Overview

  • This guideline covers identifying and managing depression in children and young people aged 5 to 18 years. Based on the stepped-care model, it aims to improve recognition and assessment and promote effective treatments for mild and moderate to severe depression.
  • This guideline replaces CG28.
  • This guideline is the basis of QS48.

Contents not included in this summary

  • Inpatient care (recommendations 1.6.34–1.6.42)
  • Electroconvulsive therapy (ECT) (recommendations 1.6.43–1.6.45)
  • Discharge after a first episode (recommendations 1.6.46–1.6.48)
  • Recurrent depression and relapse prevention (recommendations 1.6.49–1.6.52)

1.1 Care of all children and young people with depression

1.1.1 Children and young people and their families need good information, given as part of a collaborative and supportive relationship with healthcare professionals, and need to be able to give fully informed consent. [2005]

1.1.2 Healthcare professionals involved in the detection, assessment or treatment of children or young people with depression should ensure that information is provided to the patient and their parents and carers at an appropriate time. The information should be age appropriate and should cover the nature, course and treatment of depression, including the likely side effect profile of medication should this be offered. [2005]

1.1.3 Healthcare professionals involved in the treatment of children or young people with depression should take time to build a supportive and collaborative relationship with both the patient and the family or carers. [2005]

1.1.4 Healthcare professionals should make all efforts necessary to engage the child or young person and their parents or carers in treatment decisions, taking full account of patient and parental/carer expectations, so that the patient and their parents or carers can give meaningful and properly informed consent before treatment is initiated. [2005]

1.1.5 Families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate. [2005]

Language and black, Asian and minority ethnic groups

1.1.6 Where possible, all services should provide written information or audiotaped material in the language of the child or young person and their family or carers, and professional interpreters should be sought for those whose preferred language is not English. [2005]

1.1.7 Consideration should be given to providing psychological therapies and information about medication and local services in the language of the child or young person and their family or carers where the patient’s and/or their family’s or carer’s first language is not English. If this is not possible, an interpreter should be sought. [2005]

1.1.8 Healthcare professionals in primary, secondary and relevant community settings should be trained in cultural competence to aid in the diagnosis and treatment of depression in children and young people from black, Asian and minority ethnic groups. This training should take into consideration the impact of the patient’s and healthcare professional’s racial identity status on the patient’s depression. [2005]

1.1.9 Healthcare professionals working with interpreters should be provided with joint training opportunities with those interpreters, to ensure that both healthcare professionals and interpreters understand the specific requirements of interpretation in a mental health setting. [2005]

1.1.10 The development and evaluation of services for children and young people with depression should be undertaken in collaboration with stakeholders involving patients and their families and carers, including members of black, Asian and minority ethnic groups. [2005]

Assessment and coordination of care

1.1.11 When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient’s notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers. [2005]

1.1.12 In the assessment of a child or young person with depression, healthcare professionals should always ask the patient and their parents or carers 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. A young person should be offered the opportunity to discuss these issues initially in private. [2005]

1.1.13 If a child or young person with depression presents acutely having self-harmed, the immediate management should follow NICE’s guideline on self-harm as this applies to children and young people, paying particular attention to the guidance on consent and capacity. Further management should then follow this depression guideline. [2005]

1.1.14 In the assessment of a child or young person with depression, healthcare professionals should always ask the patient, and be prepared to give advice, about self-help materials or other methods used or considered potentially helpful by the patient or their parents or carers. This may include educational leaflets, helplines, self-diagnosis tools, peer, social and family support groups, complementary therapies and faith groups. [2005]

1.1.15 Healthcare professionals should only recommend self-help materials or strategies as part of a supported and planned package of care. [2005]

1.1.16 For any child or young person with suspected mood disorder, a family history should be obtained to check for unipolar or bipolar depression in parents and grandparents. [2005]

1.1.17 When a child or young person has been diagnosed with depression, consideration should be given to the possibility of parental depression, parental substance misuse, or other mental health problems and associated problems of living, as these are often associated with depression in a child or young person and, if untreated, may have a negative impact on the success of treatment offered to the child or young person. [2005]

1.1.18 When the clinical progress of children and young people with depression is being monitored in secondary care, the self-report Mood and Feelings Questionnaire (MFQ) should be considered as an adjunct to clinical judgement. [2005]

1.1.19 In the assessment and treatment of depression in children and young people, special attention should be paid to the issues of:

    • confidentiality
    • the young person’s consent (including Gillick competence)
    • parental consent
    • child protection
    • the use of the Mental Health Act in young people
    • the use of the Mental Capacity Act in young people
    • the use of the Children Act. [2005, amended 2019]

1.1.20 The form of assessment should take account of cultural and ethnic variations in communication, family values and the place of the child or young person within the family. [2005]

The organisation and planning of services

1.1.21 Healthcare professionals specialising in depression in children and young people should work with local child and adolescent mental health services (CAMHS)[A] to enhance specialist knowledge and skills regarding depression in these existing services. This work should include providing training and help with guideline implementation. [2005]

1.1.22 CAMHS and local healthcare commissioning organisations 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[A] provision within the locality. [2005]

1.1.23 Primary mental health workers (or CAMHS link workers) should establish clear lines of communication between CAMHS and tier 1 or 2, with named contact people in each tier or service, and develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2[A]. [2005]

1.1.24 CAMHS and local healthcare commissioning organisations should routinely monitor the rates of detection, referral and treatment of children and young people, from all ethnic groups, with mental health problems, including those with depression, in local schools and primary care. This information should be used for planning services and made available for local, regional and national comparison. [2005]

1.1.25 All healthcare and CAMHS professionals should routinely use, and record in the notes, appropriate outcome measures (such as those self-report measures used in screening for depression or generic outcome measures used by particular services, for example Health of the Nation Outcome Scale for Children and Adolescents [HoNOSCA] or Strengths and Difficulties Questionnaire [SDQ]), for the assessment and treatment of depression in children and young people. This information should be used for planning services, and made available for local, regional and national comparison. [2005]

Treatment and considerations in all settings

1.1.26 Most children and young people with depression should be treated on an outpatient or community basis. [2005]

1.1.27 Before any treatment is started, healthcare professionals should assess, together with the young person, the social network around him or her. This should include a written formulation, identifying factors that may have contributed to the development and maintenance of depression, and that may impact both positively or negatively on the efficacy of the treatments offered. The formulation should also indicate ways that the healthcare professionals may work in partnership with the social and professional network of the young person. [2005]

1.1.28 When bullying is considered to be a factor in a child or young person’s depression, CAMHS, primary care and educational professionals should work collaboratively to prevent bullying and to develop effective antibullying strategies. [2005]

1.1.29 Psychological therapies used in the treatment of children and young people with depression should be provided by therapists who are also trained in child and adolescent mental health. [2005]

1.1.30 Psychological therapies used in the treatment of children and young people with depression should be provided by healthcare professionals who have been trained to an appropriate level of competence in the specific modality of psychological therapy being offered. [2005]

1.1.31 Therapists should develop a treatment alliance with the family. If this proves difficult, consideration should be given to providing the family with an alternative therapist. [2005]

1.1.32 Comorbid diagnoses and developmental, social and educational problems should be assessed and managed, either in sequence or in parallel, with the treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care. [2005]

1.1.33 Attention should be paid 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, then a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services. [2005]

1.1.34 A child or young person with depression should be offered advice on the benefits of regular exercise and encouraged to consider following a structured and supervised exercise programme of typically up to 3 sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. [2005]

1.1.35 A child or young person with depression should be offered advice about sleep hygiene and anxiety management. [2005]

1.1.36 A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet. [2005]


1.2 Stepped care

The stepped-care model of depression draws attention to the different needs of children and young people with depression – depending on the characteristics of their depression and their personal and social circumstances – and the responses that are required from services. It provides a framework in which to organise the provision of services that support both healthcare professionals and patients and their parents or carers in identifying and accessing the most effective interventions (see table 1).

Table 1: The stepped care model
FocusActionResponsibility[A]

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

Tier 2 or 3

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

Depression unresponsive to treatment/ recurrent depression/ psychotic depression

Intensive psychological therapy

 

+/– fluoxetine, sertraline, citalopram, augmentation with an antipsychotic

Tier 3 or 4

CBT=cognitive–behavioural therapy; IPT=interpersonal psychotherapy; IPT-A=IPT for adolescents; NDST=non-directive supportive therapy.

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 CAMHS).
  3. Managing recognised depression in primary care and community settings—mild depression.
  4. Managing recognised depression in tier 2 or 3[A] CAMHS—moderate to severe depression.
  5. Managing recognised depression in tier 3 or 4[A] 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.


1.3 Step 1: Detection, risk profiling and referral

Detection and risk profiling

See also the recommendations on psychological and social issues in children and young people with type 1 or type 2 diabetes in the NICE guideline on diabetes (type 1 and type 2) in children and young people.

1.3.1 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, gender, family discord, bullying, physical, sexual or emotional abuse, comorbid disorders, including drug and alcohol use, and a history of parental depression; the natural history 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. [2005]

1.3.2 Healthcare professionals in primary care, schools and other relevant community settings should be trained in communications skills such as ‘active listening’ and ‘conversational technique’, so that they can deal confidently with the acute sadness and distress (‘situational dysphoria’) that may be encountered in children and young people following recent undesirable events.[2005]

1.3.3 Healthcare professionals in primary care settings should be familiar with screening for mood disorders. They should have regular access to specialist supervision and consultation. [2005]

1.3.4 Healthcare professionals in primary care, schools and other relevant community settings who are providing support for a child or young person with situational dysphoria should consider ongoing social and environmental factors if the dysphoria becomes more persistent. [2005]

1.3.5 Child and adolescent mental health services (CAMHS) tier 2 or 3[A] 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 either depressed or at significant risk of becoming depressed. [2005]

1.3.6 In the provision of training by CAMHS professionals for healthcare professionals in primary care, schools and relevant community settings, priority should be given to the training of pastoral support staff in schools (particularly secondary schools), community paediatricians and GPs. [2005]

1.3.7 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, healthcare professionals in primary care, schools and other relevant community settings should undertake an assessment of the risks of depression associated with the event and make contact with their parents or carers to help integrate parental/carer and professional responses. The risk profile should be recorded in the child or young person’s records. [2005]

1.3.8 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, in the absence of other risk factors for depression, healthcare professionals in primary care, schools and other relevant community settings should offer support and the opportunity to talk over the event with the child or young person. [2005]

1.3.9 Following an undesirable event, a child or young person should not normally be referred for further assessment or treatment, as single events are unlikely to lead to a depressive illness. [2005]

1.3.10 A child or young person who has been exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience and is identified to be at high risk of depression (the presence of 2 or more other risk factors for depression), should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1[A] and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. [2005]

1.3.11 When a child or young person is exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, and where 1 or more family members (parents or children) have multiple risk histories for depression, they should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1[A] and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. [2005]

1.3.12 If children and young people who have previously recovered from moderate or severe depression begin to show signs of a recurrence of depression, healthcare professionals in primary care, schools or other relevant community settings should refer them to CAMHS tier 2 or 3[A] for rapid assessment. [2005]

Referral criteria

1.3.13 For children and young people, the following factors should be used by healthcare professionals as indications that management can remain at tier 1[A]:

  • 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 or more other risk factors with no evidence of depression and/or self-harm
  • exposure to a recent undesirable life event, where 1 or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child or young person
  • mild depression without comorbidity. [2005]

1.3.14 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 2 or 3[A] CAMHS:

  • depression with 2 or more other risk factors for depression
  • depression where 1 or more family members (parents or children) have multiple-risk histories for depression
  • mild depression in those who have not responded to interventions in tier 1[A] after 2–3 months
  • moderate or severe depression (including psychotic depression)
  • signs of a recurrence of depression in those who have recovered from previous moderate or severe depression
  • unexplained self-neglect of at least 1 month’s duration that could be harmful to their physical health
  • active suicidal ideas or plans
  • referral requested by a young person or their parents or carers. [2005]

1.3.15 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 4[A] 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 their physical health)
  • requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3[A]. [2005]

1.4 Step 2: Recognition of depression in children and young people

1.4.1 Children and young people of 11 years or older referred to child and adolescent mental health services (CAMHS) without a diagnosis of depression should be routinely screened with a self-report questionnaire for depression as part of a general assessment procedure. [2005]

1.4.2 Training opportunities should be made available to improve the accuracy of CAMHS professionals in 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. [2005]

1.4.3 Within tier 3[A] CAMHS, professionals who specialise in the treatment of depression should have been trained in interviewer-based assessment instruments (such as K-SADS and CAPA) and have skills in non-verbal assessments of mood in younger children. [2005]


1.5 Step 3: Managing mild depression

Watchful waiting

1.5.1 For children and young people with diagnosed mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks (‘watchful waiting’). [2005]

1.5.2 Healthcare professionals should make contact with children and young people with depression who do not attend follow-up appointments. [2005]

Treatments for mild depression

For children and young people with learning disabilities, see the recommendations on psychological interventions in the NICE guideline on mental health problems in people with learning disabilities.

1.5.3 Antidepressant medication should not be used for the initial treatment of children and young people with mild depression. [2005]

1.5.4 Discuss the choice of psychological therapies with children and young people with mild depression and their family members or carers (as appropriate). Explain:

  • what the different therapies involve
  • the evidence for each age group (including the limited evidence for 5- to 11-year-olds)
  • how the therapies could meet individual needs, preferences and values. [2019]

1.5.5 Base the choice of psychological therapy on:

  • a full assessment of needs, including:
    • the circumstances of the child or young person and their family members or carers
    • their clinical and personal/social history and presentation
    • their maturity and developmental level
    • the context in which treatment is to be provided
    • comorbidities, neurodevelopmental disorders, communication needs (language, sensory impairment) and learning disabilities
  • patient and carer preferences and values (as appropriate). [2019]

1.5.6 For 5- to 11-year-olds with mild depression continuing after 2 weeks of watchful waiting, and without significant comorbid problems or active suicidal ideas or plans, consider the following options adapted to developmental level as needed:

If these options would not meet the child’s clinical needs or are unsuitable for their circumstances, consider the following adapted to developmental level as needed:

  • attachment-based family therapy
  • individual CBT. [2019]

1.5.7 For 12- to 18-year-olds with mild depression continuing after 2 weeks of watchful waiting, and without significant comorbid problems or active suicidal ideas or plans, offer a choice of the following psychological therapies for a limited period (approximately 2 to 3 months):

  • digital CBT
  • group CBT
  • group NDST
  • group IPT. [2019]

1.5.8 If the options in recommendation 1.5.7 would not meet the clinical needs of a 12- to 18-year-old with mild depression or are unsuitable for their circumstances, consider:

  • attachment-based family therapy or
  • individual CBT. [2019]

1.5.9 Provide psychological therapies in settings such as schools and colleges, primary care, social services and the voluntary sector. [2019]

1.5.10 If mild depression in a child or young person has not responded to psychological therapy after 2 to 3 months (recommendations 1.5.6 to 1.5.8 and table 1), refer the child or young person for review by a CAMHS team. [2019]

1.5.11 Follow the recommendations on treating moderate to severe depression for children and young people who have continuing depression after 2 to 3 months of psychological therapy (see section 1.6 on moderate to severe depression). [2019]

To find out why the committee made the 2019 recommendations on treatments for mild depression and how they might affect practice, see rationale and impact in the full guideline.


1.6 Steps 4 and 5: Managing moderate to severe depression

Treatments for moderate to severe depression

For children and young people with learning disabilities, see the recommendations on psychological interventions in the NICE guideline on mental health problems in people with learning disabilities.

1.6.1 Children and young people presenting with moderate to severe depression should be reviewed by a child and adolescent mental health services (CAMHS) team. [2019]

1.6.2 Discuss the choice of psychological therapies with children and young people with moderate to severe depression and their family members or carers (as appropriate). Explain:

  • what the different therapies involve
  • the evidence for each age group (including the limited evidence for 5- to 11-year-olds)
  • how the therapies could meet individual needs, preferences and values. [2019]

1.6.3 Base the choice of psychological therapy on:

  • a full assessment of needs, including:
    • the circumstances of the child or young person and their family members or carers
    • their clinical and personal/social history and presentation
    • their maturity and developmental level
    • the context in which treatment is to be provided
    • comorbidities, neurodevelopmental disorders, communication needs (language, sensory impairment) and learning disabilities
  • patient and carer preferences and values (as appropriate).

1.6.4 For 5- to 11-year-olds with moderate to severe depression, consider the following options adapted to developmental level as needed:

  • family-based IPT
  • family therapy (family-focused treatment for childhood depression and systems integrative family therapy)
  • psychodynamic psychotherapy
  • individual CBT. [2019]

1.6.5 For 12- to 18-year-olds with moderate to severe depression, offer individual CBT for at least 3 months. [2019]

1.6.6 If individual CBT would not meet the clinical needs of a 12- to 18-year-old with moderate to severe depression or is unsuitable for their circumstances, consider the following options:

To find out why the committee made the 2019 recommendations on treatments for moderate to severe depression and how they might affect practice, see rationale and impact.

Combined treatments for moderate to severe depression

1.6.7 Consider combined therapy (fluoxetine[B] 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 to recommendations 1.6.8 to 1.6.10. [2015]

1.6.8 If moderate to severe depression in a child or young person is unresponsive to psychological therapy after 4 to 6 treatment sessions, a multidisciplinary review should be carried out. [2005]

1.6.9 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. [2005]

1.6.10 Following multidisciplinary review, offer fluoxetine[C] if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions. [2015]

1.6.11 Following multidisciplinary review, cautiously consider fluoxetine[D] if moderate to severe depression in a child (5–11 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions, although the evidence for fluoxetine’s effectiveness in this age group is not established. [2015]

Depression unresponsive to combined treatment

1.6.12 If moderate to severe depression in a child or young person is unresponsive to combined treatment with a specific psychological therapy and fluoxetine after a further 6 sessions, or the patient and/or their parents or carers have declined the offer of fluoxetine, the multidisciplinary team should make a full needs and risk assessment. This should include a review of the diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family. [2005]

1.6.13 Following multidisciplinary review, the following should be considered:

  • an alternative psychological therapy, which has not been tried previously (individual CBT, interpersonal therapy or shorter-term family therapy, of at least 3 months’ duration) or
  • systemic family therapy (at least 15 fortnightly sessions) or
  • psychodynamic psychotherapy (approximately 30 weekly sessions). [2005]

How to use antidepressants in children and young people

1.6.14 Do not offer antidepressant medication to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy. Specific arrangements must be made 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 parents or carers for the first 4 weeks of treatment. The precise frequency will need to be decided on an individual basis, and recorded in the notes. In the event that psychological therapies are declined, medication may still be given, but as 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. [2015]

1.6.15 If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist. [2005]

1.6.16 When an antidepressant is prescribed to a child or young person with moderate to severe depression, it should be fluoxetine[D] as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks. [2005]

1.6.17 If a child or young person is started on antidepressant medication, they (and their parents or carers, as appropriate) should be informed about the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed. Discussion of these issues should be supplemented by written information appropriate to the child or young person’s and parents’ or carers’ needs that covers the issues described above and includes the latest patient information advice from the relevant regulatory authority. [2005]

1.6.18 A child or young person prescribed an antidepressant should be closely monitored for the appearance of suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment, by the prescribing doctor and the healthcare professional delivering the psychological therapy. Unless it is felt that medication needs to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored for 7 days before prescribing. Once medication is started the patient and their parents or carers should be informed that if there is any sign of new symptoms of these kinds, urgent contact should be made with the prescribing doctor. [2005]

1.6.19 When fluoxetine[D] is prescribed for a child or young person with depression, the starting dose should be 10 mg daily. This can be increased to 20 mg daily after 1 week if clinically necessary, although lower doses should be considered in children of lower body weight. There is little evidence regarding the effectiveness of doses higher than 20 mg daily. However, higher doses may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority. [2005]

1.6.20 When an antidepressant is prescribed in the treatment of a child or young person with depression and a self-report rating scale is used as an adjunct to clinical judgement, this should be a recognised scale such as the MFQ. [2005]

1.6.21 When a child or young person responds to treatment with fluoxetine[D], medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks); in other words, for 6 months after this 8-week period. [2005]

1.6.22 If treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, consideration should be given to the use of another antidepressant. In this case sertraline or citalopram are the recommended second-line treatments[E]. [2005]

1.6.23 Sertraline or citalopram[E] should only be used when the following criteria have been met[F]:

  • The child or young person and their parents or carers have been fully involved in discussions about the likely benefits and risks of the new treatment and have been provided with appropriate written information. This information should cover the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed; it should also include the latest patient information advice from the relevant regulatory authority.
  • The child or young person’s depression is sufficiently severe and/or causing sufficiently serious symptoms (such as weight loss or suicidal behaviour) to justify a trial of another antidepressant.
  • There is clear evidence that there has been a fair trial of the combination of fluoxetine and a psychological therapy (in other words, that all efforts have been made to ensure adherence to the recommended treatment regimen).
  • There has been a reassessment of the likely causes of the depression and of treatment resistance (for example other diagnoses such as bipolar disorder or substance misuse).
  • There has been advice from a senior child and adolescent psychiatrist – usually a consultant.
  • The child or young person and/or someone with parental responsibility for the child or young person (or the young person alone, if over 16 or deemed competent) has signed an appropriate and valid consent form. [2005]

1.6.24 When a child or young person responds to treatment with citalopram or sertraline[E], medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks). [2005]

1.6.25 When an antidepressant other than fluoxetine[D] is prescribed for a child or young person with depression, the starting dose should be half the daily starting dose for adults. This can be gradually increased to the daily dose for adults over the next 2 to 4 weeks if clinically necessary, although lower doses should be considered in children with lower body weight. There is little evidence regarding the effectiveness of the upper daily doses for adults in children and young people, but these may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority. [2005]

1.6.26 Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people. [2005]

1.6.27 Tricyclic antidepressants should not be used for the treatment of depression in children and young people. [2005]

1.6.28 Where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks with the exact dose being titrated against the level of discontinuation/withdrawal symptoms. [2005]

1.6.29 As with all other medications, consideration should be given to possible drug interactions when prescribing medication for depression in children and young people. This should include possible interactions with complementary and alternative medicines as well as with alcohol and ‘recreational’ drugs. [2005]

1.6.30 Although there is some evidence that St John’s wort may be of some benefit in adults with mild to moderate depression, this cannot be assumed for children or young people, for whom there are no trials upon which to make a clinical decision. Moreover, it has an unknown side-effect profile and is known to interact with a number of other drugs, including contraceptives. Therefore St John’s wort should not be prescribed for the treatment of depression in children and young people. [2005]

1.6.31 A child or young person with depression who is taking St John’s wort as an over- the-counter preparation should be informed of the risks and advised to discontinue treatment while being monitored for recurrence of depression and assessed for alternative treatments in accordance with this guideline. [2005]

The treatment of psychotic depression

1.6.32 For children and young people with psychotic depression, augmenting the current treatment plan with a second-generation antipsychotic medication[G] should be considered, although the optimum dose and duration of treatment are unknown. [2005]

1.6.33 Children and young people prescribed a second-generation antipsychotic medication should be monitored carefully for side effects. [2005]

See also the recommendations on choice of antipsychotics and how to use them in the NICE guideline on psychosis and schizophrenia in children and young people.


1.7 Transfer to adult services

See also the NICE guideline on transition from children’s to adults’ services for young people using health or social care services.

1.7.1 The child and adolescent mental health services (CAMHS) team currently providing treatment and care for a young person aged 17 who is recovering from a first episode of depression should normally continue to provide treatment until discharge is considered appropriate in accordance with this guideline, even when the person turns 18 years of age. [2005]

1.7.2 The CAMHS team currently providing treatment and care for a young person aged 17–18 who either has ongoing symptoms from a first episode that are not resolving or has, or is recovering from, a second or subsequent episode of depression, should normally arrange for a transfer to adult mental health services, informed by the Care Programme Approach. [2005]

1.7.3 A young person aged 17–18 with a history of recurrent depression who is being considered for discharge from CAMHS should be provided with comprehensive information about the treatment of depression in adults (including NICE’s information for the public) and information about local services and support groups suitable for young adults with depression. [2005]

1.7.4 A young person aged 17–18 who has successfully recovered from a first episode of depression and is discharged from CAMHS should not normally be referred on to adult services, unless they are considered to be at high risk of relapse (for example, if they are living in multiple-risk circumstances). [2005]

Terms used in this guideline

Tiers

June 2019 – The tiers terminology is under revision and may change in the future in line with NHS England’s Future in Mind and the Care Quality Commission’s report Are we listening. We have retained the tiers terminology and will revise this when the 2005 recommendations are updated.

The Care Quality Commission’s report ‘Are we listening’ referred to the whole system of care and support (tiers 1 to 4) as Children and Young People’s Mental Health Services. These included counselling provided through schools or GP practices, youth services, voluntary sector advice and support, and universal healthcare services like health visitors, as well as CAMHS. They used CAMHS to refer to services offering specialist care in the community (tier 3) and inpatient care (tier 4).

Digital CBT

Digital CBT is a form of CBT delivered using digital technology, such as a computer, tablet or phone. A variety of digital CBT programmes have been used for young people aged 12 to 18 years with mild depression. These include SPARX, Stressbusters and Grasp the Opportunity. Only Stressbusters has been tested in the UK. Some digital CBT interventions are supported by contact with a healthcare professional but in other cases there may be no additional support.

Common components of digital CBT programmes include: psychoeducation, relaxation, analysis of behaviour, behavioural activation, basic communication and interpersonal skills, emotional recognition, dealing with strong emotions, problem solving, cognitive restructuring (identifying thoughts, challenging unhelpful/negative thoughts), mindfulness and relapse prevention.

Brief psychosocial intervention

This intervention is based on the brief psychosocial intervention (BPI) carried out in the IMPACT trial (Goodyer et al. 2017[H]). Core components of BPI include:

  • psychoeducation about depression and action-oriented, goal-focused, interpersonal activities as therapeutic strategies
  • building health habits
  • planning and scheduling valued activities
  • advice on maintaining and improving mental and physical hygiene including sleep, diet and exercise
  • promoting engagement with and maintaining school work and peer relations, and diminishing solitariness.

BPI does not involve cognitive or reflective analytic techniques.

Footnotes 

[A] June 2019—terminology is under revision and may change in the future in line with NHS England’s Future in Mind and the Care Quality Commission’s report Are we listening. NICE have retained the tiers terminology and will revise this when they update the 2005 recommendations.

[B] At the time of publication (June 2019), fluoxetine did not have UK marketing authorisation for initial combination use (fluoxetine with psychological therapy) in children and young people who have not previously had a trial of psychological therapy on its own. For combined antidepressant treatment and psychological therapy as an initial treatment, 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.

[C] At the time of publication (June 2019), fluoxetine was the only antidepressant with UK marketing authorisation for use in this indication for children and young people aged 8 to 18 years.

[D] At the time of publication (June 2019), 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.

[E] At the time of publication (June 2019), citalopram was not licensed for use in children and young people under 18 and sertraline was not licensed for children and young people under 18 for this indication. See the individual summary of product characteristics for further information. 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.

[F] The Medicines and Healthcare products Regulatory Agency has published advice on QT prolongation with citalopram and escitalopram (2011).

[G] At the time of publication (June 2019), none of the second-generation antipsychotics were licensed for use in this indication for children and young people under 18. Licensed indications for the second-generation antipsychotics vary and clinicians should refer to the individual summary of product characteristics for licensing information. 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.

[H] Goodyer IM, Reynolds S, Barrett B et al. (2017) Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health technology assessment 21(12), 1–94.

© NICE 2019. Depression in children and young people: identification and management. Available from: www.nice.org.uk/guidance/NG134. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: July 2019.