Diagnosis and management of depression in children and young people: summary of updated NICE guidanceBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h824 (Published 04 March 2015) Cite this as: BMJ 2015;350:h824
- Kathryn Hopkins, technical analyst1,
- Paul Crosland, health economist1,
- Nicole Elliott, associate director1,
- Susan Bewley, committee chair and professor in complex obstetrics2
- On behalf of the Clinical Guidelines Update Committee B
- 1Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester M1 4BT, UK
- 2Women’s Health Academic Centre, King’s College London, London, UK
- Correspondence to: K Hopkins
The bottom line
There is little clear evidence to favour one psychological therapy over another for the treatment of depression in children and young people. Clinicians should discuss this uncertainty when recommending treatments
For initial treatment of moderate to severe depression in young people (12-18 years), antidepressants and psychological therapy may be started concurrently as an alternative to offering a trial of psychological therapy first and starting antidepressants only if this trial is unsuccessful
Depression affects around 2.8% of children under the age of 13 and 5.6% of 13-18 year olds.1 Effective treatment is important because persistent depression is associated with serious complications, including poor school performance and social functioning,2 recurring depression in adulthood,3 and suicide.4 This article summarises recommendations from the updated National Institute for Health and Care Excellence (NICE) guideline on depression in children and young people.5 The update had a narrow remit—only recommendations on the choice of psychological therapy and the combination of antidepressant treatment with psychological therapy were considered.
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. Where the evidence was minimal, recommendations in the original guidance were based on the guideline development group’s experience and opinion of what constitutes good practice. Changes to the original recommendations were based on evidence from updated systematic reviews on clinical and cost effectiveness. Evidence levels for the recommendations are given in italic in square brackets.
Assessment and detection
When assessing a child or young person with depression, routinely consider and record in the patient’s notes potential comorbidities and the social, educational, and family context for the patient and family members. This information should include the quality of interpersonal relationships between the patient and other family members and between the patient and his or her friends and peers. [Based on the experience and opinion of the 2005 guideline development group (GDG).]
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; sex; family discord; bullying; physical, sexual, or emotional abuse; comorbid disorders, including drug and alcohol use; and a history of parental depression. They should also be aware of the natural course 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. [Based on the experience and opinion of the 2005 GDG.]
In assessing a child or young person with depression, always ask the patient and the 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. Offer the young person the opportunity to discuss these issues initially in private. [Based on the experience and opinion of the 2005 GDG.]
If a child or young person with depression presents acutely having self harmed, immediate management should follow a previous NICE guideline that applies to children and young people,6 paying particular attention to the guidance on consent and capacity. Further management should then follow the current depression guideline. [Based on the experience and opinion of the 2005 GDG.]
Assess and manage comorbid diagnoses and developmental, social, and educational problems, either in sequence or in parallel with treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care. [Based on non-randomised studies.]
Pay attention to the possible need for parents’ own psychiatric problems (particularly depression) to be treated in parallel if the child or young person’s mental health is to improve. If such a need is identified, a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services. [Based on non-randomised studies.]
Child and Adolescent Mental Health Services (CAMHS) tier 2 or 3 should work with health and social care professionals in primary care, schools, and other relevant community settings to provide training and develop ethnically and culturally sensitive systems for detecting, assessing, supporting, and referring children and young people who are depressed or at high risk of becoming depressed. (Tier 2 services comprise CAMHS specialists working in community and primary care settings; tier 3 comprises a multidisciplinary team or service working in a community mental health clinic or child psychiatry outpatient service.) [Based on the experience and opinion of the 2005 GDG.]
Make training opportunities available for CAMHS professionals to improve the accuracy of diagnosing depressive conditions. The existing interviewer based instruments (such as Kiddie-Sads (K-SADS) and child and adolescent psychiatric assessment (CAPA)) could be used for this purpose but will require modification for regular use in busy routine CAMHS settings. [Based on the experience and opinion of the 2005 GDG.]
Psychological therapies used in the treatment of children and young people should be provided by trained child and adolescent mental healthcare professionals. [Based on non-randomised studies.]
Discuss the choice of psychological therapies with children and young people and their family members or carers (as appropriate). Explain that there is no good quality evidence that one type of psychological therapy is better than others. (New recommendation.) [Based on low quality randomised controlled trials (RCTs).]
Do not prescribe antidepressant drugs as initial treatment in children and young people. [Based on RCTs and the experience and opinion of the 2005 GDG.]
After up to four weeks of watchful waiting, offer individual non-directive supportive therapy, group cognitive behavioural therapy (CBT), or guided self help for a limited period (two to three months) to all children and young people with continuing mild depression and no serious comorbid problems or signs of suicidal ideation. This could be provided by appropriately trained professionals in primary care, schools, social services, and the voluntary sector or in tier 2 CAMHS. (Reviewed 2015, unchanged.) [Based on low quality RCTs and the experience and opinion of the 2005 GDG.]
Moderate to severe depression
Offer children and young people a specific psychological therapy (individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy); it is suggested that this should be of at least three months’ duration. (New recommendation.) [Based on low quality RCTs and the experience and opinion of the 2005 GDG.]
Do not offer antidepressant drugs to a child or young person except in combination with a psychological therapy. Make specific arrangements 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 four weeks of treatment. The precise frequency will need to be decided on an individual basis and recorded in the notes. If psychological therapies are declined, drugs can still be given, but because 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. (Reviewed 2015, unchanged.) [Based on moderate to low quality RCTs and the experience and opinion of the 2005 GDG.]
For initial treatment in young people (12-18 years), consider combined therapy (fluoxetine and psychological therapy) as an alternative to psychological therapy followed by combined therapy (see next recommendation). Note that use of fluoxetine for the treatment of depression in young people without an unsuccessful trial period of psychological therapy is outside of the licensed indications. (New recommendation.) [Based on moderate to low quality RCTs.]
If depression in a child or young person does not respond to psychological therapy after four to six treatment sessions, undertake a multidisciplinary review. [Based on the experience and opinion of the 2005 GDG.]
After multidisciplinary review:
-If the child or young person’s depression is not responding to psychological therapy because of coexisting factors, such as comorbid conditions, persisting psychosocial risk factors (for instance family discord), or parental mental ill health, consider alternative or additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient [Based on the experience and opinion of the 2005 GDG.]
-Offer fluoxetine if depression in a young person (12-18 years) is unresponsive to a specific psychological therapy after four to six sessions. Note that fluoxetine is the only antidepressant licensed for use in depression in young people (Reviewed 2015, unchanged.) [Based on moderate to low quality RCTs and the experience and opinion of the 2005 GDG.]
-Cautiously consider fluoxetine if depression in a child (5-11 years) is unresponsive to a specific psychological therapy after four to six sessions, although the evidence for fluoxetine’s effectiveness in this age group is not established. Note that use of fluoxetine for the treatment of depression in children under 8 years is outside of the licensed indications. (Reviewed 2015, unchanged.) [Based on moderate to low quality RCTs and the experience and opinion of the 2005 GDG.]
The original 2005 guideline recommended offering antidepressants only if a trial of psychological therapy was ineffective. The main change will be that clinicians should now consider starting treatment with antidepressants and psychological therapy simultaneously for young people with moderate to severe depression. A possible barrier to implementation may be overcoming concerns about the safety of antidepressants in young people (relating to suicidal thoughts). However, the evidence reviewed by the committee did not show an increase in suicidal ideation in young people treated with antidepressants and psychological therapy compared with those treated with psychological therapy alone, but it did show that combined treatment had clear benefits. Unfortunately, difficulties in accessing psychological therapy still exist in the United Kingdom despite previous NICE guidelines on this topic.
How patients were involved in the creation of this article
Three lay committee members (including one with specific knowledge and experience of depression in children and young people) contributed to the formulation of the recommendations summarised in this article.
Extra information on the guidance
The National Institute for Health and Care Excellence (NICE) guideline on depression in children and young people was identified for update after a surveillance review, a process that NICE guidelines go through to determine whether there is new evidence that might affect current recommendations. New evidence was found on psychological therapies and the combination of antidepressant treatment and psychological therapy. Evidence was reviewed and the guideline was updated in these specific areas only.
The update was conducted according to the methods specified in the NICE guidelines manual 2012 (www.nice.org.uk/article/pmg6/chapter/1%20introduction), with deviations from this process as specified in the interim process and methods guide for updates pilot programme 2013 (www.nice.org.uk/article/pmg17/chapter/1%20purpose). The committee is made up of 13 standing members and five topic specific members. Standing committee members include lay members, clinicians (including a general practitioner), researchers, and commissioners without specific knowledge or experience of the topic to be updated. Topic specific members included a lay member with specific knowledge and experience of depression in children and young people, a child and adolescent health service nurse, a child psychotherapist, a child psychiatrist and a children’s mental health researcher/clinical psychologist. Systematic reviews of the clinical and health economic evidence were conducted for three review questions on the choice of psychological therapy and the combination of antidepressant treatment and psychological therapy. The quality of the clinical evidence was appraised using methods specified by the grading of recommendations, assessment, developing, and evaluation (GRADE) working group.7 Stakeholders were invited to comment on a draft version of the guideline, and the final version of the guideline update took these stakeholder comments into account.
NICE has produced four different versions of the guideline: an addendum to the 2005 full version detailing the evidence for the updated recommendations; a pathway; a version known as the “NICE guideline” that summarises the recommendations, including those that have been updated; and a version for patients and the public (www.nice.org.uk/guidance/CG28/InformationForPublic). All these versions are available from the NICE website (www.nice.org.uk/guidance/CG28).
Research recommendations identified in the 2005 guideline on the effectiveness of psychological therapies and the combination of antidepressant treatment and psychological therapy remained priorities for future research. The committee also made the following new research recommendations:
What is the relative effectiveness of starting psychological therapy first, followed by additional antidepressants only if psychological therapy alone is ineffective, in children and young people with depression?
What is the relative effectiveness of starting psychological therapy and antidepressants at the same time in children and young people with depression?
Cite this as: BMJ 2015;350:h824
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The committee that updated the recommendations described in this article was made up of standing members and topic specific members. Standing members: Susan Bewley (committee chair and professor of complex obstetrics), Gita Bhutani (clinical psychologist), Simon Corbett (cardiologist), John Graham (oncologist), Peter Hoskin (oncologist), Roberta James (programme lead, Scottish Intercollegiate Guidelines Network), Jo Josh (lay member), Asma Khalil (obstetrician), Manoj Mistry (lay member), Amaka Offiah (radiologist and clinical senior lecturer), Mark Rodgers (research fellow), Nicholas Steel (clinical senior lecturer in primary care), Sietse Wieringa (general practitioner). Topic specific members: Peter Fonagy (researcher and clinical psychologist), Lynn Henderson (child and adolescent mental health service nurse), Peta Mees (psychotherapist), Maria Moldavsky (psychiatrist), Anna Wilson (lay member).
Contributors: All authors were part of the committee that made the recommendations described in this summary. KH drafted the summary and PC, NE, and SB revised it critically for important intellectual content. All authors read the final draft of the manuscript and agreed for it to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors are guarantors.
Funding: KH, PC, and NE are employees of the National Institute for Health and Care Excellence (NICE), which is commissioned and funded by the Department of Health to develop clinical guidelines. SB received a fee from NICE for chairing the committee that made the recommendations described in this summary.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: KH, PC, and NE are employed by the National Institute for Health and Care Excellence (NICE). SB is a self employed obstetric academic and expert. She has been remunerated for chairing NICE and National Collaborating Centre for Women’s and Children’s Health committees, external reviews of serious incidents, service reviews, and occasional medicolegal advice (including as a member of the Medical Defence Union cases committee and council), and she receives book royalties. The authors’ full statements can be viewed at www.bmj.com/content/bmj/350/bmj.h824/related#datasupp.
Provenance and peer review: Commissioned; not externally peer reviewed.