NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Care for children and young people with depression bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 20 September 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Child or young person at risk of depression No additional information 2 Assessment and treatment considerations across all settings Assessment Consider the following when assessing a child/young person with depression and record in the notes: potential comorbidities social, educational and family context for the patient and family members quality of patient's relationships with family members, friends and peers. Assess with the young person their social network before treatment starts. In a written formulation identify factors that: contributed to the development and maintenance of depression impact in a positive or negative way on treatment efficacy. Indicate ways to work in partnership with their social and professional network. Always ask the child/young person and their parents/carers directly about the patient's: alcohol and drug use experience of being bullied experience of being abused self-harm ideas about suicide. Give young people the opportunity to discuss these issues initially in private. Pay special attention to: confidentiality young person's consent (including Gillick competence) parental consent child protection Page 3 of 10

4 use of the Mental Health Act in young people the Children Act. Ensure that cultural and ethnic variations in communication, family values and the place of the child/young person within the family influence the form of assessment. Comorbidities If comorbid diagnoses, developmental, social and educational problems exist: manage either in sequence or in parallel with the treatment for depression work with schools or social services where appropriate. Bullying If bullying is a factor, work with schools to prevent bullying and to develop effective anti-bullying strategies. Self-harm If patient presents acutely having self-harmed: follow the NICE pathway on self-harm as it applies to children/young people pay particular attention to guidance on consent and capacity in the NICE self-harm guideline follow this pathway for further management of the depression. Considering parents' mental health Consider the possibility of parental depression and substance misuse (or other mental health problems and associated problems of living). Obtain a family history to check for unipolar or bipolar depression in parents and grandparents in all children/young people with suspected mood disorder. If a parent has a psychiatric problem, treat the child and parent in parallel if this will help the child's progress. Page 4 of 10

5 Self-help Ask the child/young person and be prepared to give advice about self-help materials or other methods used or considered potentially helpful by the patient or their family/carers. Only recommend self-help materials or strategies as part of a supported and planned package of care. Exercise Offer advice about the benefits of regular exercise. Encourage patients to consider a structured and supervised exercise programme of typically up to three sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. Sleep hygiene and anxiety management Offer advice about sleep hygiene and anxiety management. Nutrition Offer advice about nutrition and the benefits of a balanced diet. General treatment considerations Treat most children/young people on an outpatient or community basis. Consider the MFQ as an adjunct to clinical judgement in secondary care. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Depression in children and young people quality standard 1. Confirming and recording a diagnosis 5. Monitoring progress Page 5 of 10

6 3 Recognition, detection, risk profiling and referral See Depression / Depression in children and young people: recognition, detection, risk profiling and referral 4 Management of mild depression tiers 1 and 2 See Depression / Management of mild depression in children and young people tiers 1 and 2 5 Management of moderate to severe (including psychotic) depression tiers 2 4 See Depression / Management of moderate to severe (including psychotic) depression in children and young people tiers Transfer to adult services from CAMHS (young people aged years) See Depression / Depression: transfer to adult services from CAMHS Page 6 of 10

7 Glossary CAMHS child and adolescent mental health services CAPA child and adolescent psychiatric assessment CBT cognitive behavioural therapy CCBT computerised cognitive behavioural therapy DSM-IV diagnostic and Statistical Manual of Mental Disorders ECT electroconvulsive therapy HoNOSCA Health of the Nation Outcome Scales for Children and Adolescents ICD-10 International Statistical Classification of Diseases and Related Health Problems (tenth edition) IPT interpersonal therapy K-SADS schedule for affective disorders and schizophrenia for school-age children Page 7 of 10

8 MAOI monoamine oxidase inhibitor MFQ mood and feelings questionnaire Mild depression few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment, according to DSM-IV Moderate depression symptoms of depression or functional impairment are between mild and severe NSAID non-steroidal anti-inflammatory drug PCT primary care trust SDQ strengths and difficulties questionnaire Severe depression most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms SSRI selective serotonin reuptake inhibitor Subthreshold depressive symptoms fewer than 5 symptoms according to DSM-IV Page 8 of 10

9 TCA tricyclic antidepressant Tier 1 primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services Tier 2 child and adolescent mental health services relating to workers in primary care including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists Tier 3 specialised child and adolescent mental health services for more severe, complex or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community or inpatient), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists Tier 4 tertiary-level child and adolescent mental health services such as day units, highly specialised outpatient teams and inpatient units Sources Depression in children and young people (2005 updated 2015) NICE guideline CG28 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are Page 9 of 10

10 reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 10 of 10