Depression in children and young people

1. Depression in children and young people Clinical Guideline Published: September 2005

2. NICE clinical guidelines • Recommendations for good practice based on best available evidence • DH document ‘Standards for better health’ includes expectation that organisations work towards implementing clinical guidelines • Healthcare Commission will monitor compliance with NICE guidance 2

3. The guideline development process • Commissioned through the National Collaborating Centre for Mental Health based at the British Psychological Society/ Royal College of Psychiatrists • Guideline Development Group drawing on clinical, economic, patient and carer expertise • GDG considers published and unpublished data thereby drawing on the best available evidence • Transparent, inclusive process, with wide stakeholder consultation 3

4. Rationale for this guideline • Professionals involved with the care of children and young people need to be better able to identify the signs of depression – about 75% of cases may be undetected • Public and clinical concern over the prescribing of antidepressants for children and young people • Impact of the condition wider than just the NHS 4

5. What this guideline covers • Best practice advice on the care of children and young people aged 5 –18 years with depression • Recommendations for healthcare and other professionals who have a role to play in ensuring children and young people and their families and carers get appropriate care and support, in both primary and secondary care • A clinical description of depression based on ICD-10 5

6. Prevalence • At any one time, the estimated number of children and young people suffering from depression: • 1 in 100 children • 1 in 33 young people • Prevalence figures exceed treatment numbers: • about 25% of children and young people with depression detected and treated • Suicide is the: • 3rd leading cause of death in 15–24-year-olds • 6th leading cause of death in 5–14-year-olds 6

7. Symptoms • Key symptoms • persistent sadness, or low or irritable mood • loss of interests and/or pleasure • fatigue or low energy • Associated symptoms • poor or increased sleep • low self-confidence • poor concentration or indecisiveness • poor or increased appetite • suicidal thoughts or acts • guilt or self-blame • agitation or slowing of movement 7

8. Recommendations identified as key priorities • Assessment and coordination of care • Treatment considerations in all settings • Step 1: Detection and risk profiling • Step 2: Recognition • Step 3: Mild depression • Steps 4 and 5: Moderate to severe depression 8

9. Diagnosing depression Mild Up to 4 symptoms Moderate 5-6 symptoms Severe 7-10 symptoms 9

10. The tiers (1-2) 10

11. The tiers (2-3) 11

12. The stepped care model 12

13. Step 1: detecting depression • Professionals in primary care, schools and community need to: • be aware of risk factors • engage in ‘active listening’ and ‘conversational techniques’ • detect symptoms • provide appropriate support • know when to refer 13

14. Assessing and coordinating care • Care should be comprehensive and holistic and take into account: • drug and alcohol misuse • experience of bullying or abuse • parental depression • risks of self-harm and suicide • use of self-help materials and methods • issues of confidentiality 14

15. Step 2: recognising depression • To improve their ability to recognise depression CAMHS professionals should be trained especially in: • use of self-report questionnaires and interviewer-based instruments • screening for mood disorders and skills in non-verbal assessments of mood in younger children • family history and family dynamics 15

16. 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 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 in the child/young person • Mild depression without comorbidity 16

17. Step 3: mild depression • Treatment includes: • up to 4 weeks ‘watchful waiting’ • non-directive supportive therapy • group CBT • guided self-help • no use of antidepressants at this stage 17

18. Criteria for referral to tier 2 or 3 CAMHS • Depression with two or more other risk factors for depression • Depression with multiple-risk histories in another family member • Mild depression and no response to interventions in tier 1 after 2–3 months • Moderate or severe depression (including psychotic depression) • Recurrence after recovery from previous moderate or severe depression • Unexplained self-neglect of at least 1 month’s duration that could be harmful to physical health • Active suicidal ideas or plans • Young person or parent/carer requests referral 18

19. Steps 4 and 5: moderate or severe depression • General recommendations • Approach tailored to needs of family • Family’s preferences to be taken into account • E.g. when too depressed • Does not want family involved • May require change of approach especially if symptoms deteriorate • Treatment starts with review by multidisciplinary team • First line of treatment is specific psychological therapy for about 3 months • Individual cognitive behavioural therapy • Interpersonal therapy • Shorter-term family therapy 19

20. Steps 4 and 5: moderate or severe depression – if unresponsive • If there is no response after 4-6 sessions • Multidisciplinary review • Alternative psychological therapy that has not been tried • Offer fluoxetine in combination with psychological treatment to young people (12–18) and cautiously consider it in younger children (5–11) • If still no response after further 6 sessions • A further multidisciplinary review • Systemic family therapy of at least 15 fortnightly sessions • Individual child psychotherapy (30 weekly sessions) 20

21. Referral criteria for 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 physical health) • Intensity of assessment/treatment and/or level of supervision that is not available in tiers 2 or 3 21

22. Unresponsive depression • Reassess if no response • Offer more intensive psychological treatments • alternative psychological therapy which has not been tried • systemic family therapy • individual child psychotherapy • Consider combining with SSRIs 22

23. The limited place for antidepressants • Should only be prescribed following assessment by a psychiatrist • Should only be offered in combination with psychological treatments • First-line treatment is fluoxetine* • Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, St John’s wort • Monitor for agitation, hostility, suicidal ideation and self-harm and advise urgent contact with prescribing doctor if detected * Fluoxetine does not have a UK Marketing Authorisation for use in children and adolescents under the age of 18 at the time of publication (Sept 2005) 23

24. The limited place for antidepressants • Sertraline or citalopram* as second-line treatment • Consider adding atypical antipsychotic if psychotic depression • Continue for 6 months if remission, then phase out over 6–12 weeks • Issues: • Discussion, consent and written advice important • Pre- and post-prescribing monitoring • Continuation of medication post recovery * Sertraline and citalopram do not have a UK Marketing Authorisation for use in children and adolescents under the age of 18 at the time of publication (Sept 2005) 24

25. Discharge to primary care • Inform primary care professional within 2 weeks of discharge and provide contact details if symptoms recur • Review for 12 months after first remission (< 2 symptoms for 8 weeks) • Consider follow-up psychological treatment if second episode to prevent relapse • Review for 24 months if recurrent depression in remission • Re-refer early if signs of relapse 25

26. Transfer to adult services Young person (17 years) recovering from first episode Continue care until discharge appropriate, even when person reaches 18 years • Young person (17–18 years) • who either: • has ongoing symptoms from first episode • or • is recovering from further episodes Arrange transfer to adult services, informed by Care Programme Approach Young person (17–18 years) with recurrent depression considered for discharge from CAMHS • Give patient information on: • adult treatment (include NICE guideline) • local services and support groups Young person (17–18 years) recovered from first episode and discharged from CAMHS Do not refer to adult services unless high risk of relapse 26

27. Other treatment options • Inpatient care when individual is at high risk of suicide, serious self-harm or self-neglect, or when required for intensive treatment or assessment • Cautious use of electroconvulsive therapy for life-threatening depression when other treatments have failed – NOT recommended for children (5–11 years) 27

28. Implementation issues for clinicians • Diagnosis • Recognising and managing potential comorbidities and risk factors in the wider social and educational context • Providing care that is ethnically and culturally sensitive • Treatment • Knowing what psychological and drug treatments to offer and when • Applying the stepped care model in practice • Treatment of parental depression • Access to services • Transition from CAMHS to adult mental health services • Availability of services for parents • Training • Identifying and contributing to the training of other key workers 28

29. Implementation issues for managers • Active dissemination of the guidance • Carry out baseline assessment • Development and implementation of an action plan – what, when, how, who • Ensuring CBT and specialist teams can be accessed appropriately • Training of professionals in CBT • Monitor and review 29

30. Organisation and planning of services 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 • routinely monitor detection, referral and treatment rates of children/young people with mental health problems from all ethnic groups in local schools and primary care • use information about these rates to plan services, and make it available for local, regional and national comparison Primary mental health workers (or CAMHS link workers) should: • establish clear lines of communication between CAMHS and tiers 1 and 2, with named contact people in each tier/service • develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2 30

31. Organisation and planning of services All healthcare professionals should: • routinely use, and record in the notes, appropriate outcome measures (e.g. HoNOSCA or SDQ), for assessing and treating depression in children/young people • use this information from outcome measures to plan services, and make it available for local, regional and national comparison Commissioners and strategic health authorities should ensure that: • inpatient treatment is available within reasonable travelling distance to enable family involvement and maintain social links • inpatient admission occurs within an appropriate time scale • immediate inpatient admission can be offered if necessary • inpatient services have a range of interventions available including medication, individual and group psychological therapies and family support • inpatient facilities are age appropriate and culturally enriching and can provide suitable educational and recreational activities 31

32. Four implementation tools support this guideline • Costing tools • a local costing template • a national costing report • implementation advice • audit criteria • this slide set The tools are available on our website www.nice.org.uk/implementation 32

33. Where is further information available? • Quick reference guide – summary of recommendations for health professionals: • www.nice.org.uk/cg028quickrefguide • NICE guideline: • www.nice.org.uk/cg028niceguideline • Full guideline – all of the evidence and rationale behind the recommendations: • www.rcpsych.ac.uk/publications • Information for the public – plain English version for patients, carers and the public: • www.nice.org.uk/cg028publicinfo 33

34. www.nice.org.uk 34