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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.)

9Summary of recommendations

9.1. Key recommendations for implementation

9.1.1. Assessment and coordination of care

When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient's notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers.

9.1.2. Treatment considerations in all settings

Psychological therapies used in the treatment of children and young people should be provided by therapists who are also trained child and adolescent mental healthcare professionals.

Comorbid diagnoses and developmental, social and educational problems should be assessed and managed, either in sequence or in parallel, with the treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care.

Attention should be paid to the possible need for parents' own psychiatric problems (particularly depression) to be treated in parallel, if the child or young person's mental health is to improve. If such a need is identified, then a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services.

9.1.3. Step 1: Detection and risk profiling

Healthcare professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression, and to assess children and young people who may be at risk of depression. Training should include the evaluation of recent and past psychosocial risk factors, such as age, gender, family discord, bullying, physical, sexual or emotional abuse, comorbid disorders, including drug and alcohol use, and a history of parental depression; the natural history of single loss events; the importance of multiple risk factors; ethnic and cultural factors; and factors known to be associated with a high risk of depression and other health problems, such as homelessness, refugee status and living in institutional settings.

CAMHS tier 2 or 3 should work with health and social care professionals in primary care, schools and other relevant community settings to provide training and develop ethnically and culturally sensitive systems for detecting, assessing, supporting and referring children and young people who are either depressed or at significant risk of becoming depressed.

9.1.4. Step 2: Recognition

Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer-based instruments (such as Kiddie-Sads [K-SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) could be used for this purpose but will require modification for regular use in busy routine CAMHS settings.

9.1.5. Step 3: Mild depression

Antidepressant medication should not be used for the initial treatment of children and young people with mild depression.

9.1.6. Steps 4 and 5: Moderate to severe depression

Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual CBT, interpersonal therapy or shorter-term family therapy; it is suggested that this should be for at least 3 months' duration).

Antidepressant medication should not be offered to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy. Specific arrangements must be made for careful monitoring of adverse drug reactions, as well as for reviewing mental state and general progress; for example, weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks of treatment. The precise frequency will need to be decided on an individual basis, and recorded in the notes. In the event that psychological therapies are declined, medication may still be given, but as the young person will not be reviewed at psychological therapy sessions, the prescribing doctor should closely monitor the child or young person's progress on a regular basis and focus particularly on emergent adverse drug reactions.

9.2. Guidance

The following guidance is evidence based. The grading scheme used for the recommendations (A, B, C, good practice points [GPP]) is described in Chapter 2; a summary of the evidence on which the guidance is based is provided in Chapters 48.

9.3. Care of all children and young people with depression

9.3.1. Good information, informed consent and support

Children and young people and their families need good information, given as part of a collaborative and supportive relationship with healthcare professionals, and need to be able to give fully informed consent.

9.3.1.1.

Healthcare professionals involved in the detection, assessment or treatment of children or young people with depression should ensure that information is provided to the patient and their parent(s) and carer(s) at an appropriate time. The information should be age appropriate and should cover the nature, course and treatment of depression, including the likely side-effect profile of medication should this be offered. (GPP)

9.3.1.2.

Healthcare professionals involved in the treatment of children or young people with depression should take time to build a supportive and collaborative relationship with both the patient and the family or carers. (GPP)

9.3.1.3.

Healthcare professionals should make all efforts necessary to engage the child or young person and their parent(s) or carer(s) in treatment decisions, taking full account of patient and parental/carer expectations, so that the patient and their parent(s) or carer(s) can give meaningful and properly informed consent before treatment is initiated. (GPP)

9.3.1.4.

Families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate. (GPP)

9.3.2. Language and ethnic minorities

Information should be provided in a language and format that a child or young person and their family or carer(s) can properly understand; interpreters should be engaged when needed. Psychological treatments are also best conducted in the child or young person's first language. Healthcare professionals should be trained to understand the specific needs of depressed children or young people from black and minority ethnic groups. Patients, families and carers, including those from black and minority ethnic groups, should be involved in planning services.

9.3.2.1.

Where possible, all services should provide written information or audiotaped material in the language of the child or young person and their family or carer(s), and professional interpreters should be sought for those whose preferred language is not English. (GPP)

9.3.2.2.

Consideration should be given to providing psychological therapies and information about medication and local services in the language of the child or young person and their family or carers where the patient's and/or their family's or carer's first language is not English. If this is not possible, an interpreter should be sought. (GPP)

9.3.2.3.

Healthcare professionals in primary, secondary and relevant community settings should be trained in cultural competence to aid in the diagnosis and treatment of depression in children and young people from black and minority ethnic groups. This training should take into consideration the impact of the patient's and healthcare professional's racial identity status on the patient's depression. (GPP)

9.3.2.4.

Healthcare professionals working with interpreters should be provided with joint training opportunities with those interpreters, to ensure that both healthcare professionals and interpreters understand the specific requirements of interpretation in a mental health setting. (GPP)

9.3.2.5.

The development and evaluation of services for children and young people with depression should be undertaken in collaboration with stakeholders involving patients and their families and carers, including members of black and minority ethnic groups. (GPP)

9.3.3. Assessment and coordination of care

The assessment of children and young people should be comprehensive and holistic, taking into account drug and alcohol use, the risks of self-harm and suicidal ideations, and the use of self-help materials and methods. Parental depression may be an important contributing factor and needs to be identified.

9.3.3.1.

When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient's notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers. (GPP)

9.3.3.2.

In the assessment of a child or young person with depression, healthcare professionals should always ask the patient and their parent(s) or carer(s) directly about the child or young person's alcohol and drug use, any experience of being bullied or abused, self-harm and ideas about suicide. A young person should be offered the opportunity to discuss these issues initially in private. (GPP)

9.3.3.3.

If a child or young person with depression presents acutely having self-harmed, the immediate management should follow the NICE guideline ‘Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care’ (www​.nice.org.uk/CG016) as this applies to children and young people, paying particular attention to the guidance on consent and capacity. Further management should then follow this depression guideline. (GPP)

9.3.3.4.

In the assessment of a child or young person with depression, healthcare professionals should always ask the patient, and be prepared to give advice, about self-help materials or other methods used or considered potentially helpful by the patient or their parent(s) or carer(s). This may include educational leaflets, helplines, self-diagnosis tools, peer, social and family support groups, complementary therapies, and religious and spiritual groups. (GPP)

9.3.3.5.

Health professionals should only recommend self-help materials or strategies as part of a supported and planned package of care. (GPP)

9.3.3.6.

For any child or young person with suspected mood disorder, a family history should be obtained to check for unipolar or bipolar depression in parents and grandparents. (GPP)

9.3.3.7.

When a child or young person has been diagnosed with depression, consideration should be given to the possibility of parental depression, parental substance misuse, or other mental health problems and associated problems of living, as these are often associated with depression in a child or young person and, if untreated, may have a negative impact on the success of treatment offered to the child or young person. (GPP)

9.3.3.8.

When the clinical progress of children and young people with depression is being monitored in secondary care, the self-report Mood and Feelings Questionnaire (MFQ), should be considered as an adjunct to clinical judgement. (C)

9.3.3.9.

In the assessment and treatment of depression in children and young people, special attention should be paid to the issues of:

  • confidentiality
  • the young person's consent (including Gillick competence)
  • parental consent
  • child protection
  • the use of the Mental Health Act in young people
  • the use of the Children Act. (GPP)
9.3.3.10.

The form of assessment should take account of cultural and ethnic variations in communication, family values and the place of the child or young person within the family. (GPP)

9.3.4. The organisation and planning of services

Better links between CAMHS and tier 1 and tier 2 are needed to improve detection and availability of treatment. All healthcare professionals should monitor detection rates and record outcomes for local planning and local, regional and national comparison.

9.3.4.1.

Healthcare professionals specialising in depression in children and young people should work with local CAMHS to enhance specialist knowledge and skills regarding depression in these existing services. This work should include providing training and help with guideline implementation. (GPP)

9.3.4.2.

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)

9.3.4.3.

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)

9.3.4.4.

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)

9.3.4.5.

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)

9.3.5. Treatment considerations in all settings

Most treatment should be undertaken in outpatient settings or the community. Before treatment is started the social networks around the child or young person need to be clearly identified. If bullying is a factor, school and healthcare professionals should jointly develop antibullying strategies. Psychological treatments should be provided by professionally trained therapists, who should aim to quickly develop an alliance with the child or young person and their family or carer(s). Comorbid conditions will also need to be treated and interventions considered for parents with depression or other significant personal problems. Advice about exercise, sleep and nutrition should also be considered.

9.3.5.1.

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

9.3.5.2.

Before any treatment is started, healthcare professionals should assess, together with the young person, the social network around him or her. This should include a written formulation, identifying factors that may have contributed to the development and maintenance of depression, and that may impact both positively or negatively on the efficacy of the treatments offered. The formulation should also indicate ways that the healthcare professionals may work in partnership with the social and professional network of the young person. (B)

9.3.5.3.

When bullying is considered to be a factor in a child or young person's depression, CAMHS, primary care and educational professionals should work collaboratively to prevent bullying and to develop effective antibullying strategies. (C)

9.3.5.4.

Psychological therapies used in the treatment of children and young people with depression should be provided by therapists who are also trained child and adolescent mental healthcare professionals. (B)

9.3.5.5.

Psychological therapies used in the treatment of children and young people with depression should be provided by healthcare professionals who have been trained to an appropriate level of competence in the specific modality of psychological therapy being offered. (C)

9.3.5.6.

Therapists should develop a treatment alliance with the family. If this proves difficult, consideration should be given to providing the family with an alternative therapist. (C)

9.3.5.7.

Comorbid diagnoses and developmental, social and educational problems should be assessed and managed, either in sequence or in parallel, with the treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care. (B)

9.3.5.8.

Attention should be paid to the possible need for parents' own psychiatric problems (particularly depression) to be treated in parallel, if the child or young person's mental health is to improve. If such a need is identified, then a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services. (B)

9.3.5.9.

A child or young person with depression should be offered advice on the benefits of regular exercise and encouraged to consider following a structured and supervised exercise programme of typically up to three sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. (C)

9.3.5.10.

A child or young person with depression should be offered advice about sleep hygiene and anxiety management. (C)

9.3.5.11.

A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet. (GPP)

9.4. Stepped care

The stepped-care model of depression draws attention to the different needs that depressed children and young people have – depending on the characteristics of their depression and their personal and social circumstances – and the responses that are required from services. It provides a framework in which to organise the provision of services that support both healthcare professionals and patients and their parent(s) or carer(s) in identifying and accessing the most effective interventions (see Table 20).

Table 20. The stepped-care model.

Table 20

The stepped-care model.

The guidance follows these five steps.

  1. Detection and recognition of depression and risk profiling in primary care and community settings
  2. Recognition of depression in children and young people referred to CAMHS
  3. Managing recognised depression in primary care and community settings – mild depression
  4. Managing recognised depression in tier 2 or 3 CAMHS – moderate to severe depression
  5. Managing recognised depression in tier 3 or 4 CAMHS – unresponsive, recurrent and psychotic depression, including depression needing inpatient care.

Each step introduces additional interventions; the higher steps assume interventions in the previous step.

9.5. Step 1: Detection, risk profiling and referral

Healthcare professionals working with children or young people in primary care, schools and the community need training to assess the risk of depression, to provide emotional support and know when to refer, especially when a child or young person has experienced an undesirable life event. CAMHS tier 2 or 3 should work with tier 1 healthcare professionals and help provide training in the recognition of depression.

9.5.1. Detection and risk profiling

9.5.1.1.

Healthcare professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression, and to assess children and young people who may be at risk of depression. Training should include the evaluation of recent and past psychosocial risk factors, such as age, gender, family discord, bullying, physical, sexual or emotional abuse, comorbid disorders, including drug and alcohol use, and a history of parental depression; the natural history of single loss events; the importance of multiple risk factors; ethnic and cultural factors; and factors known to be associated with a high risk of depression and other health problems, such as homelessness, refugee status and living in institutional settings. (C)

9.5.1.2.

Healthcare professionals in primary care, schools and other relevant community settings should be trained in communications skills such as ‘active listening’ and ‘conversational technique’, so that they can deal confidently with acute sadness and distress (‘situational dysphoria’) encountered in children and young people following recent undesirable events. (GPP)

9.5.1.3.

Healthcare professionals in primary care settings should be familiar with screening for mood disorders. They should have regular access to specialist supervision and consultation. (GPP)

9.5.1.4.

Healthcare professionals in primary care, schools and other relevant community settings who are providing support for a child or young person with situational dysphoria should consider ongoing social and environmental factors if the dysphoria becomes more persistent. (GPP)

9.5.1.5.

CAMHS tier 2 or 3 should work with health and social care professionals in primary care, schools and other relevant community settings to provide training and develop ethnically and culturally sensitive systems for detecting, assessing, supporting and referring children and young people who are either depressed or at significant risk of becoming depressed. (GPP)

9.5.1.6.

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)

9.5.1.7.

When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, healthcare professionals in primary care, schools or other relevant community settings should undertake an assessment of the risks of depression associated with the event and make contact with their parent(s) or carer(s) to help integrate parental/carer and professional responses. The risk profile should be recorded in the child or young person's records. (C)

9.5.1.8.

When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, in the absence of other risk factors for depression, healthcare professionals in primary care, schools and other relevant community settings should offer support and the opportunity to talk over the event with the child or young person. (GPP)

9.5.1.9.

Following an undesirable event, a child or young person should not normally be referred for further assessment or treatment, as single events are unlikely to lead to a depressive illness. (C)

9.5.1.10.

A child or young person who has been exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience and is identified to be at high risk of depression (the presence of two or more other risk factors for depression) should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1 and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. (GPP)

9.5.1.11.

When a child or young person is exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, and where one or more family members (parents or children) have multiple-risk histories for depression, they should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1 and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. (GPP)

9.5.1.12.

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)

9.5.2. Referral criteria

9.5.2.1.

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
9.5.2.2.

For children and young people, the following factors should be used by healthcare professionals as referral criteria 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)
9.5.2.3.

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)

9.6. Step 2: Recognition

CAMHS professionals need to improve their ability to recognise depression.

9.6.1.1.

Children and young people of 11 years or older referred to CAMHS without a diagnosis of depression should be routinely screened with a self-report questionnaire for depression (of which the Mood and Feelings Questionnaire [MFQ] is currently the best) as part of a general assessment procedure. (B)

9.6.1.2.

Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer-based instruments (such as Kiddie-Sads [K-SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) could be used for this purpose but will require modification for regular use in busy routine CAMHS settings. (C)

9.6.1.3.

Within tier 3 CAMHS, professionals who specialise in the treatment of depression should have been trained in interviewer-based assessment instruments (such as Kiddie-Sads [K-SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) and have skills in non-verbal assessments of mood in younger children. (GPP)

9.7. Step 3: Mild depression

Some children and young people diagnosed with mild depression may not need or want a specific intervention, but they need to be monitored and followed up, especially if they miss appointments.

9.7.1. Watchful waiting

9.7.1.1.

For children and young people with diagnosed mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks (‘watchful waiting’). (C)

9.7.1.2.

Healthcare professionals should make contact with children and young people with depression who do not attend follow-up appointments. (C)

9.7.2. Interventions for mild depression

After up to 4 weeks of watchful waiting, children and young people with continuing mild depression should be offered a course of non-directive supportive therapy, group CBT or guided self-help. Ideally this should be offered by appropriately trained professionals in tier 1 (primary care, schools, social services and the voluntary sector) but may require a referral to tier 2 CAMHS depending on local resources. If this is ineffective within 2 to 3 months, they should be referred for assessment by a tier 2 or 3 CAMHS team. Antidepressant medication should not be used in the initial treatment of mild depression.

9.7.2.1.

Following a period of up to 4 weeks of watchful waiting, all children and young people with continuing mild depression and without significant comorbid problems or signs of suicidal ideation should be offered individual non-directive supportive therapy, group CBT or guided self-help for a limited period (approximately 2 to 3 months). This could be provided by appropriately trained professionals in primary care, schools, social services and the voluntary sector or in tier 2 CAMHS. (B)

9.7.2.2.

Children and young people with mild depression who do not respond after 2 to 3 months to non-directive supportive therapy, group CBT or guided self-help should be referred for review by a tier 2 or 3 CAMHS team. (GPP)

9.7.2.3.

Antidepressant medication should not be used for the initial treatment of children and young people with mild depression. (B)

9.7.2.4.

The further treatment of children and young people with persisting mild depression unresponsive to treatment at tier 1 or 2 should follow the guidance for moderate to severe depression. (GPP)

9.8. Steps 4 and 5: Moderate to severe depression

There is little research evidence on the effectiveness of treatments for the younger child (5–11 years) with moderate to severe depression. In particular, there is little evidence for the effectiveness of antidepressant medication in children, which should, therefore, only be used very cautiously in this age group. In other respects, the recommended treatments for children are based upon the evidence for effectiveness in young people (12–18 years).

In children and young people psychological therapies are the first-line treatments.

9.8.1. Treatments for moderate to severe depression

All children and young people with moderate to severe depression should be assessed by CAMHS tier 2 or 3 professionals and offered a specific psychological therapy as a first-line treatment.

9.8.1.1.

Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS tier 2 or 3 team. (B)

9.8.1.2.

Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual CBT, interpersonal therapy or shorter-term family therapy); it is suggested that this should be of at least 3 months' duration. (B)

9.8.2. Combined treatments for moderate to severe depression

If there is no response to a specific psychological therapy within four to six sessions, then review and consider alternative or additional psychological therapies for coexisting problems. Consider combining psychological therapy with fluoxetine (cautiously in younger children). If combined treatment is not effective within a further six sessions, review and consider more intensive psychological therapy.

9.8.2.1.

If moderate to severe depression in a child or young person is unresponsive to psychological therapy after four to six treatment sessions, a multidisciplinary review should be carried out. (GPP)

9.8.2.2.

Following multidisciplinary review, if the child or young person's depression is not responding to psychological therapy as a result of other coexisting factors such as the presence of comorbid conditions, persisting psychosocial risk factors such as family discord, or the presence of parental mental ill-health, alternative or perhaps additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient, should be considered. (C)

9.8.2.3.

Following multidisciplinary review, if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after four to six sessions, fluoxetine should be offered. (B)

9.8.2.4.

Following multidisciplinary review, if moderate to severe depression in a child (5–11 years) is unresponsive to a specific psychological therapy after four to six sessions, the addition of fluoxetine should be cautiously considered, although the evidence for its effectiveness in this age group is not established. (C)

9.8.3. Depression unresponsive to combined treatment

9.8.3.1.

If moderate to severe depression in a child or young person is unresponsive to combined treatment with a specific psychological therapy and fluoxetine after a further six sessions, or the patient and/or their parent(s) or carer(s) have declined the offer of fluoxetine, the multidisciplinary team should make a full needs and risk assessment. This should include a review of the diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family. (GPP)

9.8.3.2.

Following multidisciplinary review, the following should be considered:

  • an alternative psychological therapy which has not been tried previously (individual CBT, interpersonal therapy or shorter-term family therapy, of at least 3 months' duration) or
  • systemic family therapy (at least 15 fortnightly sessions) or
  • individual child psychotherapy (approximately 30 weekly sessions). (B)

9.8.4. How to use antidepressants in children and young people

All antidepressant drugs have significant risks when given to children and young people with depression and, with the exception of fluoxetine, there is little evidence that they are effective in this context. Although fluoxetine can cause significant adverse drug reactions, it is safer when combined with psychological therapies. The following guidance outlines how fluoxetine should be used, and suggests possible alternatives in the event that fluoxetine is ineffective or not tolerated because of side effects.

9.8.4.1.

Antidepressant medication should not be offered to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy. Specific arrangements must be made for careful monitoring of adverse drug reactions, as well as for reviewing mental state and general progress; for example, weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks of treatment. The precise frequency will need to be decided on an individual basis, and recorded in the notes. In the event that psychological therapies are declined, medication may still be given, but as the young person will not be reviewed at psychological therapy sessions, the prescribing doctor should closely monitor the child or young person's progress on a regular basis and focus particularly focus on emergent adverse drug reactions. (B)

9.8.4.2.

If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist. (C)

9.8.4.3.

When an antidepressant is prescribed to a child or young person with moderate to severe depression, it should be fluoxetine as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks. (A)

9.8.4.4.

If a child or young person is started on antidepressant medication, they (and their parent(s) or carer(s) as appropriate) should be informed about the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed. Discussion of these issues should be supplemented by written information appropriate to the child or young person's and parents' or carers' needs that covers the issues described above and includes the latest patient information advice from the relevant regulatory authority. (GPP)

9.8.4.5.

A child or young person prescribed an antidepressant should be closely monitored for the appearance of suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment, by the prescribing doctor and the healthcare professional delivering the psychological therapy. Unless it is felt that medication needs to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored for 7 days before prescribing. Once medication is started the patient and their parent(s) or carer(s) should be informed that if there is any sign of new symptoms of these kinds, urgent contact should be made with the prescribing doctor. (GPP)

9.8.4.6.

When fluoxetine is prescribed to a child or young person with depression, the starting dose should be 10 mg daily. This can be increased to 20 mg daily after 1 week if clinically necessary, although lower doses should be considered in children with lower body weight. There is little evidence regarding the effectiveness of doses higher than 20 mg daily. However, higher doses may be considered in older children of higher body weight and/or when, in severe illness an early clinical response is considered a priority. (GPP)

9.8.4.7.

When an antidepressant is prescribed in the treatment of a child or young person with depression, and a self-report rating scale is used as an adjunct to clinical judgement, this should be a recognised scale such as the Mood and Feelings Questionnaire (MFQ). (GPP)

9.8.4.8.

When a child or young person responds to treatment with fluoxetine, medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks); in other words, for 6 months after this 8- week period. (C)

9.8.4.9.

If treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, consideration should be given to the use of another antidepressant. In this case sertraline or citalopram are the recommended second-line treatments. (B)

9.8.4.10.

Sertraline or citalopram should only be used when the following criteria have been met.

  • The child or young person and their parent(s) or carer(s) have been fully involved in discussions about the likely benefits and risks of the new treatment and have been provided with appropriate written information. This information should cover the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed; it should also include the latest patient information advice from the relevant regulatory authority
  • The child or young person's depression is sufficiently severe and/or causing sufficiently serious symptoms (such as weight loss or suicidal behaviour) to justify a trial of another antidepressant
  • There is clear evidence that there has been a fair trial of the combination of fluoxetine and a psychological therapy (in other words that all efforts have been made to ensure adherence to the recommended treatment regimen)
  • There has been a reassessment of the likely causes of the depression and of treatment resistance (for example other diagnoses such as bipolar disorder or substance abuse)
  • There has been advice from a senior child and adolescent psychiatrist – usually a consultant
  • The child or young person and/or someone with parental responsibility for the child or young person (or the young person alone, if over 16 or deemed competent) has signed an appropriate and valid consent form. (C)
9.8.4.11.

When a child or young person responds to treatment with citalopram or sertraline, medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks). (C)

9.8.4.12.

When an antidepressant other than fluoxetine is prescribed for a child or young person with depression, the starting dose should be half the daily starting dose for adults. This can be gradually increased to the daily dose for adults over the next 2 to 4 weeks if clinically necessary, although lower doses should be considered in children with lower body weight. There is little evidence regarding the effectiveness of the upper daily doses for adults in children and young people, but these may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority. (GPP)

9.8.4.13.

Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people. (A)

9.8.4.14.

Tricyclic antidepressants should not be used in the treatment of depression in children and young people. (C)

9.8.4.15.

Where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks with the exact dose being titrated against the level of discontinuation/ withdrawal symptoms. (C)

9.8.4.16.

As with all other medications, consideration should be given to possible drug interactions when prescribing medication for depression in children and young people. This should include possible interactions with complementary and alternative medicines as well as with alcohol and ‘recreational’ drugs. (GPP)

9.8.4.17.

Although there is some evidence that St John's wort may be of some benefit in adults with mild to moderate depression, this cannot be assumed for children or young people, for whom there are no trials upon which to make a clinical decision. Moreover, it has an unknown side-effect profile and is known to interact with a number of other drugs, including contraceptives. Therefore St John's wort should not be prescribed for the treatment of depression in children and young people. (C)

9.8.4.18.

A child or young person with depression who is taking St John's wort as an over-the-counter preparation should be informed of the risks and advised to discontinue treatment while being monitored for recurrence of depression and assessed for alternative treatments in accordance with this guideline. (C)

9.8.5. The treatment of psychotic depression

9.8.5.1.

For children and young people with psychotic depression, augmenting the current treatment plan with an atypical antipsychotic medication should be considered, although the optimum dose and duration of treatment are unknown. (C)

9.8.5.2.

Children and young people prescribed an atypical antipsychotic medication should be monitored carefully for side effects. (C)

9.8.6. Inpatient care

Inpatient treatment for children and young people with depression should only be considered when the patient is at significant risk of self-harm and/or needs intensive treatment or supervision not available elsewhere. The following guidance outlines the use of inpatient facilities.

9.8.6.1.

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)

9.8.6.2.

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)

9.8.6.3.

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)

9.8.6.4.

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)

9.8.6.5.

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)

9.8.6.6.

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

9.8.6.7.

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

9.8.6.8.

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)

9.8.6.9.

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)

9.8.7. Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) should be reserved for life-threatening depression unresponsive to other treatments in young people. If it is used, ECT should be used in accordance with NICE guidance. ECT is not recommended for children (5–11 years).

9.8.7.1.

ECT should only be considered for young people with very severe depression and either life-threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments. (C)

9.8.7.2.

ECT should be used extremely rarely in young people and only after careful assessment by a practitioner experienced in its use and only in a specialist environment in accordance with NICE recommendations. (C)

9.8.7.3.

ECT is not recommended in the treatment of depression in children (5–11 years). (C)

9.8.8. Discharge after a first episode

After full remission, children and young people who have been depressed should be followed up for a year. After discharge, those re-referred should be seen quickly and should not be placed on a routine waiting list.

9.8.8.1.

When a child or young person is in remission (less than two symptoms and full functioning for at least 8 weeks) they should be reviewed regularly for 12 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parent(s) or carer(s) and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. (C)

9.8.8.2.

CAMHS should keep primary care professionals up to date about progress and the need for monitoring of the child or young person in primary care. CAMHS should also inform relevant primary care professionals within 2 weeks of a patient being discharged and should provide advice about who to contact in the event of a recurrence of depressive symptoms. (GPP)

9.8.8.3.

Children and young people who have been successfully treated and discharged but then re-referred should be seen as soon as possible rather than placed on a routine waiting list. (GPP)

9.8.9. Recurrent depression and relapse prevention

Those at high risk of relapse, including those with recurrent depression, may benefit from an extended period of psychological therapy and practical help to self-monitor symptoms of relapse. They should be followed up for at least 2 years after remission, and should be seen urgently if they are re-referred.

9.8.9.1.

Specific follow-up psychological therapy sessions to reduce the likelihood of, or at least detect, a recurrence of depression should be considered for children and young people who are at a high risk of relapse (for example individuals who have already experienced two prior episodes, those who have high levels of subsyndromal symptoms, or those who remain exposed to multiple-risk circumstances). (B)

9.8.9.2.

CAMHS specialists should teach recognition of illness features, early warning signs, and subthreshold disorders to tier 1 professionals, children or young people with recurrent depression and their families and carer(s). Self-management techniques may help individuals to avoid and/or cope with trigger factors. (GPP)

9.8.9.3.

When a child or young person with recurrent depression is in remission (less than two symptoms and full functioning for at least 8 weeks) they should be reviewed regularly for 24 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parent(s) or carer(s) and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. (C)

9.8.9.4.

Children and young people with recurrent depression who have been successfully treated and discharged but then re-referred should be seen as a matter of urgency. (GPP)

9.9. Transfer to adult 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 cooperatively using the Care Programme Approach to ensure smooth transfer to adult services for those with recurrent depression, prepare young people for transfer, and provide good information about treatment for adults, and about local services.

9.9.1.1.

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)

9.9.1.2.

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 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)

9.9.1.3.

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)

9.9.1.4.

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)

9.10. Research recommendations

The Guideline Development Group has made the following recommendations for research, on the basis of its review of the evidence. The Group regards these recommendations as the most important research areas to improve NICE guidance and patient care in the future.

9.10.1. Phase one

An appropriately blinded, randomised controlled trial should be conducted to assess the efficacy (including measures of family and social functioning as well as depression) and the cost effectiveness of individual CBT, systemic family therapy and child psychodynamic psychotherapy compared with each other and treatment as usual in a broadly based sample of children and young people diagnosed with moderate to severe depression (using minimal exclusion criteria). The trial should be powered to examine the effect of treatment in children and young people separately and involve a follow-up of 12 to 18 months (but no less than 6 months).

9.10.2. Phase two

An appropriately blinded, randomised controlled trial should be conducted to assess the efficacy (including measures of family and social functioning as well as depression) and the cost effectiveness of fluoxetine, the favoured psychological therapy (from phase one), the combination of fluoxetine and psychological therapy compared with each other and placebo in a broadly based sample of children and young people diagnosed with moderate to severe depression (using minimal exclusion criteria). The trial should be powered to examine the effect of treatment in children and young people separately and involve a follow up of 12 to 18 months (but no less than 6 months). In order for this trial to be conducted, the previous trial (phase 1) needs to be completed.

9.10.3. Additional research

9.10.3.1.

An appropriately blinded, randomised controlled trial should be conducted to assess the efficacy (including measures of family and social functioning as well as depression) and the cost effectiveness of another self-help intervention compared with computerised CBT and treatment as usual in a sample of children and young people treated in primary care who have been diagnosed with depression. The trial should be powered to examine the effect of treatment in children and young people separately and involve a follow up of 12 to 18 months (but no less than 6 months).

9.10.3.2.

A qualitative study should be conducted that examines the experiences in the care pathway of children and young people and their families (and perhaps professionals) in order to inform decisions about what the most appropriate care pathway should be.

9.10.3.3.

An appropriately designed study should be conducted to compare validated screening instruments for the detection of depression in children and young people. An emphasis should be placed on examining those that use computer technology and more child-friendly methods of assessing current mood and feelings, and take into account cultural and ethnic variations in communication, family values and the place of the child or young person within the family.

9.11. Audit criteria

Measures that could be used as a basis for an audit (see Table 21).

Table 21. Audit criteria.

Table 21

Audit criteria.

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.

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

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