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childhood depression

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The concept of depression in adolescence is complicated by factors such as the multiple meanings of the term depression, and the high prevalence of unhappiness at some time in the teenage years as a result of the emotional variability of adolescence, as distinct from actual depressive disorder.

There are practical problems too, with under-reporting of symptoms by shy, immature teenagers and under-recognition of the condition by parents.

Depression is a broad diagnosis that can include different symptoms in different people

  • 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
  • the International Statistical Classification of Diseases (ICD-10) uses an agreed list of 10 depressive symptoms, and divides depression into 4 categories: not depressed (fewer than 4 symptoms), mild depression (4 symptoms), moderate depression (5 to 6 symptoms), and severe depression (7 or more symptoms, with or without psychotic symptoms).

For a diagnosis of depression, symptoms should be present for at least 2 weeks and every symptom should be present for most of the day.

Mild depression

  • four depressive symptoms as defined by the ICD-10.

Moderate depression

  • five or six depressive symptoms as defined by the ICD-10.

Severe depression

  • seven or more depressive symptoms as defined by the ICD-10.

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

  • provides a framework in which to organise the provision of services that support both healthcare professionals and patients and their parents or carers in identifying and accessing the most effective interventions
Focus Action Responsibility
Detection Risk Profiling Tier 1
Recognition Identification in presenting children or young people Tiers 2 to 4
Mild depression (including dysthymia) Watchful waiting Tier 1
Mild depression (including dysthymia)

 

Digital CBT, group CBT, group IPT or group NDST

If shared decision making based on full assessment (including maturity and developmental level) indicates needs not met, individual CBT or attachment-based family therapy

 

Tier 1 or 2

Moderate to severe depression

5- to 11-year-olds

Family-based IPT, family therapy (family-focused treatment for childhood depression and systems integrative family therapy), psychodynamic psychotherapy, or individual CBT

+/- fluoxetine

Tier2 or Tier3
Moderate to severe depression

12- to 18-year-olds

Individual CBT

+/- fluoxetine

If shared decision making based on full assessment (including maturity and developmental level) indicates needs not met, IPT-A, family therapy (attachment-based or systemic), brief psychosocial intervention or psychodynamic psychotherapy

+/- fluoxetine

Tier2 or Tier3
Depression unresponsive to treatment/ recurrent depression/ psychotic depression

Intensive psychological therapy

+/- fluoxetine, sertraline, citalopram, augmentation with an antipsychotic

Tier 3 or 4

Abbreviations: CBT, cognitive-behavioural therapy; IPT, interpersonal psychotherapy; IPT-A, IPT for adolescents; NDST, non-directive supportive therapy.

Notes:

  • 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 CAMHS
    • services provided by professionals 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

  • Tier 3 CAMHS
    • specialised 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

  • Tier 4 CAMHS
    • tertiary-level services such as day units, highly specialised outpatient teams and inpatient units

Reference:

Last edited 08/2019

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