Depression in children

Source:
Clinical Knowledge Summaries - CKS
Publication date:
01 February 2016

Abstract

Depression in children Last revised in February 2016 Next planned review by December 2021 Summary Back to topDepression in children: Summary The prevalence of childhood depression has been estimated to be 1% in pre-pubertal children and around 3% in post-pubertal young people. It is experienced by twice as many adolescent females as males.Consider offering the child or young person a consultation alone. Be aware of confidentiality and consent (including Gillick competence, Fraser guidelines) and child protection issues.Key symptoms of depression in children are:Persistent sadness or low mood (may present as irritability).Loss of interest or loss of pleasure (anhedonia).Fatigue/ low energy.If any key symptoms are present, the presence of other associated symptoms should be determined:Poor quality or increased need for, sleep.Poor concentration or indecisiveness.Low self-confidence.Poor or increased appetite.Agitation or slowing of movements.Guilt or self blame.Suicidal thoughts or acts.A diagnosis can be made of:A mild depressive episode if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus two associated symptoms.A moderate-to-severe depressive episode if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus three or more associated symptoms.A severe depressive episode with psychotic symptoms if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus seven or more associated symptoms or psychotic symptoms.In childhood, depression can have a more insidious onset than in adults, characterized by irritability more than sadness, and often occurs with other behavioural disorders.Contributing factors should be considered:Potential comorbidities such as anxiety or conduct disorder.Alcohol or drug use, history of bullying or abuse, self harm, or suicidal ideation.Problems in family, relationships, and social life.Recent negative life events (for example parental divorce or bereavement).Risk factors for depression should be explored, including family history of unipolar or bipolar disorder.An urgent referral to the child and adolescent mental health service (CAMHS) should be arranged if there is:Risk of self harm or suicide.Significant ongoing self neglect.A referral to CAMHS should be arranged if the child has:Mild depression and two or more risk factors for depression; one or more family member with multiple risk-histories for depression; no improvement after 4 weeks of watchful waiting.Moderate or severe depression (including recurrent episodes from which they have recovered, including psychotic depression).Unexplained self neglect of at least 1 month's duration that could be harmful to physical health.Severe impairment of functioning (at school, or within family and relationships).Watchful waiting and lifestyle advice are recommended for other children or young people who do not meet the above criteria. Watchful waiting can be for up to 4 weeks. However, follow up should take place after 2 weeks to reassess symptoms and consider the need for referral. Have I got the right topic? Back to topHave I got the right topic? From age 5 years to 18 years.This CKS topic is based on the National Institute for Health and Care Excellence guideline Depression in children and young people [National Collaborating Centre for Mental Health, 2005].This CKS topic covers the management of depression in people 5–18 years of age.This CKS topic does not cover the management of depression in adults.There are separate CKS topics on Attention deficit hyperactivity disorder, Child maltreatment - recognition and management, Depression, and Depression - antenatal and postnatal.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes February 2016 — reviewed. Interim updated, the topic has been updated to align with the recommendations on psychological therapies and antidepressants included in the March 2015 update of the NICE Clinical Guideline (CG28) on Depression in children and young people [NICE, 2005]. Back to top Previous changes Previous changes July 2013 — a literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. There are no changes to this topic.February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.March 2011 — minor update. Change of reference regarding prevalence estimates for depression in children. Issued in June 2011.September 2008 to January 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesGuidelines published since the last revision of this topic:Cleare, A., Pariante, C.M., Young, A.H., et al. (2015) Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines.Journal of psychopharmacology29(5), 459-525. [Abstract]NICE (2017) Depression in children and young people: identification and management. National Insitute for Health and Care Excellence. www.nice.org.uk [Free Full-text] HTAs (Health Technology Assessments)No new HTAs since 1 July 2013.Economic appraisalsNo new economic appraisals relevant to England since 1 July 2013.Systematic reviews and meta-analysesSystematic reviews published since the last revision of this topic:Dolle, K. and Schulte-Korne, G. (2013) The treatment of depressive disorders in children and adolescents.Deutsches Arzteblatt International110(50), 854-860. [Abstract] [Free Full-text]Kohler, O., Benros, M. E., Nordentoft, M., et al. (2014) Effect of anti-inflammatory treatment on depression, depressive symptoms, and adverse effects: a systematic review and meta-analysis of randomized clinical trials.JAMA Psychiatry71(12), 1381-1291. [Abstract] [Free Full-text]Spielmans, G.I. and Gerwig, K. (2014) The efficacy of antidepressants on overall well-being and self-reported depression symptom severity in youth: a meta-analysis.Psychotherapy and Psychosomatics83(3), 158-164. [Abstract]Primary evidenceRandomized controlled trials published since the last revision of this topic:Stallard, P., Phillips, R., Montgomery, A., et al. (2013) A cluster randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents.Health Technology Assessment17(47). [Abstract] [Free Full-text]Observational studies published since the last revision of this topic:Miller, M., Swanson, S.A., Azrael, D., et al. (2014) Antidepressant dose, age, and the risk of deliberate self-harm.JAMA Internal Medicineepub ahead of print. Back to top New policies New policies No new policies since 1 July 2013. Back to top New safety alerts New safety alerts No new safety alerts since 1 July 2013. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 July 2013. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Recognize depression in children at an early stage.Make an accurate diagnosis.Make an accurate assessment of the severity of depression.Make an appropriate referral to secondary care or other specialist service.Prescribe appropriate treatment and monitor in primary care. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators No QOF indicators were found during the review of this topic. Back to top QIPP - Options for local implementation QIPP - Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE quality standards NICE quality standards No NICE quality standards were found during the review of this topic. Background information Back to topBackground information Back to top Prevalence How common is it? The prevalence of childhood depression has been estimated to be 1% in pre-pubertal children and around 3% in post-pubertal young people. It is experienced by twice as many adolescent females as males [National Collaborating Centre for Mental Health, 2005]. Back to top Prognosis What is the prognosis? Ten per cent of children and young people with depression recover spontaneously within 3 months, and 50% recover within the first year [NICE, 2005]. Diagnosis Back to topDiagnosis Back to top General issues What issues should I be aware of when assessing a child or young person with depression? Consider offering the child or young person a consultation alone (without their parents or carers).Be aware of the following issues:Confidentiality.Consent (including Gillick competence and Fraser guidelines).Parental consent.Child protection.The use of the Mental Health Act in young people.The use of the Children Act. Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence guideline Depression in children and young people  [NICE, 2005]. Back to top Assessment Assessment Ask about the following contributing factors:Potential comorbidities such as anxiety or conduct disorder.Alcohol or drug use, history of bullying or abuse, self harm, or suicidal ideation.Family and social life (including homelessness, refugee status, and institutional accommodation). Ask about relationships with siblings, parents, and friends.Recent negative life events (for example parental divorce, bereavement, or parental job loss).Ask about coping strategies.Explore risk factors for depression, including age, gender (depression is more common in pubertal young females), and family history of unipolar or bipolar disorder.Look for signs of self neglect (for example unkempt appearance), signs of self harm, or suicidal ideation. Back to top Coping strategies Coping strategies It is important to explore day to day functioning in a number of settings (for example, at school, with peers and family). A combination of biological, psychological, and social factors have a significant impact on response to treatment [National Collaborating Centre for Mental Health, 2005].Expert opinion has indicated that a discussion of coping strategies is an important part of the assessment, especially with regard to functional impairment (for example, at school). Positive coping strategies can be built upon and unhelpful ones, such as alcohol and drug abuse, can be addressed. Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence guideline Depression in children and young people [NICE, 2005]. Back to top Diagnosis How do I make a diagnosis of depression in children? Ask about key symptoms:Persistent sadness or low mood, which may present as irritability.Loss of interest or loss of pleasure (anhedonia).Fatigue or low energy.If any key symptoms are present, ask about other associated symptoms:Poor quality, or increased need for, sleep.Poor concentration or indecisiveness.Low self-confidence.Poor or increased appetite.Agitation or slowing of movements.Guilt or self blame.Suicidal thoughts or acts.Diagnose:A mild depressive episode if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus two associated symptoms.A moderate-to-severe depressive episode if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus three or more associated symptoms.A severe depressive episode with psychotic symptoms if there is persistent sadness or low mood (or irritability) with either anhedonia or tiredness, plus seven or more associated symptoms or psychotic symptoms.Be aware that, in childhood, depression can have a more insidious onset than in adults. It may be characterized by irritability more than sadness, and often occurs concurrently with other behavioural disorders.Record details of signs and symptoms accurately in the notes, as they may not all be present at any one time and may fluctuate in severity. Back to top Additional information Additional information It is difficult to diagnose depression from a single symptom count [National Collaborating Centre for Mental Health, 2005].It has been reported that primary care physicians under-diagnose adolescent depression [Zuckerbrot et al, 2007]. A systematic assessment that involves specifically asking about depression and suicide provides better results than relying on the young person volunteering the information. Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence guideline Depression in children and young people [NICE, 2005]. The NICE guideline has classified the treatment and management of depression into three categories in agreement with the World Health Organization ICD-10 Classification of Mental and Behavioural Disorders [WHO, 1992]. Management Back to topManagement Scenario: Management: covers the management of depression in children. Back to top Scenario: Management Scenario: Management From age 5 years to 18 years. Back to top General issues What issues should I be aware of when managing a child or young person with depression? General considerations when diagnosing a child or young person is covered in the section on What issues should I be aware of when assessing a child or young person with depression? Back to top Moderate to severe depression How do I manage a child or young person with moderate to severe depression? If a child or young person has moderate to severe depression:They should be reviewed by a CAMHS tier 2 or 3 team.They should be offered a specific psychological intervention such as individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy.Psychological intervention should continue for at least 3 months (that is 15 sessions over 15 weeks).Discuss the choice of psychological intervention with the child or young person and their family members or carers.Explain that they will be reviewed by a child psychologists or paediatrician with specialist training in mental health.Explain that there is no evidence to support one type of psychological therapy over another.When should combined treatment be offered? In children (aged 5–11 years), before offering combined therapy (fluoxetine with psychological therapy) the following should be considered:The child should have a multidisciplinary review, if psychological therapy has been tried for four to six treatment sessions.Following multidisciplinary review, if the child's depression is not responding to psychological therapy as a result of other coexisting factors (such as comorbid conditions, persisting psychosocial risk factors such as family discord, or parental mental health problems), consider:An alternative psychological therapy for the child or young person.An alternative, or an additional psychological therapy for the parent or other family members.Offering fluoxetine with caution, in addition to psychological therapy, if symptoms are unresponsive to a specific psychological therapy after four to six sessions.In young people (aged 12–18 years), before offering combined therapy (fluoxetine with psychological therapy) the following should be considered:The young person should have a multidisciplinary review, if psychological therapy has been tried for four to six treatment sessions.Following multidisciplinary review, if the young person's depression is not responding to psychological therapy as a result of other coexisting factors (such as comorbid conditions, persisting psychosocial risk factors such as family discord, or parental mental health problems), consider:An alternative psychological therapy for the child or young person.An alternative, or an additional psychological therapy for the parent or other family members.Offering fluoxetine, in addition to psychological therapy, if a young person is unresponsive to a specific psychological therapy after four to six sessions. Back to top Antidepressant treatment What is the preferred antidepressant for children and young people? Antidepressants should only be prescribed following an assessment and diagnosis by a child and adolescent psychiatrist.Only children and young people who are undergoing concurrent psychological interventions should be given antidepressants.Fluoxetine is the preferred antidepressant for moderate and severe depression in children and young people. It is the only antidepressant where the benefits outweigh the risks.Specific arrangements must be made for careful monitoring of adverse effects, as well as for reviewing mental state and general progress of the child or young person.This may involve weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks of treatment.When starting a child or young person on antidepressant medication, they should be informed about:The rationale for the drug treatment.The delay in onset of effect.The time course of treatment.The possible adverse effects.The need to take the medication as prescribed.Give written information appropriate to the child or young person's and parents' or carers' needs.Plan a review and provide information on who to contact if they experience adverse effects or other issues during treatment.What dose of fluoxetine should be prescribed?The starting dose should be 10 mg daily, this can be increased to 20 mg daily after one week if clinically necessary.There is little evidence regarding the effectiveness of doses higher than 20 mg daily.How long should fluoxetine be prescribed?If a child or young person is responding to fluoxetine, treatment should be continued for at least 6 months after remission.Remission is defined as no symptoms and full functioning for at least 8 weeks, treatment should continue for 6 months beyond this 8 week period.[NICE, 2005]What are the alternative antidepressants for children and young people?Consider another antidepressant, such as sertraline or citalopram, if treatment with fluoxetine is unsuccessful or is not tolerated because of adverse effects. Seek advice from a senior child and adolescent psychiatrist, such as a Consultant.Sertraline or citalopram should only be used when the following criteria have been met:Discuss the benefits and risks of the new treatment with the child or young person and their parent(s) or carer(s).The child or young person's depression is severe and/or causing serious symptoms such as weight loss or suicidal behaviour to justify a trial of another antidepressant. There has been a fair trial of the combination of fluoxetine and a psychological therapy, that is all efforts should be made to ensure adherence to the recommended treatment regimen. Reassess the likely causes of the depression and of treatment resistance, for example other diagnoses such as bipolar disorder or substance misuse. Provide appropriate written information. This should cover the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible adverse effects, and the need to take the medication as prescribed; it should also include the latest patient information advice.Written consent must be sought from the child or young person and/or someone with parental responsibility for the child or young person. The young person alone, if over 16, can give consent if deemed competent.Continue medication for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks) when a child or young person responds to treatment with citalopram or sertraline. The starting dose should be half the daily starting dose for adults (sertraline 25 mg per day; citalopram 10 mg per day). The dose can be gradually increased to the daily dose for adults (sertraline 50 mg per day; citalopram 20 mg per day) over the next 2 to 4 weeks if clinically necessary.There is little evidence regarding the effectiveness of the upper daily doses for adults in children and young people, but these may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority.[NICE, 2005] Back to top Depression unresponsive to combined treatment What should I do if a child or young person is unresponsive to combined treatment? The multidisciplinary team should make a full needs and risk assessment if:The child or young person is unresponsive to combined treatment with a specific psychological therapy and fluoxetine after a further six weekly sessions.The child or young person and/or their parent(s) or carer(s) have declined the offer of fluoxetine.The needs and risk assessment should include:A review of the diagnosis.Evaluation of the possibility of comorbid diagnoses.A reassessment of any possible individual, family, and social causes of depression.Consideration of whether there has been a fair trial of treatment.An assessment for further psychological therapy for the child or young person and/or additional help for the family.Following the needs and risk assessment, the following should be considered:An alternative psychological therapy, which has not been tried previously. This should involve individual CBT, interpersonal therapy or shorter-term family therapy for at least 3 months.Systemic family therapy, at least 15 fortnightly sessions, orIndividual child psychotherapy, approximately 30 weekly sessions.[NICE, 2005] Back to top Basis for recommendation Basis for recommendation The recommendations on treatment options for moderate to severe depression in children and young people have been adapted from the National Institute for Health and Care Excellence guideline Depression in children and young people [NICE, 2005]. Back to top Mild depression How do I manage a child or young person with mild depression? Back to top Watchful waiting Watchful waiting Watchful waiting and lifestyle advice are recommended for children or young people in one of the following categories:The person has mild depression but they or their guardian do not want a formal intervention.The person has been exposed to a single undesirable event:In the absence of other risk factors for depression.In the presence of two or more risk factors with no evidence of depression or self harm.Where one or more family members have multiple risk-histories for depression, providing that there is no evidence of depression or self harm in the young person.Mild depression without comorbidity.Watchful waiting can be for up to 4 weeks. However, follow up should take place after 2 weeks to reassess symptoms and consider the need for psychological interventions, drug treatment and referral.Encourage structured exercise (three times a week), a healthy diet, and good sleep hygiene. See the CKS topics on Obesity and Insomnia for more information.Encourage positive coping strategies that help the young person feel better, such as involvement in a hobby or activity, and discourage those that may be exacerbating the problem, such as alcohol or cannabis use. See the CKS topic on If the person has symptoms of anxiety, provide advice on management (for example relaxation techniques). See the CKS topic on Generalized anxiety disorder for more information.If bullying is an issue, liaise with the school to encourage anti-bullying strategies.After an undesirable event, allow an opportunity to discuss the event and if appropriate, liaise with support services (such as ChildLine or the Samaritans).Provide information — see the section on Information and advice. Back to top Psychological interventions When should psychological interventions be offered? Offer all children and young people with continuing mild depression psychological interventions following a period of watchful waiting.Psychological interventions include individual non-directive supportive therapy, group cognitive behavioural therapy (CBT) or guided self-help.Psychological interventions should last for approximately 2 to 3 months.Only offer psychological interventions to children and young people who do not have significant coexisting factors or signs of suicidal ideation. Coexisting factors include;Comorbid conditions such as physical health problems or smoking.Persisting psychosocial risk factors such as family discord.The presence of parental mental health problems.Discuss the choice of psychological interventions with children and young people and their family members or carers. Explain that there is no evidence to support one type of psychological intervention over another.Psychological interventions should be provided by appropriately trained professionals in primary care, schools, social services, and the voluntary sector, or by a tier 2 community and adolescent mental health service (CAMHS) team.Refer a child or young person for review by a tier 2 or 3 CAMHS team who do not respond after 2 to 3 months.Treatment options for moderate to severe depression should be followed for children and young people with persisting mild depression who are unresponsive to psychological interventions.[NICE, 2005] Back to top Antidepressants Should a child or young person with mild depression be prescribed antidepressants? Antidepressant medication should not be used for the initial treatment of children and young people with mild depression.Children and young people with persistent mild depression unresponsive to psychological interventions at CAMHS tier 1 or 2 should follow the recommendations for moderate to severe depression. See the section on How do I manage a child or young person with moderate to severe depression? for more information.[NICE, 2005] Back to top Basis for recommendation Basis for recommendation The recommendations on treatment options for mild depression in children and young people have been adapted from the National Institute for Health and Care Excellence guideline Depression in children and young people [National Collaborating Centre for Mental Health, 2005]. Back to top Referral When should I refer a child or young person with depression? Referral to tier 2 or 3 Child and Adolescent Mental Health Service (CAMHS).Urgently refer to tier 2 or tier 3 CAMHS any child or young person:At risk of self harm or suicide (that is, active suicidal plans or ideas).With unexplained self neglect (for example, poor personal hygiene or reduction in eating) lasting at least 1 month that could be harmful to their physical health.Refer to tier 2 or tier 3 CAMHS, any child or young person with:Mild depression and:Two or more risk factors for depression.One or more family member with multiple-risk histories for depression.No improvement after 4 weeks of watchful waiting.Moderate or severe depression (including recurrent episodes from which they have recovered, including psychotic depression).Unexplained self neglect of at least 1 month's duration that could be harmful to physical health.If there is severe impairment of functioning (at school, or within the family and relationships).Consider referring the child or young person to tier 2 or tier 3 CAMHS if a referral is specifically requested (for example, by the individual, carer, or parent).Referral to tier 4 Child and Adolescent Mental Health Service (CAMHS).Urgently refer to tier 4 CAMHS any child or young person:At a high recurrent risk of acts of self harm or suicide.With significant ongoing self neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health).Who requires a level of intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3. Back to top Basis for recommendation Basis for recommendation Referral criteria are adapted from the National Institute for Health and Care Excellence guideline Depression in children and young people [NICE, 2005]. A referral to CAMHS will allow the appropriate intervention to be carried out (for example individual non-directive supportive therapy, group cognitive behavioural therapy, or guided self-help). Back to top Admission When should I admit a child or young person with depression? Consider admitting a child or young person for inpatient treatment if there is a high risk of suicide, serious self harm or self neglect.Consider admission when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated. Consider the benefits of inpatient treatment against potential detrimental effects before admission, for example loss of family and community support.When inpatient treatment is indicated, CAMHS professionals should involve the child or young person and their parent(s) or carer(s) in the admission and treatment process whenever possible. Back to top Basis for recommendation Basis for recommendation Recommendations regarding admission are taken from the National Institute for Health and Care Excellence guideline Depression in children and young people [NICE, 2005]. A referral to CAMHS will allow the appropriate intervention to be carried out (for example individual non-directive supportive therapy, group cognitive behavioural therapy, guided self-help). Back to top CAMHS Child and Adolescent Mental Health Service (CAMHS) The Child and Adolescent Mental Health Service (CAMHS) usually provides coordinated care involving professionals in both a primary and secondary care setting. Four tiers exist within CAMHS, offering different areas of specialism:Tier 1: Primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies, and social services.Tier 2: The CAMHS provided by professionals working with 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 or nurse specialists, and family therapists.Tier 3: CAMHS specialized services for more severe, complex, or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community- or hospital-based), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists.Tier 4: Tertiary-level services such as day units, highly specialized outpatient teams, and inpatient units. The availability of services will vary depending on locality, but all children should be seen by a specialist with experience in child and adolescent mental health.[NICE, 2005] Back to top Information and advice Information and advice Give advice about guided self-help and support groups.Guided self-help may include:Self-help leaflets or books, using cognitive behavioural therapy principles.Self-help computer programmes or the internet.Exercise sessions (three sessions each week for up to 1 hour), for 10–12 weeks.Information specific for children and young people can be found at Young Minds (http://www.youngminds.org.uk).Organizations that offer materials and/or support to people with depression include:Mental Health Foundation — www.mentalhealth.org.uk.MIND — www.mind.org.uk.Depression Alliance — www.depressionalliance.org.Depression UK (previously the Fellowship of Depressives Anonymous) — www.depressionuk.org.Samaritans — telephone helpline: 08457 90 90 90.SaneLine: telephone helpline: 0845 767 8000. Open from 6pm to 11pm every day of the year.Provide written and verbal information about depression and its treatment. Good quality patient information can be found on the website of the Royal College of Psychiatrists (www.rcpsych.ac.uk). Leaflets include: DepressionDepression: key factsDepression in children and young people: information for young peopleDepression in young people - helping children to cope: information for parents, carers and anyone who works with young peopleAntidepressantsCognitive Behavioural TherapyWhen starting any antidepressant, advise the person, and their parents or carers:To be vigilant for worsening depressive symptoms and suicidal ideas, particularly when starting and changing medications, and at times of increased personal stress. Advise them to seek help promptly if they are concerned.That it usually takes 2–4 weeks for symptoms to improve, although some people improve within a few days of treatment.That antidepressant should be taken for at least 6 months after they have recovered, to reduce the risk of relapse. People who are at high risk of relapse may need to take them for longer than this.That antidepressant drugs are not addictive.That they need to take the medication as prescribed and should not stop them suddenly. This helps to prevent discontinuation symptoms occurring (dizziness, nausea, paraesthesiae, anxiety, diarrhoea, flu-like symptoms, and headaches). This advice is particularly important for drugs with a shorter half-life such as paroxetine.That some antidepressants potentially have sedating effects, and may affect the person's ability to drive. This effect is likely to be greatest in the first month after starting treatment or increasing the dose. The Driver and Vehicle Licensing Agency (DVLA) advises that people should not drive during this time if affected. Back to top Basis for recommendation Basis for recommendation Information on depressionThe information and advice on depression and its treatment is taken from information leaflets published by the Royal College of Psychiatrists (www.rcpsych.ac.uk). Information on antidepressantsThis information is based on guidance issued by the National Institute for Health and Care Excellence (NICE) Depression in Children and Young People [National Collaborating Centre for Mental Health, 2005], the Driver and Vehicle Licensing Agency (DVLA) [DVLA, 2015], the manufacturer's Summary of Product Characteristics for fluoxetine [ABPI Medicines Compendium, 2013], and the Maudsley prescribing guidelines [Taylor et al, 2012].Guided self-help and support groupsPeople with depression may benefit from information about self-help groups, support groups, and other available resources (locally and nationally) that provide support, activities, and social contact in order to improve the outcome of depression. Prescribing information Back to topPrescribing information Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the CKS topic Depression, the electronic Medicines Compendium (eMC), or the British National Formulary (BNF) . Back to top Fluoxetine What issues should I consider when prescribing fluoxetine? Fluoxetine should only be offered to a child or young person in combination with a psychological intervention, and prescribed by a consultant in child psychiatry. Specific arrangements should be made for careful monitoring of adverse effects as well as for reviewing mental state and general progress. Weekly contact is recommended for the first 4 weeks of treatment. The precise frequency should be decided on an individual basis and recorded in the notes. If a psychological intervention is declined, fluoxetine may be given but the child or young person should be closely monitored on a regular basis focusing particularly on emergent adverse drug reactions. [NICE, 2005] Back to top Contraindications and cautions Fluoxetine contraindications and cautions Fluoxetine should be used with caution in children or young people with:Epilepsy.Cardiovascular disease.Diabetes mellitus.[ABPI Medicines Compendium, 2013; BNF 70, 2015] Back to top Adverse effects Fluoxetine adverse effects Children and young people should be monitored for suicidal behaviour and risk of self-harm, particularly at the beginning of treatment or if the dose is changed. Suicidal behaviour has been linked with the use of antidepressants, particularly in children and young people. Adverse effects associated with fluoxetine are dose-related. The most common adverse effects include:Gastrointestinal effects:NauseaVomitingAbdominal painDyspepsiaConstipationDiarrhoeaCentral nervous system effects:DizzinessAgitationAnxietyInsomniaTremorHeadacheSexual dysfunction.[ABPI Medicines Compendium, 2013; BNF 70, 2015] Supporting evidence Back to topSupporting evidence A brief summary of the evidence identified by NICE is given in the basis for recommendation sections of the individual recommendations within this CKS topic. For a more detailed discussion of the evidence, see the NICE guideline Depression in children and young people: identification and management [NICE, 2005].  This update includes new recommendations on psychological therapies and antidepressants added to and updated in the March 2015 addendum to the full NICE guideline. How this topic was developed Back to topHow this topic was developed This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website. Back to top Search strategy Search strategy Scope of searchA literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of depression in children.Search datesJuly 2003 - February 2016Key search termsVarious combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.exp Depression/, exp Depressive Disorder/, exp Dysthymic Disorder/, exp Seasonal Affective Disorder/, depress$.tw., depressive disorder.tw., dysthymic disorder.tw., seasonal affective disorder.tw.exp Pediatrics/, exp Adolescent/, exp Child/, child$.tw., pediatric$.tw., paediatric$.tw., adolescen$.tw.Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences ABPI (2013) SPC for Prozac 20mg hard capsules, and 20mg per 5ml oral liquid. Electronic Medicines Compendium. Datapharm Communications.. www.medicines.org.uk [Free Full-text] BNF 70 (2015) British National Formulary.70th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. DVLA (2015) At a glance guide to the current medical standards of fitness to drive (updated 2014 edition). Driver and Vehicle Licensing Agency.. www.gov.uk [Free Full-text] National Collaborating Centre for Mental Health (2005) Depression in children and young people: identification and management in primary, community and secondary care (NICE guideline CG28). National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] NICE (2005) Depression in children and young people: identification and management (NICE guideline CG28) [Updated 2015]. National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] Taylor,D., Paton,C. and Kapure,S. (2012) The Maudsley prescribing guidelines.11th edn. London: Informa Healthcare. WHO (1992) The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. World Health Organization.. www.who.int [Free Full-text] Zuckerbrot R.A., Cheung A.H. and Jensen P.S. (2007) Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 120(5), e1299-e1312.