Treatment Guidelines for Depression in Young People and Adolescents

Summarized from Great Britain’s National Institute for Health and Clinical Excellence, Issued April, 2007

 

Great Britain’s National Institute for Health and Clinical Excellence (NICE) issues guidelines upon which the National Health Service bases its healthcare treatments for the entire country. Unlike the Food and Drug Administration in the United States, NICE has acquired a reputation of being relatively free from the pressures of the pharmaceutical industry, so therapists looking for information on treatments for various disorders would do well to check with NICE’s various guidelines (www.nice.org.uk)

The NICE guidelines for treating depression in young people and adolescents begin by stating that “Treatment and care should take into account the child’s or young person’s individual needs and preferences as well as the wishes of the parent(s) or carer(s).” In other words, right from the beginning, the NICE guidelines implicitly address the powerlessness of depression, insisting that young people be partners in decisions affecting their mental health and treatment. The guidelines do however go on to state that, “Where a child or young person is not old enough or does not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines.”

Further addressing the notion of powerlessness, the guidelines state, “Good communication between healthcare professionals and children or young people and their parent(s) or carer(s) is essential. It should be supported by the provision of evidence-based information offered in a form that is tailored to the needs of the individual. The treatment, care and information provided should be culturally appropriate and in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.”

The NICE guidelines take great care to avoid the kind of quick medical promise of an antidepressant. Antidepressants are specifically NOT recommended as a frontline treatment for depression. Further, the assessment and treatment decisions should take into account “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.” For moderate to severe depression, the recommended frontline treatment is cognitive-behavior therapy (CBT), interpersonal therapy or short-term family therapy, all of at least three months’ duration. If antidepressants are offered, they must be in combination with a concurrent psychotherapy, and the antidepressant’s effects should be closely monitored, with “specific arrangements” for side effects.

Clearly, NICE is concerned about the effects and too casual prescribing of antidepressants. The guidelines stress that fluoxetine is the only antidepressant with empirical evidence of efficacy in young people. They are cautious about that efficacy, however, saying that the beneficial effects appear to outweigh the potential adverse effects. Although they do not proscribe other SSRIs, (with the exception of paroxetine and venlafaxine which, they caution, should NOT be used) NICE advises that they should be used only when the depression is severe, intractable, other treatments are not working, and there is reason to believe the child is intolerant of fluoxetine.

Healthcare professionals—and keep in mind that the NICE guidelines are for mental health professionals as well as physicians—are advised to “take time to build a supportive and collaborative relationship with both the patient and the family,” and to “engage the child or young person and their parent(s)…in treatment decisions, taking full account of patient and parental…expectations, so that the patient and their parent(s)… can give meaningful and properly informed consent before treatment isinitiated.” Throughout the guidelines, the notion of depression as a family systemic disorder, rather than as a biological disorder mostly contained within an individual’s brain, is stressed. “When a child or young person has been diagnosed with depression,” the guidelines state, “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 treatmentoffered to the child or young person.”

The guidelines even go beyond the family in recommending systemic interventions. “Before any treatment is started,” the guidelines state, “healthcare professionals shouldassess, 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 ornegatively 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.”

NICE is also cognizant of what we in our own country call alternative or complementary treatments, stating, “A child or young person with depression should be offered adviceon the benefits of regular exercise and encouraged to consider following a structured and supervised exercise programme of typically up to three sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks.” Children should also be offered information on sleep hygiene, anxiety management, nutrition and “the benefits of a balanced diet.”

Interventions for mild depression.

NICE recommends, if the young people decline treatment, up to four weeks of watchful waiting, followed by a reassessment, stressing that if the patient does not show up for theFollow-up appointment, the healthcare professional should contact them and aggressively follow through. They should then be offered “non-directive supportive therapy, group cognitive behavioural therapy (CBT) or guided selfhelp.” If the depression does not respond, the guidelines for moderate to severe depression should then be followed.

Interventions for moderate to severe depression.

Keeping in mind, NICE says, that there is little on treatment for research for moderate to severe depression on children 5 to 11 years of age, the guidelines call for “first-line treatment [of] 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.” If there is no response after 4 to six therapy s sessions, NICE calls for a multi-disciplinary review. Treating professions should also “Consider combining psychological therapy with fluoxetine (cautiously in younger children). If combined treatment is not effective within a further six sessions, review and consider more intensive psychological therapy.” Following a multi-disciplinary review, professionals should consider “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 individual child psychotherapy (approximately 30 weekly sessions).”

Echoing research by people such as Michael Lambert of Brigham Young University, which finds that therapists who receive early and regular feedback from patients have higher success rates, the guidelines stress the importance of regular feedback to the healthcare professional. “When the clinical progress of children and young people withdepression is being monitored in secondary care, the self-report Mood and Feelings Questionnaire (MFQ) should be considered as an adjunct to clinical judgment.”

During the assessment, “healthcare professionals should always ask the patient and theirparent(s) or carer(s) 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.”

NICE strongly believes in self-help as a treatment adjunct. The guidelines state that, ” 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 parent(s)or carer(s). This may include educational leaflets, helplines, selfdiagnosis tools, peer, social and family support groups, complementary therapies, and religious and spiritual groups. These, however, should be offered only “as part of a supported and planned package of care.”

The complete NICE guidelines are available for free online at http://guidance.nice.org.uk/CG28/niceguidance/pdf/English