Management of moderate to severe ere (including psychotic) depression in children and young people tiers 2 4 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: http://pathways.nice.org.uk/pathways/depression Pathway last updated: 15 December 2015 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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1 Child or young person with moderate to severe depression No additional information 2 Review and psychological therapies Carry out a review in CAMHS tier 2 or tier 3. 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 the others. Offer children and young people with moderate to severe depression a specific psychological therapy (individual CBT, interpersonal therapy (IPT), family therapy, or psychodynamic psychotherapy) that runs for at least three months. Providing psychological therapies for children and young people Ensure psychological therapies are provided by: therapists who are also trained child and adolescent mental healthcare professionals healthcare professionals who have been trained to an appropriate level of competence in the therapy being offered. Develop a joint treatment alliance with the family. If this proves difficult consider providing the family with an alternative therapist. Quality standards The following quality statements are relevant to this part of the pathway. Depression in children and young people quality standard 3. Suspected severe depression and at high risk of suicide 4. Suspected severe depression without high risk of suicide Page 3 of 11
3 Considering alternative psychological therapy or combining with antidepressants Consider combined therapy (fluoxetine 1 and psychological therapy) for initial treatment of moderate to severe depression in young people (12 18 years), as an alternative to psychological therapy followed by combined therapy and a multidisciplinary review (see recommendations below for further information). If moderate to severe depression in a child or young person is unresponsive to psychological therapy after 4 6 treatment sessions, a multidisciplinary review should be carried out. After multidisciplinary review Following multidisciplinary review, if the child or young person's depression is not responding to psychological therapy as a result of other coexisting factors such as the presence of comorbid conditions, persisting psychosocial risk factors such as family discord, or the presence of parental mental ill-health, alternative or perhaps additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient, should be considered. Following multidisciplinary review, offer fluoxetine if moderate to severe depression in a young person (12 18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions. See the section on using antidepressants in children and young people in this pathway. 2 4 Using antidepressants in children and young people See Depression / Using antidepressants in children and young people 1 At the time of publication (March 2015), Fluoxetine was the only antidepressant with UK marketing authorisation for use for children and young people aged 8 to 18 years. 2 At the time of publication (April 2015), fluoxetine did not have a UK marketing authorisation for use in children under the age of 8 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. Page 4 of 11
5 Child or young person at high risk of suicide or self-harm or intensive assessment or treatment is needed Inpatient treatment Consider inpatient treatment for children and young people at high risk of suicide, serious selfharm and self-neglect, and/or when the required intensity of treatment (or supervision) is not available elsewhere, or when intensive assessment is indicated. Balance the benefits against potential detrimental effects (such as loss of family and community support). Involve the child/young person and their parent(s)/carer(s) in the admission and treatment process wherever possible. Plan aftercare arrangements based on the Care Programme Approach before admission (or as early as possible after admission). ECT Only consider ECT for young people (12 18 years) with very severe depression and either lifethreatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments. Use ECT extremely rarely in young people (12 18 years) and only: after careful assessment by a practitioner experienced in its use, and in a specialised environment in accordance with the recommendations in NICE clinical guideline 90 see the Treatment of severe or resistant depression, including inpatient care section of this pathway. Do not use ECT in the treatment of depression in children (5 11 years). Quality standards The following quality statement is relevant to this part of the pathway. Page 5 of 11
Depression in children and young people quality standard 3. Suspected severe depression and at high risk of suicide 6 Psychotic depression For children and young people with psychotic depression, consider augmenting the current treatment plan with an atypical antipsychotic (the optimum dose and duration of treatment are unknown) 1. Monitor patient carefully for side effects. 7 Remission and relapse No additional information 8 In remission after a first episode When a child or young person is in remission after a first episode (less than two symptoms and full functioning for at least 8 weeks): Review regularly for 12 months. Agree exact frequency of contact with the patient and/or the parent(s)/carer(s) and record in the notes. If remission is maintained for 12 months, discharge to primary care. Keep primary care professionals up to date about progress and the need to monitor the patient in primary care. Inform relevant primary care professionals within 2 weeks of discharge and provide advice about whom to contact if depressive symptoms recur. See patients who have been successfully treated and discharged but then re-referred as soon as possible (do not put them on a routine waiting list). 1 At the time this pathway was created (May 2011), there were no atypical antipsychotic drugs with UK marketing authorisation for depression in children. Check the summary of product characteristics of individual drugs for current licensed indications. Unlicensed medicines can be legally prescribed where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion (Royal College of Page 6 of 11
9 High risk of relapse or recurrence When a child or young person has a high risk of relapse or recurrence (such as those who have experienced two prior episodes, or have high levels of subsyndromal symptoms, or remain exposed to multiple-risk circumstances): Consider specific follow-up psychological therapy to reduce or detect recurrence. Teach tier 1 professionals, the patient, family and carer(s) recognition of: illness features early warning signs subthreshold disorders. Self-management techniques may help individuals to avoid and/or cope with trigger factors. 10 In remission after recurrent depression When child or young person is in remission after recurrent depression (less than two symptoms and full functioning for at least 8 weeks): review regularly for 24 months agree the exact frequency of contact with the patient and/or the parent(s)/carer(s) and record in the notes if remission is maintained for 24 months, discharge to primary care see patients with recurrent depression who have been successfully treated and discharged but then re-referred as a matter of urgency. Paediatrics and Child Health, 2000; reissued in 2010; also see the NICE guideline on depression in children and young people). Page 7 of 11
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 8 of 11
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 9 of 11
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 10 of 11
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 2015. 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 www.nice.org.uk nice@nice.org.uk 0845 003 7781 Page 11 of 11