or not further inpatient treatment is indicated. Inpatient assessment may also aid diagnosis. Young people with features of an emerging personality disorder, for example, may present with variable mood, including depression. Evidence of such comorbid disorder can help guide future management.

8.2.2.2. Contra-indications or risks of admission

It is important when considering an admission, that the potential benefits are balanced against potential harm. There is a range of reasons why inpatient treatment may not be appropriate:

  • There may be concerns about admitting a particularly vulnerable depressed child/young person into an environment where there were high levels of disturbance potentially compounding their distress
  • An impressionable child/young person admitted to an environment with high levels of deliberate self-harm or acting out behaviours is at risk of acquiring additional dysfunctional behaviours or coping strategies, even where a skilled and experienced staff team openly address such difficulties
  • If protracted, an admission runs the risk of ‘institutionalisation’ for the young person, including loss of support from the child's local environment, and detrimental effects on family life (Green & Jones, 1998)
  • Inpatient treatments are expensive (e.g. Green et al., 2001).

For these reasons inpatient admission is often considered a last resort.

8.2.3. Evidence of the efficacy of inpatient treatment

Most of the evidence of efficacy of inpatient treatment comes from single sample pre-test, post-test studies with no control or comparison groups. In many of these studies, outcome ratings are made by the treating clinician, introducing the possibility of rater-bias. Inpatient populations tend to be a heterogeneous group with relatively small numbers, hence few studies specifically look at treatment effects of inpatient admissions for young people with depressive disorder. Randomised controlled trials would not be an appropriate design in this context as the need for admission is often a direct consequence of alternatives being either unavailable or involving unacceptable risks. Nevertheless, when competing alternatives are justifiable and available, controlled studies become a possibility.

8.2.3.1. Controlled trials – United States

A small number of controlled trials comparing inpatient treatment with outpatient treatment have been carried out in the United States. Flomenhaft (1974) and Winsberg et al., (1980) just looked at young people with anti-social behaviour or externalising disorder.

The most recently published randomised controlled trial (Henggeler et al., 1999) conducted in the US compared a home-based multi-systemic therapy (MST) with brief (1–2 week) inpatient psychiatric hospitalisation. MST offers a range of therapeutic interventions designed to impact on multiple determinants of the young person's key problems arising from the individual, family, peers, school and community. The sample was 113 adolescents, aged 10–17 years, who had been approved for emergency psychiatric hospitalisation. Inclusion criteria included the presence of symptoms of suicidal ideation, homicidal ideation, psychosis, or threat of harm to self or others due to mental illness severe enough to warrant psychiatric hospitalisation. When interpreting the results it is notable that 44% of the ‘home-based’ treatment sample also received hospitalisation. In addition, it appears that the MST group benefited from a far more intensive individualised therapeutic intervention. Only 15 of the sample received a diagnosis of depression according to the Diagnostic Interview Schedule for Children, so it is not possible to draw significant conclusions about this subgroup. However, hospitalisation was more effective in improving young people's self-esteem. Multi-systemic therapy was more effective in decreasing the young people's externalising (behavioural) symptoms.

8.2.3.2. Other studies – UK

Rothery et al. (1995) reviewed outcomes according to a set of 16 predetermined treatment goals and diagnosis in a multi-centre study of 320 consecutive admissions to four specialist adolescent units in the UK. Forty-four did not give consent, leaving 276 in the study. Of the 7% diagnosed (by clinical assessment carried out by the multidisciplinary team) with a ‘major depressive illness’, 90% were rated as having improved affective symptoms at discharge using a clinician rated 5-point scale.

Sheerin and colleagues (1999) studied a sample of 29 consecutive admissions (results from 26 reported) to a psychiatric inpatient unit for children aged 3–13 years (mean age = 8.6 years) in Scotland. At 3-month and 15-month post-discharge follow-up in a subgroup with depressive symptoms (n = 17), they found a significant reduction in symptoms (p<0.05) as rated by the Birleson Depression Scale between admission and at both 3- and 15-month follow-up.

Green and colleagues (2001), in an English study, looked at 55 consecutive admissions of children and adolescents aged 6–17 years (mean 11.4 years) to two inpatient units from late 1995 to 1997. Referrals came from other child mental health specialists. Health gain was inferred from change scores in a range of measures taken at referral, admission, discharge and 6-month follow-up. Measures were made from multiple perspectives, including family, teacher, clinician and an independent researcher. Measures of C-GAS and Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) showed no significant changes between referral and admission (waitilist control). Median waiting list time was 3 months. Significant health gain was found on most measures by discharge and sustained at follow-up. The sample included 40% with a primary mood disorder, but no separate analysis is reported for children and adolescents with depressive disorder.

Jacobs and colleagues (2005) have repeated the Green and colleagues (2001) study on a larger scale (n = 155). The sample consisted of sequential admissions of children and adolescents aged 3–17 years (mean 13.9 years) to eight UK inpatient units (four child, four adolescent) between January 2001 and April 2002). Diagnosis at admission was made using the researcher-rated schedule of affective disorders for children (K-SADS). A range of measures was used to monitor symptom change and health gain before admission, during admission and 1 year following discharge. Significant improvements were found in global functioning, psychopathology and ‘cardinal problem’ measures at discharge, which were maintained at 1-year follow-up. This compared with a much smaller (although still significant) improvement whilst on the waiting list. The findings based on the whole sample analysis remain significant for a subgroup with the diagnosis of depressive disorder. This subgroup is 44 on the basis of the clinicians ICD-10 diagnosis or 66 when the K-SADS is used, illustrating a difference in rates of diagnosis depending on whether diagnosis is based on use of a diagnostic instrument or clinical judgement. Clinical outcome ratings in this study rely largely on treating clinician scores for the C-GAS and the HoNOSCA.

Gowers and colleagues (2000) used the HoNOSCA, a crude outcome measure rated by the treating clinician, on 35 consecutive admissions to an adolescent unit in England. This showed significant reductions in HoNOSCA scores between admission and discharge of 18.0 to 9.3 respectively in clinician-rated scores (p < 0.001) and 18.3 to 12.6 respectively in user-rated scores (p < 0.001).

8.2.4. Predictors of outcome

Pfeiffer and Strzelecki (1990) carried out a literature search using MEDLINE, the Psychological Information Database and Mental Health Abstracts to look for publications on outcome and follow-up investigations of residential and inpatient psychiatric hospitalisations between 1975 and 1990. Thirty-four studies were identified. When analysing the findings weightings were applied that reflected sample size. These studies were not specific to depression in children and young people. They found a positive relationship between good outcome and the following factors:

  • Specific characteristics of treatments (for example, completion of treatment programme, planned discharge and therapeutic alliance)
  • The use of after care
  • Level of family functioning and involvement with treatment
  • Length of stay (longer)
  • Higher intelligence.

Some symptom areas were found to be associated with poorer outcomes, such as:

  • Presence of psychotic symptoms
  • Bizarre symptoms
  • Anti-social behaviours
  • Under-socialised aggressive conduct disorder.

Kutash and Rivera (1996) carried out a systematic review of subsequent studies using a similar methodology, finding additional support for Pfeiffer and Strzelecki's conclusions and in particular under scoring the benefit of family participation.

More recent studies have confirmed and clarified the following factors as predictors of outcome: length of stay (Sheerin et al., 1999; Green et al., 2001; Jacobs et al., 2005); therapeutic alliance between the child and their family with the inpatient team, and family participation in the therapeutic process (Green et al., 2001; Jacobs et al., 2005); pre-admission family functioning (King et al., 1997; Green et al., 2001); and severity of depressive symptoms (King et al., 1997).

8.2.5. Issues of consent for admission

It is desirable to admit young people with both the informed consent of both the patient and their parents, not least because the success of any treatment approach significantly depends upon the development of a positive therapeutic alliance between the child, the family and the inpatient team. However, there may be times when professionals consider admission to be necessary, but either the young person or the family do not consent.

If a young person below 18 years of age refuses treatment, but the parent (or guardian) believe strongly enough that treatment is desirable, then the young person's wishes may be overruled. On the other hand, a child has the right to consent to treatment after their 16th birthday, or younger, if deemed ‘Gillick competent’, without involving the consent of the parents. Whilst the use of parental consent is legal, it is now considered good practice to only use parental consent for up to 2 weeks. In other contexts, the use the Mental Health Act 1983 should be considered as it includes safeguards such as the involvement of other professionals, a time limit and a straightforward procedure for appeals and regular reviews.

Alternative legislation includes using a care order (Section 31) under the Children Act 1989 or a specific issue order (Section 8). Both of these options normally involve social services and can be time consuming. Another, more rapid alternative to the Children Act, is to apply for a Wardship Order, which in an emergency can be organised over the phone. It should be noted that at the time of writing, a new Mental Health Bill is under consideration which may alter current practice in this area.

8.2.6. Clinical summary

For some young people and children with depression, particularly those at high risk of self-harm or neglect, or needing intensive assessment and/or treatment, there is often no alternative to inpatient admission. Although there are no randomised control trials specifically looking at psychiatric inpatient admission as a treatment for children and young people with depressive disorder, there are a number of studies using other methodologies suggesting that young people with depression have good outcomes from a period of admission. Clinical factors which appear to predict outcome, include: specific characteristics of treatments (for example, completion of treatment programme, planned discharge and therapeutic alliance), the use of after care, the level of family functioning pre-admission, the level of family involvement with treatment, length of stay (longer), and higher intelligence. Little is known about the impact of service and treatment variables within the inpatient setting.

8.3. Clinical practice recommendations

8.3.1. Service configuration

8.3.1.1.

CAMHS and PCTs should consider introducing a primary mental health worker (or CAMHS link worker) into each secondary school and secondary pupil referral unit as part of tier 2 provision within the locality. (GPP)

8.3.1.2.

In the provision of training by CAMHS professionals for healthcare professionals in primary care, schools and relevant community settings, priority should be given to the training of pastoral support staff in schools (particularly secondary schools), community paediatricians and GPs. (GPP)

8.3.1.3.

Primary mental health workers (or CAMHS link workers) should establish clear lines of communication between CAMHS and tier 1 or 2, with named contact people in each tier or service, and develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2. (GPP)

8.3.1.4.

CAMHS and PCTs should routinely monitor the rates of detection, referral and treatment of children and young people, from all ethnic groups, with mental health problems, including those with depression, in local schools and primary care. This information should be used for planning services and made available for local, regional and national comparison. (GPP)

8.3.1.5.

All healthcare professionals should routinely use, and record in the notes, appropriate outcome measures (such as those self-report measures used in screening for depression or generic outcome measures used by particular services, for example Health of the Nation Outcome Scale for Children and Adolescents [HoNOSCA] or Strengths and Difficulties Questionnaire [SDQ], for the assessment and treatment of depression in children and young people. This information should be used for planning services, and made available for local, regional and national comparison. (GPP)

8.3.1.6.

If children and young people who have previously recovered from moderate or severe depression begin to show signs of a recurrence of depression, healthcare professionals in primary care, schools or other relevant community settings should refer them to CAMHS tier 2 or 3 for rapid assessment. (GPP)

8.3.2. Referral criteria

It is acknowledged that whilst conforming to the broad principles of a tiered service as suggested in the National Service Framework, local circumstances require different local solutions to the development of a tiered CAMHS. These criteria are intended to provide broad guidance about referral of children and young people to the appropriate CAMHS tier and must be interpreted in the light of local service characteristics. Decisions about referral should always be discussed with the child/young person and their carers whose wishes need to be take into account.

8.3.2.1.

For children and young people, the following factors should be used by healthcare professionals as indications that management can remain at tier 1:

  • exposure to a single undesirable event in the absence of other risk factors for depression
  • exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm
  • exposure to a recent undesirable life event, where one or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child or young person
8.3.2.2.

For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 2 or 3 CAMHS:

  • depression with two or more other risks for depression
  • depression where one or more family members (parents or children) have multiple-risk histories for depression
  • mild depression in those who have not responded to interventions in tier 1 after 2 to 3 months
  • moderate or severe depression (including psychotic depression)
  • signs of a recurrence of depression in those who have recovered from previous moderate or severe depression
  • unexplained self-neglect of at least 1 month's duration that could be harmful to their physical health
  • active suicidal ideas or plans
  • referral requested by a young person or their parent(s) or carer(s). (GPP)
8.3.2.3.

For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 4 services:

  • high recurrent risk of acts of self-harm or suicide
  • significant ongoing self-neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health)
  • requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3. (GPP)

8.3.3. Transfer to adult services

8.3.3.1.

The CAMHS team currently providing treatment and care for a young person aged 17 who is recovering from a first episode of depression should normally continue to provide treatment until discharge is considered appropriate in accordance with this guideline, even when the person turns 18 years of age. (GPP)

8.3.3.2.

The CAMHS team currently providing treatment and care for a young person aged 17–18 who either has ongoing symptoms from a first episode that are not resolving or who has, or is recovering from, a second or subsequent episode of depression should normally arrange for a transfer to adult services, informed by the Care Programme Approach. (GPP)

8.3.3.3.

A young person aged 17–18 with a history of recurrent depression who is being considered for discharge from CAMHS should be provided with comprehensive information about the treatment of depression in adults (including the NICE ‘Information for the public’ version for adult depression) and information about local services and support groups suitable for young adults with depression. (GPP)

8.3.3.4.

A young person aged 17–18 who has successfully recovered from a first episode of depression and is discharged from CAMHS should not normally be referred on to adult services, unless they are considered to be at high risk of relapse (for example if they are living in multiple-risk circumstances). (GPP)

8.3.4. Inpatient treatment

8.3.4.1.

Most children and young people with depression should be treated on an outpatient or community basis. (C)

8.3.4.2.

Inpatient treatment should be considered for children and young people who present with a high risk of suicide, high risk of serious self-harm or high risk of self-neglect, and/or when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated. (C)

8.3.4.3.

When considering admission for a child or young person with depression, the benefits of inpatient treatment need to be balanced against potential detrimental effects, for example loss of family and community support. (C)

8.3.4.4.

When inpatient treatment is indicated, CAMHS professionals should involve the child or young person and their parent(s) or carer(s) in the admission and treatment process whenever possible. (B)

8.3.4.5.

Commissioners and strategic health authorities should ensure that inpatient treatment is available within reasonable travelling distance to enable the involvement of families and maintain social links. (B)

8.3.4.6.

Commissioners and strategic health authorities should ensure that inpatient services are able to admit a young person within an appropriate timescale, including immediate admission if necessary. (GPP)

8.3.4.7.

Inpatient services should have a range of interventions available including medication, individual and group psychological therapies and family support. (C)

8.3.4.8.

Inpatient facilities should be age appropriate and culturally enriching with the capacity to provide appropriate educational and recreational activities. (C)

8.3.4.9.

Planning for aftercare arrangements should take place before admission or as early as possible after admission and should be based on the Care Programme Approach. (GPP)

8.3.4.10.

Tier 4 CAMHS professionals involved in assessing children or young people for possible inpatient admission should be specifically trained in issues of consent and capacity, the use of current mental health legislation, and the use of childcare laws, as they apply to this group of patients. (GPP)

Copyright © 2005, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK56431

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