Dr Janice Allister identifies five key learning points for primary care from the updated NICE guideline on depression in children and young people

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Read this article to learn more about:

  • when to consider depression in children and young people who are presenting with unrelated complaints
  • appropriate psychological therapies for children and young people with mild, moderate, or severe depression
  • the importance of personal choice when making decisions about treatment.

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The landscape of general practice has changed since the 2005 publication of NICE Clinical Guideline (CG) 28 on Depression in children and young people: identification and management.1 There now seems to be less emphasis on the continuity of care and patients being able to rely on contact with a known and trusted source of support. Further to this, many more children and young people are reportedly struggling with mental health and emotional problems.2

NICE Guideline (NG) 134,3 published in June 2019, updates and replaces CG28. It was updated following the IMPACT trial,4 which found that brief psychosocial intervention, cognitive behavioural therapy (CBT), and short-term psychoanalytical therapy were all effective in maintaining a reduction of depression symptoms in adolescents 12 months after the end of treatment. The NG134 guideline committee evaluated the evidence and cost effectiveness of these and a wider range of therapies including:

  • group and individual
  • those with and without parents or carers present
  • face-to-face and digital
  • active and reflective
  • mindfulness
  • guided self-help
  • counselling
  • CBT.

The committee considered separate evidence for 5–11-year-olds and 12–18-year-olds, and classified depression severity as mild and moderate to severe.

The tiered structure of child and adolescent mental health services (CAMHS) was deemed to be outside the scope of the updated guideline, as it may soon change and is being covered elsewhere.5 The scope also did not include the current difficulties with CAMHS thresholds and waiting lists.6 The stepped-care model was not revised fully but has been updated to include new choices of therapies and the implications for services for mild and moderate to severe depression. Inequalities in service provision are hopefully subject to ongoing change in light of the publication of Transforming children and young people’s mental health provision: a green paper7 in 2017 and the Five year forward view for mental health8 in 2016.

NICE Guideline 134 assumes easy access to help in primary care and collaboration with the patient’s education provider (school, academy, college) or place of work. However, barriers to care can be significant, especially for young people seeking appointments. NG134 also assumes individualised help, but austerity, poverty, housing, employment, and community issues affect the availability of, and access to, care.

The NG134 guideline committee agreed that some evidence relating to children and young people who have depression with co-morbidities such as diabetes, obesity, and learning or developmental disabilities should be included. The process of assessment at tier 1 (including general practice, education, and community services) and tier 2 includes prevention following undesirable life events [see NG134; 1.3.1, 1.3.7–1.3.12], detection, risk profiling, recognition, and early help. Risk is easily missed if a young person presents with a different complaint, for example, a minor skin rash, cough, or a request for a note for school or for the contraceptive pill, when the actual reason may be low mood or hopelessness. The most cost-effective interventions for mild, moderate, and severe depression, all of which are seen in general practice, are described. Early help means having resources that are available, accessible, and evidence based. The offer of personal continuity is also important. More research is needed to provide appropriate treatment for all groups, especially 5–11-year-olds.3

This article highlights key recommendations from NG134 for primary care (the numbers in brackets refer to specific recommendations from NG134). It aims to enable GPs and practice teams to reflect on how they can help children and young people navigate complex mental health problems.

1. Consider preferences, values, maturity, developmental level, and capacity

When considering treatment for mild and moderate to severe depression there should be a discussion about the choice of psychological therapies and an explanation of what the different therapies involve, the evidence for the relevant age group, and how the therapies could meet individual needs, preferences, and values [see NG134; 1.5.4 and 1.6.2]. The choice is based on patient and carer preferences and values and a full assessment of needs, to include [see NG134; 1.5.5 and 1.6.3]:3

  • 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
  • co-morbidities, neurodevelopmental disorders, communication needs (language, sensory impairment), and learning disabilities.

Some aspects can involve negotiation with the child or young person (and/or parent/carer), especially where there are safeguarding concerns and police or social care need to be consulted. Negotiation might include who else to tell and how to tell them, or to agree actions that both the young person and GP will take. Consent for referral should usually be sought.9

A GP usually has some advantage in having the patient’s medical notes to hand and knowing the child or young person and their family from previous attendances and reports. Nevertheless, in the context of a busy surgery it is easy to regard a child or young person’s consultation as a ‘quick one’. It can be important to ask: ‘What else would you like to mention while you’re here?’ A series of appointments may be needed if the risk is not immediate. GPs also need respect for a parent or carer’s concerns reflecting their own difficulties, including balancing other family problems, mental health problems, or diagnoses.

Physical issues, whether obesity, acne, scars, or a chronic medical condition, may or may not be obvious from the notes or the person’s appearance. Other guidance such as Action for Children’s guide to supporting trans children and young people10 or Childline’s web page about gender identity11 refer to medical and gender issues.

2. Assess risk of depression

Assess children and young people who may be at risk of depression by evaluating recent and past psychosocial risk factors; some risks will already be known to GPs such as cultural and ethnic factors, living in an institutional setting, refugee status, or homelessness. Other risk factors include family history of depression; family discord; bullying; physical, sexual, or emotional abuse; loss of a friend or relative; drug or alcohol use; other health problems; and self-harm or self-neglect.3 Psychosis may be evidenced by abnormal perceptions and beliefs.

Diagnosis of mild, moderate, or severe depression is based on the symptoms experienced. The following factors indicate that the child or young person can be managed in primary care (tier 1) [see NG134; 1.3.13]:3

  • exposure to a single undesirable event without other risk factors for depression
  • exposure to a recent undesirable event with two or more other risk factors but no evidence of depression and/or self-harm
  • exposure to a recent undesirable event where one or more family members (parents or children) have multiple-risk histories for depression, provided that the child or young person has no evidence of depression and/or self-harm
  • mild depression (including dysthymia) without co-morbidity.

GPs are used to using the Hospital Anxiety and Depression Scale12 or the General Health Questionnaire13 to assess mental health problems in adult patients. Tools to assess the severity of depression or deterioration in children and young people are available at tier 2–4 services. They include the Revised children’s anxiety and depression scale (and subscales)14 and Health of the nation outcome scales for children and adolescents.15 Self-harm is covered separately in NICE CG16.16

3. Share decision making using the stepped-care model

When assessing the patient it is helpful to keep in mind the stepped-care model (see Table 1), which describes the most effective but least resource-intensive intervention for the degree of depression.3 The ‘tier’ model is retained in NG134, with tier 1 being primary care and tier 4 specialist inpatient care. Context is always important, for example, a 14-year-old girl may be depressed following her family being rehoused to one room in a hostel. Social care, housing referrals, and networking may be needed before CAMHS. The steps are not necessarily sequential. Not all treatments suit everyone so individual needs and preferences, in consultation with the child’s parents or carers, should be considered and addressed.

Table 1: The stepped-care model3
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

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

© NICE 2019. Depression in children and young people: identification and management.  Available from www.nice.org.uk/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 publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licencefor further details.

Mild depression

‘Watchful waiting’ is the first step,3 allowing time (usually 2 weeks) for natural recovery and consideration of options. Questions about lifestyle (nutrition, sleep, and exercise) are part of history taking and relevant advice should be offered. Shared decision making starts when the child or young person indicates their preferences, although these can be subject to change. If the parents are involved they will have their own opinions. Reaching shared decisions on what is preferable and possible is an art.

If there is no improvement after watchful waiting, possible interventions include digital CBT, group CBT, group non-directive supportive therapy, or group interpersonal psychotherapy (IPT) [see NG134; 1.5.6, 1.5.7]. If these are not suitable, attachment-based family therapy or individual CBT have been shown to be of benefit to 12–18-year olds [see NG134; 1.5.8].3 There was limited evidence for the younger age group who vary in maturity. They and their parents/carers should be able to choose from the options available to older children until there are more research results [see NG134; 1.5.6].3

Now that mental health is considered a current priority it is hoped that a wider range of therapies will soon become available to primary care in all localities.

Child and adolescent mental health services are increasingly providing telephone advice services to GPs to help triage referrals—check if these are available in your area and keep contact details to hand for when you need them. It is also valuable to have a point of contact in social care or the police with whom to discuss anonymised specific problems.

Supporting children in accessing Childline, or children and young people and parents/carers in accessing educational psychology, charitable groups, sexual health, social care, or police support as appropriate can be helpful.

Moderate to severe depression

GPs often feel unsupported when they diagnose moderate to severe depression (see Table 1) in a child or young person, especially when their referral is rejected by CAMHS, education, or social care. Patience, ingenuity, and team work can help to achieve collaborative community support with CAMHS triage, education, emergency services, practice discussions, and all available local resources.

Evidence-based interventions for 5–11-year-olds include family-based IPT, family therapy, psychodynamic psychotherapy, or individual CBT [see NG134; 1.6.4]. A multidisciplinary review is helpful for establishing whether or not there is improvement, usually after 4–6 sessions. Fluoxetine may be cautiously considered at this stage (see NG134; 1.6.11) although its effectiveness in this younger age group is not established and it is not licensed for use in children aged under 8 years.17

4. Know the role of antidepressants

The pressure to prescribe is significant, especially in cases where parents take long-term antidepressants themselves or where functioning is affected and the waiting list for psychological therapies is long. Six months is a greater proportion of a child’s life than an adult’s. Part of the initial discussion should include the increased risk of suicidal thinking and self-harm in a minority of young people starting selective serotonin reuptake inhibitors (SSRIs) [see NG134; 1.6.18].3

NICE Guideline 134 recommends considering psychological therapies in combination with antidepressants for initial treatment of moderate to severe depression in 12–18-year-olds, as an alternative to psychological therapy followed by combination therapy [see NG134; 1.6.7].3 An early review after 1–2 weeks is helpful to assess contributing factors and progress. If there is no improvement after 4–6 sessions of therapy, alternative psychological therapies can be offered [see NG134; 1.6.8–1.6.10].3

When prescribing, low-dose fluoxetine should be used first then sertraline or citalopram if treatment with fluoxetine is unsuccessful or is not tolerated [see NG134; 1.6.16, 1.6.22].3

Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people [see NG134; 1.6.26].3 Note: Sertraline and citalopram do not currently (October 2019) have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for all clinical decisions. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices18 for further information. For specific cases you may wish to seek advice from the local medicines management team.

Be aware of interactions with other medications or non-prescribed substances, such as herbal remedies, or anabolic steroids taken for body building, as they can be significant.3

5. Keep in touch and be prepared to change treatment

Keeping in touch with children and young people with mild depression or on the waiting list for treatment seems a common-sense approach but it can be difficult. Recovery is hoped for but can be elusive. Following up reported missed appointments, school refusals, and navigating incompatibilities with therapists or others is tricky.

For children or young people with moderate to severe depression, or whose mild depression persists for 2–3 months [see NG134; 1.3.14, 1.5.11], NG134 recommends a referral to tier 2 or 3 CAMHS. A multidisciplinary review should be carried out if the child or young person’s depression is unresponsive to treatment after four to six treatment sessions [see NG134; 1.6.8].3 Previously overlooked factors such as co-morbid conditions or persisting family discord should be explored [see NG134; 1.6.9].3 Other evidence-based psychological therapies may be appropriate. Patience and persistence are required.

Conclusion

It is easy to be overwhelmed in primary care when depression in children and young people seems so prevalent. There is significant variation in the availability of resources in different localities. The updated NICE guideline presents evidence-based recommendations on prioritising care and effective approaches to treatment. Further research is required, particularly in the clinical and cost effectiveness, post-treatment, and at longer-term follow-up, of psychological therapies for children aged 5 to 11 years with mild or moderate to severe depression; digital CBT; family therapy, interpersonal psychotherapy for adolescents and psychodynamic psychotherapy; brief psychosocial intervention delivered by non-psychiatrists and in other settings; and behavioural activation.3

Dr Janice Allister

GP, Edinburgh

Member of the guideline development group for NG134

The guideline referred to in this article was produced by the Guideline Updates Team for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the authors and not necessarily those of NICE.

National Institute for Health and Care Excellence (2019). Depression in children and young people: identification and management. Available from: www.nice.org.uk/guidance/ng134

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Conduct a baseline audit of local services to review current provision against NICE Guideline 134
  • Establish clear care pathways for referral of patients into the various tiers, with specific referral guidance
  • Consider provision of telephone advice services, both direct to patients and also to healthcare professionals
  • Commission sufficient specialist psychological services to provide the recommended therapies, which are identified as the most cost effective
  • Ensure these are readily and locally accessible to children, including those in deprived areas
  • Identify clearly in local formularies the (limited) role of antidepressants for managing depression in children and young people, and the need for weekly monitoring for suicidal thinking in all patients aged under 30 years who are commencing treatment with antidepressants.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. NICE. Depression in children and young people: identification and management. NICE Clinical Guideline 28. NICE, 2005. Available at: www.nice.org.uk/cg28
  2. NHS Digital. Mental health of children and young people in England, 2017. Available at: files.digital.nhs.uk/A6/EA7D58/MHCYP%202017%20Summary.pdf
  3. NICE. Depression in children and young people: identification and management. NICE Guideline 134. NICE, 2019. Available at: www.nice.org.uk/ng134
  4. Goodyer I, Reynolds S, Barrett B et al. Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry 2017; 4 (2): 109–119.
  5. NHS England. Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing. NHSE, 2015. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf
  6. Care Quality Commission. Are we listening? CQC, 2018. Available at: www.cqc.org.uk/sites/default/files/20180308b_arewelistening_report.pdf
  7. Department of Health and Social Care and Department for Education. Transforming children and young people’s mental health provision: a green paper. DH and DfE, 2017. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf
  8. NHS England. The five year forward view for mental health. NHSE, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf
  9. General Medical Council. Protecting children and young people. GMC, 2012. Available at: www.gmc-uk.org/-/media/documents/Protecting_children_and_young_people___English_1015.pdf_48978248.pdf
  10. Action for Children. A guide to supporting trans children and young people. Action for Children, 2016. Available at: www.actionforchildren.org.uk/media/6718/a-guide-to-supporting-trans-children-and-young-people.pdf
  11. Childline website. Gender identity. www.childline.org.uk/info-advice/your-feelings/sexual-identity/transgender-identity/ (accessed 2 October 2019).
  12. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67 (6): 361–370.
  13. Goldberg D. Manual of the general health questionnaire. Windsor: NFER Publishing, 1978.
  14. Child Outcomes Research Consortium. Revised children’s anxiety and depression scale (and subscales). www.corc.uk.net/outcome-experience-measures/revised-childrens-anxiety-and-depression-scale-and-subscales (accessed 9 August 2019).
  15. Child Outcomes Research Consortium. Health of the nation outcome scales for children and adolescents. www.corc.uk.net/outcome-experience-measures/health-of-the-nation-outcome-scales-for-children-and-adolescents (accessed 9 August 2019).
  16. NICE. Self-harm in over 8s: short-term management and prevention of recurrence. Clinical Guideline 16. NICE, 2004. Available at: www.nice.org.uk/cg16
  17. NICE. British National Formulary for children. Fluoxetine. Available at: bnfc.nice.org.uk/drug/fluoxetine.html (accessed 2 October 2019).
  18. General Medical Council. Good practice in prescribing and managing medicines and devices. www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices (accessed 9 August 2019.)