Depression in children and young people: identification and management

National Institute for Health and Care Excellence


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  • This Guidelines summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

Care of all children and young people with depression

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
  • 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
  • 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
  • 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
  • Families and carers should be informed of self‑help groups and support groups and be encouraged to participate in such programmes where appropriate

Language and ethnic minorities

  • 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

Assessment and coordination of care

  • 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
  • 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 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
  • 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
  • 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
  • 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
  • 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

Treatment considerations in all settings

  • 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
  • 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
  • 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 hour) for between 10 and 12 weeks
  • A child or young person with depression should be offered advice about sleep hygiene and anxiety management
  • A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet

Stepped care

Table 1: The stepped-care model

Focus Action Responsibility
Detection Risk profiling Tier 1
Recognition Identification in presenting in young people Tier 2–4
Mild depression (including dysthymia) Watchful waiting

Non-directive supportive therapy/group cognitive behavioural therapy/guided self-help
Tier 1

Tier 1 or 2
Moderate to severe depression Brief psychological therapy +/- fluoxetine Tier 2 or 3
Depression unresponsive to treatment/recurrent depression/psychotic depression Intensive psychological therapy +/- fluoxetine, sertraline, citalopram, augmentation with an antipsychotic Tier 3 or 4

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

Step 1: Detection, risk profiling and referral

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

Referral criteria

  • 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
    • mild depression without comorbidity
  • 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 risk factors 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 2–3 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)
  • 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

Step 3: Mild depression

Watchful waiting

  • 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')
  • Healthcare professionals should make contact with children and young people with depression who do not attend follow‑up appointments

Steps 4 and 5: Moderate to severe depression

Treatments for moderate to severe depression

  • Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS tier 2 or 3 team
  • Offer children and young people with moderate to severe depression a specific psychological therapy (individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy) that runs for at least 3 months

Combined treatments for moderate to severe depression

  • Consider combined therapy (fluoxetine* and psychological therapy) for initial treatment of moderate to severe depression in young people (12–18 years), as an alternative to psychological therapy followed by combined therapy and to the recommendations below
  • 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
  • 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
  • Following multidisciplinary review, offer fluoxetine if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions
  • Following multidisciplinary review, cautiously consider fluoxetine if moderate to severe depression in a child (5–11 years) is unresponsive to a specific psychological therapy after to sessions, although the evidence for fluoxetine's effectiveness in this age group is not established

Depression unresponsive to combined treatment

  • 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
  • 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)

How to use antidepressants in children and young people

  • Do not offer antidepressant medication 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
  • If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist
  • 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
  • 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
  • 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
  • When fluoxetine is prescribed for 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 of 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
  • 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)
  • 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
  • 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§
  • 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
  • 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)
  • 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
  • Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people
  • Tricyclic antidepressants should not be used for the treatment of depression in children and young people
  • 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
  • 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
  • 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
  • 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

The treatment of psychotic depression

  • For children and young people with psychotic depression, augmenting the current treatment plan with an atypical antipsychotic medicationl should be considered, although the optimum dose and duration of treatment are unknown
  • Children and young people prescribed an atypical antipsychotic medication should be monitored carefully for side effects

Discharge after a first episode

  • 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 whom to contact in the event of a recurrence of depressive symptoms

Recurrent depression and relapse prevention

  • 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
  • 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

Transfer to adult services

  • 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
  • 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
  • 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. 
  • 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)

* At the time of publication (March 2015), fluoxetine did not have UK marketing authorisation for use in young people (aged 12–18), without a previous trial of psychological therapy that was ineffective. For combined antidepressant treatment and psychological therapy as an initial treatment, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

† At the time of publication (March 2015), fluoxetine was the only antidepressant with UK marketing authorisation for use for children and young people aged 8 to 18 years

‡ At the time of publication (March 2015), fluoxetine did not have a UK marketing authorisation for use in children under the age of 8 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information

§ At the time of publication (March 2015), sertraline and citalopram did not have a UK marketing authorisation for use in young people under the age of 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information

At the time of publication (March 2015), risperidone did not have a UK marketing authorisation for use in young people under the age of 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

References

full guideline available from…

National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG28

National Institute for Health and Care Excellence. Depression in children and young people: identification and management. March 2015.
First included: Mar 15.


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