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Depression in children and young people

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What is covered

This interactive flowchart covers the identification and treatment of depression in children (5–11 years) and young people (12–18 years) in primary, community and secondary care.
Depression is a broad diagnosis that can include different symptoms in different people. However, depressed mood or loss of pleasure in most activities, are key signs of depression. Depressive symptoms are frequently accompanied by symptoms of anxiety, but may also occur on their own.
For the purposes of this interactive flowchart, the management of depression has been divided into the following categories as defined by the ICD-10:
  • mild depression
  • moderate and severe depression
  • severe depression with psychotic symptoms.
However, it is not clear whether the severity of depression can be understood in a single symptom count. Family context, previous history, and the degree of associated impairment are all important in helping to assess depression. Because of this, it is important to assess how the child or young person functions in different settings (for example, at school, with peers and with family), as well as asking about specific symptoms of depression.

Updates

Updates to this interactive flowchart

24 June 2019 The flowchart has been restructured and updated to include the Mental Capacity Act in assessment and new recommendations on psychological therapy for children and young people with depression in offer psychological therapies for mild depression, managing mild depression that is unresponsive to initial psychological therapy and offer psychological therapies and lifestyle advice for moderate to severe depression. Footnotes in managing psychotic depression and prescribing sertraline and citaloprim and treatments not to be used in children and young people with moderate to severe depression also updated to clarify the advice on marketing authorisation and licensed indications.

The stepped care model of depression

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 children and young people and their parents or carers in identifying and accessing the most effective interventions.
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 as 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 tier 3 CAMHS – moderate to severe depression.
5. Managing recognised depression in tier 3 or tier 4 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.
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. We have retained the tiers terminology and will revise this when we update the 2005 recommendations.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on identifying, treating and managing depression in children and young people in an interactive flowchart

What is covered

This interactive flowchart covers the identification and treatment of depression in children (5–11 years) and young people (12–18 years) in primary, community and secondary care.
Depression is a broad diagnosis that can include different symptoms in different people. However, depressed mood or loss of pleasure in most activities, are key signs of depression. Depressive symptoms are frequently accompanied by symptoms of anxiety, but may also occur on their own.
For the purposes of this interactive flowchart, the management of depression has been divided into the following categories as defined by the ICD-10:
  • mild depression
  • moderate and severe depression
  • severe depression with psychotic symptoms.
However, it is not clear whether the severity of depression can be understood in a single symptom count. Family context, previous history, and the degree of associated impairment are all important in helping to assess depression. Because of this, it is important to assess how the child or young person functions in different settings (for example, at school, with peers and with family), as well as asking about specific symptoms of depression.

Updates

Updates to this interactive flowchart

24 June 2019 The flowchart has been restructured and updated to include the Mental Capacity Act in assessment and new recommendations on psychological therapy for children and young people with depression in offer psychological therapies for mild depression, managing mild depression that is unresponsive to initial psychological therapy and offer psychological therapies and lifestyle advice for moderate to severe depression. Footnotes in managing psychotic depression and prescribing sertraline and citaloprim and treatments not to be used in children and young people with moderate to severe depression also updated to clarify the advice on marketing authorisation and licensed indications.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Depression in children and young people (2013 update 2019) NICE quality standard 48

Quality standards

Depression in children and young people

These quality statements are taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statements

Confirming and recording a diagnosis

This quality statement is taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statement

Children and young people with suspected depression have a diagnosis confirmed and recorded in their medical records.

Rationale

Diagnosing depression in children and young people can be difficult. Confirming and accurately recording a diagnosis can facilitate appropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with suspected depression have a diagnosis confirmed and recorded in their medical records.
Data source: Local data collection.
Process
Proportion of children and young people with suspected depression who have a diagnosis confirmed and recorded in their medical records.
Numerator – the number of people in the denominator who have a diagnosis confirmed and recorded in their medical records.
Denominator – the number of children and young people who presented with suspected depression.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for staff to confirm a diagnosis of depression in children and young people with suspected depression and to record the diagnosis in their medical records.
Healthcare and CAMHS (Child and Adolescent Mental Health Services) professionals ensure that they confirm a diagnosis of depression in children and young people with suspected depression and record the diagnosis in their medical records.
Commissioners ensure that they commission services that can confirm a diagnosis of depression in children and young people with suspected depression and record the diagnosis in their medical records.
Children and young people with suspected depression have tests (for example, being asked questions) to confirm a diagnosis of depression, and the diagnosis is recorded in their health records.

Source guidance

Depression in children and young people: identification and management (2019) NICE guideline NG134, recommendations 1.4.2 and 1.4.3

Definitions of terms used in this quality statement

Confirming a diagnosis
The use of tools may be helpful in confirming a diagnosis of depression. NICE’s guideline on depression in children and young people indicates that Kiddie Sads (K SADS) and Child and Adolescent Psychiatric Assessment (CAPA) could be used to diagnose depression in children and young people, but these would need to be modified for regular use in busy routine CAMHS settings.

Information appropriate to age

This quality statement is taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statement

Children and young people with depression are given information appropriate to their age about the diagnosis and their treatment options.

Rationale

Children and young people need age appropriate information they can understand about their diagnosis and treatment options, so that they can participate in shared decision making. Information should also be appropriate to the developmental level, emotional maturity and cognitive capacity of the child or young person, taking into account any learning disabilities, sight or hearing problems or delays in language development.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with depression are given information appropriate to their age about the diagnosis and their treatment options.
Data source: Local data collection.
Process
Proportion of children and young people with depression who are given information appropriate to their age about the diagnosis and their treatment options.
Numerator – the number of people in the denominator given information appropriate to their age about the diagnosis and their treatment options.
Denominator – the number of children and young people diagnosed with depression.
Data source: Local data collection.
Outcome
Evidence from experience surveys and feedback that children and young people with depression understand the diagnosis and their treatment options.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for children and young people with depression to be given age appropriate information about the diagnosis and their treatment options.
Healthcare and CAMHS (Child and Adolescent Mental Health Services) professionals ensure that they give age appropriate information about the diagnosis and treatment options to children and young people with depression.
Commissioners ensure that they commission services in which age appropriate information about the diagnosis and treatment options is given to children and young people with depression.
Children and young people with depression are given information they can understand about their diagnosis and the different treatments that are available.

Source guidance

Depression in children and young people: identification and management (2019) NICE guideline NG134, recommendation 1.1.1

Equality and diversity considerations

Information should be accessible in a variety of formats – for example, web based resources and written information. It should be tailored to the person’s needs.
NICE’s guideline on depression in children and young people, recommendation 1.1.6 states that, if possible, written information or audiotaped material should be provided in the language of the child or young person and their parents or carers. Interpreters should be used if this is not possible.
Healthcare and CAMHS professionals should take account of the developmental level, emotional maturity and cognitive capacity of the child or young person, including any learning disabilities, sight or hearing problems or delays in language development.

Suspected severe depression and at high risk of suicide

This quality statement is taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statement

Children and young people with suspected severe depression and at high risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health Services) professionals within a maximum of 24 hours of referral. If necessary, children and young people are provided with a safe place while waiting for the assessment.

Rationale

Prompt access to services is essential if children and young people are to receive the right treatment at the right time. Arrangements should be in place so that children and young people referred to CAMHS with suspected severe depression and at high risk of suicide are assessed by CAMHS professionals as an emergency, within a maximum of 24 hours of referral. Healthcare professionals who refer a child or young person to CAMHS should also ensure that, at the time of referral, they assess the need for a safe place for the child or young person until the CAMHS assessment is carried out. This should help to prevent injury or worsening of symptoms.

Quality measures

Structure
a) Evidence of local arrangements to ensure that CAMHS professionals assess all children and young people with suspected severe depression and at high risk of suicide within a maximum of 24 hours of referral.
b) Evidence of local arrangements to ensure that children and young people with suspected severe depression and at high risk of suicide who are referred to CAMHS are provided with a safe place if necessary while waiting for an assessment.
Data source: Local data collection.
Process
a) Proportion of children and young people with suspected severe depression and at high risk of suicide who are assessed by CAMHS professionals within 24 hours of referral.
Numerator – the number of people in the denominator assessed by CAMHS professionals within 24 hours of referral.
Denominator – the number of children and young people referred to CAMHS with suspected severe depression and at high risk of suicide.
Data source: Local data collection. For CAMHS, data on referral and waiting times are collected in the Child and Adolescent Mental Health Services secondary uses data set.

What the quality statement means for different audiences

Service providers ensure that systems are in place for CAMHS professionals to assess all children and young people with suspected severe depression and at high risk of suicide within a maximum of 24 hours of referral. Service providers also ensure that systems are in place so that children and young people are provided with a safe place if necessary while waiting for CAMHS assessment.
CAMHS professionals assess all children and young people with suspected severe depression and at high risk of suicide within a maximum of 24 hours of referral.
Healthcare professionals and social care practitioners ensure that children and young people with suspected severe depression and at high risk of suicide who are waiting for CAMHS assessment are provided with a safe place if necessary.
Commissioners ensure that they commission CAMHS to assess all children and young people with suspected severe depression and at high risk of suicide within a maximum of 24 hours of referral. Commissioners also ensure that they commission services in which children and young people are provided with a safe place if necessary while waiting for CAMHS assessment.
Children and young people with suspected severe depression and at high risk of suicide are assessed within a maximum of 24 hours of being referred to CAMHS (Child and Adolescent Mental Health Services). If the child or young person needs a safe place while waiting for the CAMHS assessment, this is provided.

Source guidance

Depression in children and young people: identification and management (2019) NICE guideline NG134, recommendation 1.6.1

Definitions of terms used in this quality statement

  • The time frame of 24 hours is based on consensus of expert opinion.
  • The provision of a safe place is based on consensus of expert opinion.
Severe depression
ICD 10 classification of mental and behavioural disorders describes severe depression as 7 or more depressive symptoms, with or without psychotic symptoms.
Assessment
An assessment by CAMHS is likely to include but is not limited to:
  • assessment of diagnosis
  • initiation of treatment.
High risk of suicide
NICE’s guideline on depression in children and young people defines suicidal ideation as thoughts about suicide or of taking action to end one’s own life. For the purposes of this quality standard high risk of suicide could include, but is not limited to, children and young people with current active suicidal plans or thoughts.

Suspected severe depression without high risk of suicide

This quality statement is taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statement

Children and young people with suspected severe depression but not at high risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health Services) professionals within a maximum of 2 weeks of referral.

Rationale

Prompt access to services is essential if children and young people are to receive the right treatment at the right time. Arrangements should be in place so that children and young people referred to CAMHS with suspected severe depression but not at high risk of suicide are assessed quickly to help prevent injury or worsening of symptoms.

Quality measures

Structure
Evidence of local arrangements to ensure that CAMHS professionals assess children and young people with suspected severe depression but not at high risk of suicide within a maximum of 2 weeks of referral.
Data source: Local data collection.
Process
Proportion of children and young people with suspected severe depression but not at high risk of suicide who are assessed by CAMHS professionals within 2 weeks of referral.
Numerator – the number of people in the denominator assessed by CAMHS professionals within 2 weeks of referral.
Denominator – the number of children and young people referred to CAMHS with suspected severe depression but not at high risk of suicide.
Data source: Local data collection. For CAMHS, data on referral and waiting times are collected in the Child and Adolescent Mental Health Services secondary uses data set.

What the quality statement means for different audiences

Service providers ensure that systems are in place for CAMHS professionals to assess children and young people with suspected severe depression but not at high risk of suicide within a maximum of 2 weeks of referral.
CAMHS professionals assess children and young people with suspected severe depression but not at high risk of suicide within a maximum of 2 weeks of referral.
Commissioners ensure that they commission CAMHS to assess children and young people with suspected severe depression but not at high risk of suicide within a maximum of 2 weeks of referral.
Children and young people with suspected severe depression but not at high risk of suicide are assessed within a maximum of 2 weeks of being referred to CAMHS (Child and Adolescent Mental Health Services).

Source guidance

Depression in children and young people: identification and management (2019) NICE guideline NG134, recommendation 1.6.1

Definitions of terms used in this quality statement

The time frame of 2 weeks is based on consensus of expert opinion.
Severe depression
ICD 10 classification of mental and behavioural disorders describes severe depression as 7 or more depressive symptoms, with or without psychotic symptoms.
Assessment
An assessment by CAMHS is likely to include but is not limited to:
  • assessment of diagnosis
  • initiation of treatment.
High risk of suicide
NICE’s guideline on depression in children and young people defines suicidal ideation as thoughts about suicide or of taking action to end one’s own life. For the purposes of this quality standard high risk of suicide could include, but is not limited to, children and young people with current active suicidal plans or thoughts.

Monitoring progress

This quality statement is taken from the depression in children and young people quality standard. The quality standard defines clinical best practice for depression in children and young people and should be read in full.

Quality statement

Children and young people receiving treatment for depression have their health outcomes recorded at the beginning and end of each step in treatment.

Rationale

It is important to monitor the mood and feelings of children and young people who are receiving treatment for depression so that the effectiveness of treatment can be assessed and adjustments made to ensure maximum benefit.

Quality measures

Structure
Evidence of local arrangements to ensure that the health outcomes of children and young people receiving treatment for depression are recorded at the beginning and end of each step in treatment.
Data source: Local data collection.
Process
Proportion of children and young people receiving treatment for depression who have their health outcomes recorded at the beginning and end of each step in treatment.
Numerator – the number of people in the denominator who have their health outcomes recorded at the beginning and end of each step in treatment.
Denominator – the number of children and young people receiving treatment for depression.
Data source: Local data collection. For CAMHS (Child and Adolescent Mental Health Services), data on outcomes are collected in the Child and Adolescent Mental Health Services secondary uses data set. Routine outcome monitoring is part of The Children and Young People’s IAPT project.

What the quality statement means for different audiences

Service providers ensure that systems are in place for the health outcomes of children and young people receiving treatment for depression to be recorded at the beginning and end of each step in treatment.
Healthcare and CAMHS professionals record the health outcomes of children and young people receiving treatment for depression at the beginning and end of each step in treatment.
Commissioners ensure that they commission services that record the health outcomes of children and young people receiving treatment for depression at the beginning and end of each step in treatment.
Children and young people being treated for depression are asked a set of standard questions every time their treatment changes to check whether the treatment is working.

Source guidance

Depression in children and young people: identification and management (2019) NICE guideline NG134, recommendations 1.1.18 and 1.1.25

Definitions of terms used in this quality statement

Methods to monitor health outcomes
NICE’s guideline on depression in children and young people indicates that healthcare and CAMHS professionals can use self report measures, as used in screening for depression (for example, the Mood and Feelings Questionnaire), or generic outcome measures (for example, Health of the Nation Outcome Scale for Children and Adolescents or the Strengths and Difficulties Questionnaire) to record health outcomes.
A step in treatment
This is the movement between steps of the stepped care model. For further information, see table 1 The stepped-care model in NICE’s guideline on depression in children and young people.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

The stepped care model of depression

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 children and young people and their parents or carers in identifying and accessing the most effective interventions.
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 as 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 tier 3 CAMHS – moderate to severe depression.
5. Managing recognised depression in tier 3 or tier 4 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.
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. We have retained the tiers terminology and will revise this when we update the 2005 recommendations.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

This intervention is based on the brief psychosocial intervention (BPI) carried out in the IMPACT trial (Goodyer et al. 2017)1.
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.
1 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.
Digital CBT is a form of cognitive behaviour therapy 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.
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. We have retained the tiers terminology and will revise this when we update the 2005 recommendations.
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.
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.
A child or young person with depression should be offered advice about sleep hygiene and anxiety management.
A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet.
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.
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.
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.
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.

Glossary

child and adolescent mental health services
child and adolescent psychiatric assessment
cognitive behavioural therapy
computerised cognitive behavioural therapy
electroconvulsive therapy
Health of the Nation Outcome Scales for Children and Adolescents
International Statistical Classification of Diseases and Related Health Problems (tenth edition)
interpersonal therapy
interpersonal therapy for adolescents
(schedule for affective disorders and schizophrenia for school-age children)
Mood and Feelings Questionnaire
non-directive supportive therapy
Strengths and Difficulties Questionnaire
(primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services)
(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)
(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)
(tertiary-level child and adolescent mental health services such as day units, highly specialised outpatient teams and inpatient units)

Paths in this pathway

Pathway created: May 2011 Last updated: June 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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