Depression in children and young people: a summary of recommendations from NICE

  • NICE

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Depression in children and young people: identification and management NICE guideline [NG134]

Update type: New guideline

Published: June 2019

Takeaway

  • NICE has published a new guideline that focuses on the identification and management of depression in children and young people aged 5 to 18 years.
  • The guidance endorses the stepped-care model to improve the recognition, assessment, effective treatment of mild and moderate to severe depression.

Assessment of care

  • During the assessment and treatment of depression in children and young people, special attention should be given to confidentiality and consent of the young patient, consent of parents, child protection, and adherence to the Mental Health Act in young people, Mental Capacity Act in young people, and Children Act.

Stepped care model

  • The stepped-care model of depression provides a framework for organising the provision of services that enable healthcare professionals, patients, and family members/carers to identify and access the most effective interventions.
  • The guidance follows these 5 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 Children and Young People's Mental Health Services (including Child and Adolescent Mental Health Services [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.

Focus Action Responsibility
Detection Risk profiling Tier 1
Recognition Identification in presenting children or young people Tiers 2 to 4
Mild depression (including dysthymia)

Watchful waiting

Digital CBT, group CBT, group IPT or group NDST

If shared decision making based on full assessment (including maturity and developmental level) indicates needs not met, individual CBT or attachment-based family therapy

Tier 1

Tier 1 or 2

 

 

 

 

Moderate to severe depression

5- to 11-year-olds
Family-based IPT, family therapy (family-focused treatment for childhood depression and systems integrative family therapy), psychodynamic psychotherapy, or individual CBT
+/– fluoxetine

12- to 18-year-olds
Individual CBT
+/– fluoxetine

If shared decision making based on full assessment (including maturity and developmental level) indicates needs not met, IPT‑A, family therapy (attachment-based or systemic), brief psychosocial intervention or psychodynamic psychotherapy
+/– 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

Detection and risk profiling

  • Healthcare professionals in schools and relevant community settings should be trained to detect symptoms of depression and evaluate those at risk of depression. Factors for evaluation should include:
    • Age;
    • Gender;
    • Family discord;
    • Bullying;
    • Physical, sexual or emotional abuse;
    • Comorbid illnesses, including substance use;
    • History of parental depression;
    • Natural history of single loss events;
    • Ethnic and cultural factors;
    • Homelessness, refugee status and institutionalisation.

Referral criteria

  • Factors to be considered as indications for referral to tier 1 management:
    • 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 ≥2 other risk factors with no evidence of depression and/or self-harm.
    • Exposure to a recent undesirable life event, and ≥1 family member have multiple-risk histories for depression, providing there is no evidence of depression and/or self-harm in the child or young person.
    • Mild depression without comorbidity.
  • Factors to be considered as indications for referral to tier 2 or 3 CAMHS:
    • Depression with ≥2 other risk factors.
    • depression with ≥1 family member having multiple-risk histories.
    • Mild depression unresponsive to tier 1 interventions after 2–3 months.
    • Moderate or severe depression (including psychosis).
    • Signs of a recurrence of depression after recovery from moderate or severe depression.
    • Unexplained self-neglect for at least 1 month, detrimental to physical health.
    • Active suicidal ideas or plans.
    • Referral requested by a young person or their parents/carers.
  • Factors to be considered as indications for referral to tier 4 services:
    • High recurrent risk of self-harm or suicide.
    • Substantial ongoing self-neglect.
    • Assessment/treatment and/or level of supervision not available in tier 2 or 3.

Managing mild depression

Watchful waiting

  • Children and young people with mild depression not opting for an intervention or who are expected to recover without any intervention in the opinion of the healthcare professional should receive further assessment within 2 weeks (watchful waiting).
  • Individuals not attending follow-up appointments should be contacted by healthcare professionals.

Treatments for mild depression

  • Antidepressant medications are not recommended for the initial treatment of mild depression
  • The choice of psychological therapies should be made after a discussion with the patients and their family members or carers. They should be explained about what different therapies involve, their evidence base, and how they can comply with individual needs, preferences and values.
  • The patient and carer preferences and values should be considered when choosing a psychological therapy and a complete assessment of needs should be conducted which includes:
    • Circumstances of the patient and the family members or carers.
    • Clinical and personal/social history and presentation.
    • Maturity and developmental level.
    • Context in which treatment is to be given.
    • Comorbidities, neurodevelopmental disorders, communication needs, and learning disabilities.
  • For 5- to 11-year-olds with mild depression persisting after 2 weeks of watchful waiting, in absence of comorbid problems or active suicidal ideas or plans, consider digital cognitive-behavioural therapy (CBT), group CBT, group non-directive supportive therapy (NDST) or group interpersonal psychotherapy (IPT).
  • If the above options are inadequate on unsuitable, consider attachment-based family therapy or individual CBT adapted to their developmental level.
  • For 12- to 18-year-olds with mild depression persisting after 2 weeks of watchful waiting, in absence of comorbid problems or active suicidal ideas or plans, consider digital CBT, group CBT, group NDST or group IPT for a limited duration (~2-3 months).
  • If the above options are inadequate on unsuitable, consider attachment-based family therapy or individual CBT.
  • Psychological therapies should be provided in settings such as educational institutions, primary care, social services and the voluntary sector
  • If mild depression is not responsive to psychological therapy after 2 to 3 months, refer the patient for review by a CAMHS team.

Managing moderate to severe depression

  • Children and young people with moderate to severe depression should be reviewed by a CAMHS team.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP, FFCI, FRSA