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• GDG considers published and unpublished data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 1524-year-olds
• 6th leading cause of death in 514-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
KEY SYMPTOMS ASSOCIATED SYMPTOMS
persistent sadness, or low or irritable mood AND/OR loss of interests and/or pleasure fatigue or low energy poor or increased sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame
Mild Up to 4 symptoms
Moderate 5-6 symptoms
Severe 7-10 symptoms
9
10
The tiers (1-2)
TIER 1 Primary care services GPs and paediatricians Health visitors and school nurses Social workers, teachers, juvenile justice workers Voluntary agencies and social services
TIER 2 CAMHS Professionals relating to primary care workers Clinical child psychologists and educational psychologists Paediatricians with training in mental health Child and adolescent psychiatrists and psychotherapists Counsellors and community and specialist nurses Family therapists
10
11
The tiers (2-3)
TIER 3 CAMHS Services for more severe, complex or persistent disorders Child and adolescent psychiatrists and psychotherapists Clinical child psychologists Community and inpatient nurses Occupational therapists and speech and language therapists Art, music and drama therapists and family therapists
TIER 4 CAMHS Tertiary-level services Day units Specialised outpatient teams Specialised inpatient units
11
12
The stepped care model
Focus Action Responsibility
Detection Risk profiling Tier 1
Recognition Detection in presenting children All tiers
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 intervention / fluoxetine Tier 2 or 3
Depression unresponsive to treatment/recurrent depression/psychotic depression Intensive psychological intervention / fluoxetine Tier 3 or 4
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 23 months
• Moderate or severe depression (including
  psychotic depression)
• Recurrence after recovery from previous moderate
  or severe depression
• Unexplained self-neglect of at least 1 months
  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
• Familys 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 (1218)
  and cautiously consider it in younger children
  (511)
• 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 Johns 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 612 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 (lt 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 (1718 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 (1718 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 (1718 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 (511
  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