Depression in children and young people

National Institute for Health and Clinical Excellence

Key priorities for implementation

Assessment and coordination of care

• 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

Treatment considerations in all settings

• Psychological therapies used in the treatment of children and young people should be provided by therapists who are also trained child and adolescent mental healthcare professionals

• 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

• 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

Step 1: Detection and risk profiling

• 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:
  • 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
    • history of parental depression
  • the natural history of single loss events
  • the importance of multiple risk factors
  • ethnic and cultural factors
  • 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

• Child and Adolescent Mental Health Services (CAMHS) tier 2 or 3 (see below) 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

Step 2: Recognition

• 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

Step 3: Mild depression

• Antidepressant medication should not be used for the initial treatment of children and young people with mild depression

Steps 4 and 5: Moderate to severe depression

• Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual cognitive behavioural therapy [CBT], interpersonal therapy or shorter-term family therapy; it is suggested that this should be of at least 3 months' duration)

• Antidepressant medication should not be offered 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 parent(s) or carer(s) 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