This site is intended for healthcare professionals

Go to /sign-in page

You can view 5 more pages before signing in

Treatment

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Refer for specialist advice.

NICE have suggested a framework for the management of childhood depression (1):

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.

NICE guidance (2) suggests with respect to use of antidepressants in childhood depression:

  • antidepressant treatment in children and young people how to use antidepressants in children and young people:
    • children and young people presenting with moderate to severe depression should be reviewed by a CAMHS team (1)

    • combined therapy (fluoxetine and psychological therapy) should be considered for initial treatment of moderate to severe depression in young people (12-18 years), as an alternative to psychological therapy followed by combined therapy
    • if psychological therapy as initial treatment
      • following multidisciplinary review, offer fluoxetine if moderate to severe depression in a young person (12-18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions
      • following multidisciplinary review, cautiously consider fluoxetine if moderate to severe depression in a child (5-11 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions, although the evidence for fluoxetine's effectiveness in this age group is not established

    • if an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist

    • when an antidepressant is prescribed to a child or young person with moderate to severe depression
      • fluoxetine should be used as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks

    • when fluoxetine is prescribed for a child or young person with depression, the starting dose should be 10 mg daily
      • can be increased to 20 mg daily after 1 week if clinically necessary, although lower doses should be considered in children of lower body weight
      • little evidence regarding the effectiveness of doses higher than 20 mg daily. However, higher doses may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority

    • when a child or young person responds to treatment with fluoxetine
      • fluoxetine should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks); in other words, for 6 months after this 8-week period

    • if treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, an alternative antidepressant should be considered. In this case sertraline or citalopram are the recommended second-line treatments
      • when a child or young person responds to treatment with citalopram or sertraline, medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks)

    • paroxetine and venlafaxine should not be used for the treatment of depression in children and young people

    • tricyclic antidepressants should not be used for the treatment of depression in children and young people

    • where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks
      • exact dose of the antidepressant being titrated against the level of discontinuation/withdrawal symptoms

Notes:

  • at the time of NICE publication (June 2019), fluoxetine did not have UK marketing authorisation for use in young people (aged 12-18), without a previous trial of psychological therapy that was ineffective. For combined antidepressant treatment and psychological therapy as an initial treatment, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented
  • at the time of NICE publication (June 2019), sertraline and citalopram did not have a UK marketing authorisation for use in young people under the age of 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented
  • study evidence has examined the long-term effectiveness of SSRIs in adolescents with depression (2,3):
    • for adolescents with a major depression, the Treatment for Adolescents with Depression Study (TADS) suggests that treatment with a combination of fluoxetine and cognitive behavioural therapy (CBT) is superior to either treatment approach on its own
    • fluoxetine as a maintenance therapy for depression is associated with an increased risk for suicidal ideation which may be minimised by combining treatment with CBT

  • 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:

  1. NICE (June 2019). Depression in children and young people: Identification and management in primary, community and secondary care
  2. The TADS team, The Treatment for Adolescents with Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Arch Gen Psychiatry. 2007 Oct;64(10):1132-1143
  3. Whittington CJ et al (2004). Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet;363:1341-5

Create an account to add page annotations

Add information to this page that would be handy to have on hand during a consultation, such as a web address or phone number. This information will always be displayed when you visit this page

The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

Connect

Copyright 2024 Oxbridge Solutions Limited, a subsidiary of OmniaMed Communications Limited. All rights reserved. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions receives funding from advertising but maintains editorial independence.