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

2. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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Guideline Development Group drawing on clinical, economic, patient and carer expertise GDG considers published and unpublished data thereby drawing on the best available evidence Transparent, inclusive process, with wide stakeholder consultation 3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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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: –3 rd leading cause of death in 15–24-year-olds –6 th leading cause of death in 5–14-year-olds 6

7. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 Diagnosing depression KEY SYMPTOMSASSOCIATED 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 9 Mild Up to 4 symptoms Moderate 5-6 symptoms Severe 7-10 symptoms

10. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 The stepped care model FocusActionResponsibility DetectionRisk profilingTier 1 RecognitionDetection in presenting childrenAll 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 Transfer to adult services Young person (17 years) recovering from first episode Young person (17–18 years) who either: has ongoing symptoms from first episode or is recovering from further episodes Young person (17–18 years) with recurrent depression considered for discharge from CAMHS Young person (17–18 years) recovered from first episode and discharged from CAMHS Continue care until discharge appropriate, even when person reaches 18 years Arrange transfer to adult services, informed by Care Programme Approach Give patient information on: adult treatment (include NICE guideline) local services and support groups Do not refer to adult services unless high risk of relapse 26

27. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 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 www.nice.org.uk/implementation 32

33. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 Where is further information available? Quick reference guide – summary of recommendations for health professionals: –www.nice.org.uk/cg028quickrefguidewww.nice.org.uk/cg028quickrefguide NICE guideline: –www.nice.org.uk/cg028niceguidelinewww.nice.org.uk/cg028niceguideline Full guideline – all of the evidence and rationale behind the recommendations: –www.rcpsych.ac.uk/publicationswww.rcpsych.ac.uk/publications Information for the public – plain English version for patients, carers and the public: –www.nice.org.uk/cg028publicinfowww.nice.org.uk/cg028publicinfo 33

34. IntroContextKey priorities and recommendationsImplementation 123456789101112131415161718192021222324252627 Info 28293031323334 www.nice.org.uk 34