The new guideline from NICE highlights the need to train GPs to recognise depression in children and young people, says Dr John Hague


   

The NICE guideline on depression in children and young people,1 published in September 2005, covers the treatment of depression in children (aged 5 to 11 years) and young people (those aged 12 to 17) in both primary and secondary care.

The guideline states that 1% of children and 3% of adolescents will suffer from depression in any one year. However, only 25% of those who suffer are detected and treated.

This is the sixth NICE guideline to recommend psychological therapies as key treatments and the third to recommend them as first-line treatments.

Implementing the recommendations for these psychological treatments in today's 'adverse financial climate' is going to be very challenging.

Developing the guideline

NICE commissioned the National Collaborating Centre for Mental Health to develop this guideline.The Centre established a multi-disciplinary guideline development group, which followed the standard NICE methodology to develop the guideline. The evidence was considered using the standard NICE grading system (Figure 1).

Figure 1: Evidence and recommendations grading scheme

Reproduced by kind permission of the National Institute for Health and Care Excellence

The majority of the recommendations are graded as C or GPP (approximately one-third and just over half, respectively), with only a couple being graded A, and the remainder B. This reflects the difficulty in providing 'class A evidence' in this area.

Key priorities for implementation

The key priorities seem slanted towards specialist services or commissioners. The reality of implementing most of them, in the context of a brief primary care consultation, will be challenging.

The key priorities also clarify the role that primary care plays in managing most of these cases, beyond recognition, proper record keeping, and provision of knowledge about the family of the patient.

Three of these key recommendations stand out:

  • Healthcare professionals in primary care should be trained to detect symptoms of depression, and to assess children and young people who may be at risk of depression
  • Psychological therapies should be provided by therapists who are also trained child and adolescent mental healthcare professionals
  • Antidepressant medication should not be used for the initial treatment of children and young people with mild depression

Principles of care

As in previous mental health guidelines these principles are very sensible and should form the bedrock of primary care. All are based on 'good practice points'.

The principles cover providing age-appropriate information; building a collaborative relationship with the patient and their family so that they can be involved in treatment decisions and give consent; and providing details of self help and support groups.

Lastly, there are two points concerning providing information and psychological therapy in the language of the patient and their family/carers where possible, and seeking professional interpreters for those whose first language is not English.

Stepped care

The guideline refers to tiers of services.

These tiers have the effect of stratifying care and making it clear who should be providing the care, what that care should entail, and in what setting.

The tiers are numbered 1-4:

  • Primary care services are involved in tiers 1 and 2
  • Specialised secondary and tertiary child & adolescent mental health services (CAMHS) make up tiers 3 and 4.

The guidance follows five steps:

1. Detection and recognition of depression and risk profiling in primary care and community settings (Figure 2).

2. Recognition of depression in children and young people referred to CAMHS.

3. Managing recognised depression in primary care and community settings – mild depression.

4. Managing recognised depression in tier 2 or 3 CAMHS – moderate to severe depression.

5. Managing recognised depression in tier 3 or 4 CAMHS – unresponsive, recurrent and psychotic depression, including depression needing in-patient care.

Each step introduces additional interventions; the higher steps assume interventions at the previous step.

Figure 2: Recognition, detection, risk profiling and referral pathway in tier 1

Reproduced by kind permission of the National Institute for Health and Care Excellence

Assessment and treatment across all tiers

Although the recommendations are laudable, their sheer volume will make fitting them into a 10-15 minute primary care consultation difficult.

GPs should elicit information about the patient's substance use, bullying, self-harm and suicidal ideation, as well as co-morbidity, the mental health of the patient's parents, and family history of unipolar or bipolar depression in parents and grandparents.

Primary care is well placed to provide self-help materials, but at present is not able to offer a planned and supported package of care. Advice about exercise, sleep hygiene, anxiety management and nutrition could easily be provided in primary care, perhaps in the form of leaflets agreed with the CAMHS service.

Recognition and detection in tier 1

Sensibly this section of the guideline starts with the bald statement that there is a great need for training among healthcare professionals in assessing the risk of depression, providing support, and deciding when to refer. It is clear that reading the guideline is not, in itself, sufficient.

Psychosocial risk factors for depression include:

  • age
  • gender
  • family discord
  • bullying
  • physical, sexual or emotional abuse
  • co-morbidity including drug or alcohol use
  • parental mental illness
  • ethnic and cultural factors
  • homelessness
  • refugee status
  • living in an institution.

The guideline recommends that priority in pastoral support training is given to staff in schools, paediatricians and GPs.

Children or young people who have previously recovered from moderate or severe depression should be re-referred to tier 2 or 3 services if it is felt that they are beginning to show signs of a recurrence.

Tucked away at the back of the full guideline, appendix E contains some very clear resources to help assess the severity of depression, and information to guide the practitioner on whether to treat in primary care or refer to a specialist.

Referral criteria

Criteria for referral are summarised in Figure 3. Interestingly the guideline states that extra training in recognition of depression is also needed for CAMHS professionals. Particular rating instruments, or modifications of these, are recommended, e.g. the Mood and Feelings Questionnaire (MFQ).

Figure 3: Referral criteria

Reproduced by kind permission of the National Institute for Health and Care Excellence

Management of mild depression in tiers 1 and 2

The key point in this section is the responsibility to follow up and monitor patients, especially if they fail to attend appointments.

Watchful waiting is a very reasonable first step in those who do not want an intervention, or where the healthcare professional feels the patient may recover without one.

If the patient has failed to respond to 2 weeks of watchful waiting then an intervention is needed. At present in most areas this will only be available by referral to a CAMHS service. The guideline recommends not using medication, but using one of three therapies, which it says could be provided in primary care:

  • individual non-directive supportive therapy
  • group cognitive behavioural therapy (CBT)
  • guided self-help.

Provision of these therapies in primary care is going to have to be very tightly commissioned and provided in a way that ensures that it is continuous with tiers 2, 3 and 4 CAMHS services, so that those at risk, or who fail to respond, are picked up by a tier 2 service.

Steps 4 and 5 – moderate to severe depression

Steps 4 and 5 are entirely aimed at those in tier 2, 3 or 4 CAMHS services, and deal with the specifics of more complex therapies and the use of medication – none of which are relevant to primary care.

The guideline makes the point that there is little research evidence on the effectiveness of treatments for the younger child, especially regarding the use of drugs. Again the point is made that psychological treatments are a first-line treatment.

Transfer to adult services

Simple and clear guidance is given to facilitate services' understanding of what their transfer responsibilities are. This is useful for GPs so they can help ensure that appropriate transfers are made.

Implementation

A separate implementation guide is provided by NICE, along with a cost impact report and template, and a PowerPoint presentation to help those implementing the guideline.

The cost impact report estimates that the recurrent costs of implementation will be almost £19.5 million, with non-recurrent costs (e.g. training) of £1.72 million.2

Implementation tools
NICE has developed the following tools to support implementation of its guideline on depression in children and young people.They are now available to download from the NICE website: www.nice.org.uk.
Implementation advice
The implementation advice document contains suggested actions for implementing the guideline. It aims to help implementers identify recommendations in the guideline that are not part of current practice and should be used alongside the costing report and template.
Slide set
The slides are aimed at supporting organisations to help implement the guideline recommendations at a local level.They do not try to cover all the recommendations from the guideline but contain key messages and should be used in conjunction with the quick reference guide.
Costing tools
National cost reports and local cost templates for the guideline have also been produced.
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice and predictions of how it might change following implementation of the guideline.
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates and quickly assess the impact the guideline may have on local budgets.

Impact on primary care

Most of the care of children and young people suffering from depression will be, of necessity, outside primary care.

However, the core theme is the great need to raise the standard of detection in the community from the current 25%. This inevitably means that the biggest impact on primary care will be in training, and participating in re-training to ensure that skills are not lost.

Another major impact on primary care is the time required to fulfil the recommendations for tier 1 services.

Conclusion

It is easier to follow the guideline if both the quick reference guide and the full guideline are read in tandem – the flow charts in the former are very useful, but need the backing of the text to be understood fully.

After reading both the full guideline and the quick reference guide, you may feel, as I did, in need of training to help detect and treat depressed children and young people. I hope that many GPs may want to attend a training course, and it should feature in many personal learning plans.

I also hope that commissioners will recognise that training in primary care to raise the detection rate of childhood depression from the current low figure of 25% should be a priority. I look forward to the wider availability of such training that will signal the implementation of this guideline for primary care.

Copies of the full guideline and the quick reference guide can be downloaded from the NICE website: www.nice.org.uk

 

Guidelines in Practice, April 2006, Volume 9(4)
© 2006 MGP Ltd
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  1. NICE clinical guideline 28. Depression in children and young people: identification and management in primary, community and secondary care. London: NICE, The British Psychological Society, Royal College of Psychiatrists, 2005.
  2. NICE clinical guideline 28. Depression in children and young people: cost impact report. London: NICE, 2005.