Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management
Practice Preparation
Once PC practices have buy-in from administrative and clinical staff to improve depression care for youth, 2 important steps are necessary. First, before practices embark on screening for or identifying youth who are at risk for depression, training in such issues as appropriate screening tools, assessment and diagnostic methods, safety planning, and so on is important. Second, it is necessary to have access to community resources, such as mental health specialists (mental health specialists can include child and adolescent psychiatrists, psychiatric nurse practitioners, and therapists), not just as a potential referral resource but also for as-needed consultation for case patients that the PC clinicians choose to manage. We review the available evidence pertaining to these 2 areas (provider training and specialty consultation) below.
Effective Training Methods
PC practices vary widely in their capacity to implement full-scale collaborative or integrative behavioral health programs to address psychological difficulties in youth. At minimum, providing PC providers with guidance, education, and training in key topic areas such as identification, evaluation of suicide risk, and initial management of adolescent depression can be a feasible and cost-efficient means of improving care delivery when comprehensive organizational restructuring efforts are out of reach. However, simply providing PC providers with relevant information is not enough because passive education strategies are usually inadequate for producing lasting change in provider behavior.27
Researchers in large-scale review studies suggest that the adoption of practice guidelines improves when training and implementation strategies are tailored to the PC practice (eg, training that is developed by primary mental health care specialists, such as the training provided by the REACH Institute [http://www.thereachinstitute.org/] and Child and Adolescent Psychology for Primary Care [http://www.cappcny.org/])28 and/or use comprehensive training methods, such as varying information delivery methods and skill-building exercises, such as role-playing.27 Evidence regarding which specific theory-driven training strategies are most effective at eliciting behavior change with PC providers, particularly related to mental health, is sparse, but 1 promising framework leverages principles from the theories of reasoned action and planned behavior to inform training methodology (see Perkins et al29 for explanation and review). This approach posits 3 primary determinants of PC behavior change: attitudes toward the practice innovation, the strength of intention to adopt the new practice(s), and sense of self-efficacy in one’s ability to continue the new behavior. Although no randomized trials in which researchers use this or other systematic frameworks for PC provider–training methodologies were identified, researchers in preliminary studies offer support for training approaches that incorporate basic science-guided behavior change theory and methods. There is increasing evidence that quality-improvement strategies and techniques can change PC practitioner behavior both in mental health and in other arenas.30,31 The REACH Institute (which is committed to renewing and improving techniques for professionals and parents to treat children with behavioral and emotional needs) has developed and widely implemented a 3-day intensive training on evidence-based pediatric mental health assessment, diagnosis, and treatment practices (including for youth depression) that is guided by basic science behavior change principles, demonstrating long-term practice changes (eg, increased use of symptom scales) as well as favorable PC provider attitudes toward, intentions to follow, and self-efficacy to adhere to the clinical guidelines up to 1 year later.32 In another study of the same training approach, participating PC providers showed higher levels of self-efficacy in diagnosing and managing youth depression and related disorders than those who received only more traditional continuing education programs (eg, lectures).33
An unrelated study demonstrated that provider attitudes toward youth mental health in PC impacts rates of identification. PC providers who viewed psychosocial treatment as burdensome were less likely to identify youth mental health problems.34 A subsequent follow-up to the study revealed that providing PC staff with communication training enhanced their self-efficacy and willingness to discuss depression symptoms with patients and staff, and this was associated with long-term changes in practice behaviors, such as providing an agenda during the PC visit, querying for additional mental health concerns, and making encouraging statements to patients and families when symptoms are disclosed.35 The small amount of available literature offers support for hands-on, interactive, and basic science theory–driven training strategies for PC clinicians, but more research is needed before a consensus can be reached on how best to optimize training and educational strategies for PC providers.
Access to Specialty Consultation
In addition to obtaining relevant training, PC providers will benefit from having access to ongoing consultation with mental health specialists.36,37 Consultation after training allows learning to be tailored to the PC provider’s actual practice38 and can increase provider comfort with diagnosing and treating mental health issues.33,39 More than 25 states have established programs to promote collaboration between PC providers and child psychiatrists by providing PC providers with education, rapid access to consultation, and referral options. Among the first psychiatric consultation programs was Targeted Child Psychiatry Services (TCPS) in the state of Massachusetts,40,41 which offered regional providers access to real-time telephone consultation with a child psychiatrist and the option to refer a child to the psychiatry practice for a mental health evaluation, short-term psychosocial therapy, and/or pharmacotherapy. Program use data revealed that TCPS consultation support alone was sufficient to retain and treat in PC 43% of youth who potentially would have been referred to specialty services.40 TCPS was subsequently expanded statewide and became known as the Massachusetts Child Psychiatry Access Project.14 Similar programs in other states offer free training, telephone consultation, and referral advice to PC providers.14,42,43 Participating PC providers consistently report being highly satisfied with the consultation they receive14,42,43 and increasingly comfortable with treating mental health problems within the PC setting after consultation.14,42,43 Additionally, consultation programs may improve access to mental health care not only by increasing its availability within PC but also by decreasing potentially unnecessary referrals to specialty care, which in turn makes specialty providers more available to treat complex or severe patients.41,44
Identification and Assessment
In 2009, after the publication of the GLAD-PC, the United States Preventive Services Task Force (USPSTF) endorsed universal adolescent depression screening in teenagers ages 12 to 18 years.45 This recommendation was based on evidence that there are validated depression screening tools that work in an adolescent PC population and the evidence that there are treatments that work for the identified population.45,46 On the basis of our review to date, no researchers in a randomized control trial (RCT) have compared functional or depressive outcomes in a cohort of adolescents who were screened in PC by the PC providers themselves versus a cohort of adolescents who were not screened. This lack of evidence, which is also mentioned in the Canadian review of the literature in 2005,47 the 2009 Williams et al46 review performed for the USPSTF, the updated 2016 Forman-Hoffman et al48 review for the USPSTF, and a 2013 systematic literature review published in Pediatrics,49 becomes less relevant as more evidence accumulates regarding the specific steps in the process, such as the validity of PC screening, the feasibility of PC screening, the feasibility of implementing treatment in those who are identified as having depression, and the efficacy of treatment of those who received evidence-based treatments in PC. In our updated review in this area, we found 8 new articles that provide some psychometric data regarding the use of depression screens in the pediatric PC population (Supplemental Table 1) and 38 other articles that touch on screening issues that range from whether screening is taking place and whether screening impacts follow-up procedures or treatment to the specifics of screening, such as the use of mobile devices or gated procedures (Supplemental Table 2). Supplemental Tables 1 and 2 present the new evidence as well as the limitations for existing screening tools and protocols. Please see our original 2007 guidelines for the past review of screening tools and protocols.
During the original GLAD-PC development process, secondary to the paucity of data on the validity of screening tools in the adolescent PC population, the original GLAD-PC guideline was used to review instruments that are used in community and psychiatric populations as well.17 Given that those screens are still in use and that their psychometric data still apply, in this current review, we focus only on new screening data in PC. Eight of the articles present psychometric data, such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), or area under the curve (Supplemental Table 1). Most relevant were the 2 publications by Richardson et al56,57 in which they validated the Patient Health Questionnaire-2 (PHQ-2) and the Patient Health Questionnaire-9 (PHQ-9) in a PC sample against a gold standard diagnostic interview (the Diagnostic Interview Schedule for Children-IV [DISC-IV]). The PHQ-9, with a cut-point of 11, had a sensitivity and specificity of 89.5% and 77.5%, respectively, to DISC-IV MDD with a PPV of 15.2% and NPV of 99.4%. A PHQ-2 cut score of 3 had a sensitivity and specificity of 73.7% and 75.2%, respectively, to DISC-IV MDD.
Researchers have looked at brief depression-specific screening questions that stand alone (eg, the PHQ-2),51,57,65,75,79,82,85 longer depression-specific scales that stand alone (eg, the PHQ-9, the Mood and Feelings Questionnaire, the Columbia Depression Scale, and the PHQ-9: Modified for Teens),58,62,63,66,67,70,74,78,80–82,86–88 brief depression screening questions that are part of a larger psychosocial tool (eg, the Guidelines for Adolescent Preventive Services [GAPS] questionnaire and the Pediatric Symptom Checklist [PSC]),53,54,64,68,69 and brief screening questions or longer depression-specific scales that are combined with other screens for either other psychiatric disorders (eg, Screen for Child Anxiety Related Disorders-5) and/or screens for other high-risk behaviors (eg, substance use and sexual activity) to make a more multidimensional tool or packet in 1 (eg, the behavioral health screen [BHS]).50,52,55,59–61,76,77,83,84,89 Not all of the screens in these studies have specific psychometric validation data (eg, 2 depression questions on the GAPS). Clinicians may also consider the use of tools that can be used to screen for depression and other risk behaviors or more disorders. Although no researchers have compared the functional or depressive outcomes of a cohort of adolescents who were initially screened only for depression with a cohort of adolescents who were initially screened for an array of high-risk behaviors and emotional issues, some hint at the possibility that too much information may overwhelm the clinician and result in positive depression screening questions being overlooked in the morass of issues needing to be addressed.52,53,59–61,64,76,80,82–84,89 Therefore, clinicians should base the selection of a depression-specific tool versus a more general tool on their own expertise and clinical supports in their practices. For example, a solo practitioner starting to address depression care in his or her practice may choose to start with screening for depression alone before moving to more general screening for riskier behaviors or disorders.
There is limited evidence to evaluate whether one can use a general parent questionnaire as a gated entry for adolescent self-report depression screening. Researchers in 1 study of general mental health screening used the parent- or youth-completed Pediatric Symptom Checklist-35 alone to screen for internalizing disorders, but this provides no psychometric data,69 whereas others used the Parent Pediatric Symptom Checklist-17 (PSC-17) along with other, more depression-specific child and parent scales.54,56,57,82 One of these studies reveals adequate psychometric data for the parent PSC-17 internalizing subscale as compared with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) MDD module, performing as well as the Children’s Depression Inventory but only with children aged 8 to 15 years.54 Richardson et al56,57,82 suggest some correlation with adolescent depression self-report tools, with the adolescent scores that are higher on the PHQ-9 or PHQ-2 being associated with higher mean on the parent PSC-17 internalizing subscale, with a correlation of 0.21 (P = .02). However, the data presented do reveal that some teenagers who scored above the cutoffs on the self-reports would have parents who score below the cutoff of 5 on the internalizing subscale of the PSC-17. The authors do not present the data regarding how many teenagers would be missed by using the internalizing subscale as a gate and whether those teenagers met DISC-IV MDD criteria. Lastly, researchers in 1 study looked at the correlation of the PSC-17 internalizing subscale between the parent- and youth-completed PSC-17 but only among subjects whose parents were already positive.53 The data revealed low agreement, with a κ of 0.15 (95% confidence interval of 0.00–0.30). However, those adolescents who did match with their parents were of higher severity than those parents who were positive but did not match with their negative-scoring teenagers. In addition, the parent PSC-17 in general has usually been studied with the younger adolescent cohort and not the older adolescent cohort. Once again, there is no RCT in which researchers compare the outcomes of a cohort of adolescents who were universally screened with an adolescent depression self-report versus a cohort that was only screened with self-reports after a positive parent PSC result. All of these data reveal that there is limited evidence in the older teenage cohort about using parent reports alone, that parent information may be helpful if used in conjunction with child reports when a clinician is available to resolve discrepant data, and that if used alone, parent reports may only account for the adolescents with the most severe conditions, but those data are unclear.
Researchers have also looked at paper screens, Internet-based screens, and electronic screens that are accessed through a mobile or personal digital assistant device. Although there appears to be no evidence of researchers comparing such screening methods to each other, all methods seem to be equally successful (in that adolescents rarely refuse screening) and equally problematic (obstacles to universal screening exist with every method). See Supplemental Tables 1 and 2 for more specific information.
Some researchers report adaptive (brief initial questions and, if gated questions have positive results, then automated additional questions)61 as well as algorithmic screening, in which a positive PHQ-2 result or the equivalent triggers a person to then administer a PHQ-9 or the equivalent.65,75,79,85 Although evidence for this type of gated screening is limited, researchers in 1 study compared the psychometric data of the PHQ-2 versus the PHQ-9 in the same population.57
One limitation of brief depression screening may be the loss of the suicide questions if one focuses only on brief questions on the basis of criterion A for MDD. The validation study of the PHQ-2 found that 19% of teenagers who did endorse suicidality did not screen positive on the PHQ-2, suggesting that in a real-world setting, they would have been missed.57 Several studies in which researchers used brief or long depression-specific screenings that did not include a suicide question did add a suicide question for this reason.60,70,83,84,89 In this review, we did not review the suicide screening in pediatric PC literature but are aware of the USPSTF decision not to endorse suicide screening secondary to its conclusion for the lack of evidence for PC intervention for suicidal adolescents.90 However, we do note which depression screening studies also looked for suicide as well as the rates of suicidality that were found (Supplemental Tables 1 and 2).
One other area that was examined in the review is the definition of depression when screening for depression. The definition of depression affects the psychometric properties and evidence for the use of a screen given that trying to find only MDD versus trying to find any depressive symptoms requires different specificities and sensitivities, and using the same screens for both purposes would result in choosing different cutoffs. Again, whereas the USPSTF comments on screening for MDD, the screening literature seems to be more unfocused. Richardson et al79 used a score of 2 as the initial gate and a score of 10 on the PHQ-9 as a positive score for entry into the next step. Forty percent of the sample did not meet the criteria for MDD but were deemed to be impaired enough with depressive symptoms to enter the study. When Lewandowski et al74 studied the large-scale use of the PHQ-9 modified in the health maintenance organization (HMO), they looked at whether any depressive disorder was identified, even adjustment disorder, rather than just MDD. The Youth Partners in Care (YPIC) intervention11,58 also included teenagers without MDD who had clinically significant and current depressive symptoms. Van Voorhees et al,91 in a series of small studies and now in a large RCT, have been purposely screening to account for depressive symptoms and depressive disorders other than MDD because the Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training (CATCH-IT) prevention model was developed for teenagers with depressive symptoms and disorders other than MDD.65 Thus, the evidence for choosing instruments and cutoff scores may depend on what depression end point a PC provider is pursuing and what intervention the clinician wishes to put in place.
Although the USPSTF clearly endorsed screening at age 12 years, the literature in which researchers look at depression screening includes studies that have starting ages ranging from age 8 to 14 years and later ages ranging from 15 to 24 years. Most of the younger-age studies include depression as part of a broader psychosocial screening effort, with the researchers looking specifically at depression screening that focuses on some of the older age ranges (Supplemental Tables 1 and 2). With that said, there is no evidence to compare outcomes in a cohort of adolescents who were screened at age 11 years versus age 12 years versus age 13 years.
The last guideline review included the YPIC study, which did reveal that an identification program in PC, when combined with high-quality depression treatment, actually yields better outcomes than treatment-as-usual conditions (when no high-quality depression treatment is available).11 Two follow-up publications from the same intervention58,87 are included in this review and once again show that identified youth who receive evidence-based treatment do have better outcomes. More recently, Richardson and colleagues, in their collaborative care for adolescent depression RCT, compared controls who screened positive and whose positive results were given to both parents and PC clinicians with subjects who were screened and placed in a collaborative care intervention.79 Those in the collaborative care intervention had a greater chance of response and remission at 12 months and a greater likelihood of receiving evidence-based treatments. The researchers only tracked outcomes in those who were screened; although it is possible that those who were screened did better than those adolescents with depression who were not screened, the study does reveal that screening alone is not likely to improve outcomes by much given how much better those in the group that had screening combined with an intervention in place did and how much more likely they were to receive care than those who were only screened.
Although much of the literature on identification crosses both the area of screening and assessment in that the PC provider can use the screening tool to aid in the assessment, we found some studies that focused less on the screening tools and more on the assessment of depression in pediatric PC. These studies included those in which researchers used standardized patients to help with depression and suicide assessment as well as a protocol to teach PC clinicians how to do a therapeutic interview during the assessment process.62,63,71–73
In summary, no perfect depression screening and/or assessment tool exists, and no perfect screening algorithm or systematic protocol exists, but a number of adolescent depression assessment instruments do possess adequate psychometric properties to recommend their use in depression detection and assessment, and there is a limited amount of evidence to support some differing methods of implementation (Supplemental Table 3). Thus, it is reasonable to expect that depression detection in PC can be improved by the use of adolescent self-report checklists with or without parent self-reports. Reliance on adolescent self-report depression checklists alone will lead to substantial numbers of false-positive and false-negative cases. Screening and detection are only the first step to making a diagnosis. Instead, optimal diagnostic procedures should combine the use of depression-specific screening tools as diagnostic aids, buttressed by follow-up clinical interviews in which one obtains information from other informants (eg, parents) as legally permissible and uses either other tools or interviews to assess for other psychiatric diagnoses as well, reconciling discrepant information to arrive at an accurate diagnosis and impairment assessment before treatment. Although screening parents may not be required, gathering information from third-party collaterals to make a diagnosis is important. Teenagers should be encouraged to allow their parents to access their information, and the importance of including parents in the diagnostic discussion should be emphasized. For more information about rating scales and cutoff scores, please refer to the GLAD-PC tool kit.
Initial Management of Adolescent Depression
On behalf of the initial GLAD-PC team, Stein et al92 reviewed the literature on psychosocial interventions for anticipatory guidance. No RCTs or evidence-based reviews were found. Citing earlier literature reviews in the area of injury prevention93 and anticipatory guidance,94 Stein et al92 found some limited evidence that anticipatory guidance strategies, such as education and counseling, in the PC setting can be effective.
Another area reviewed by Stein et al92 involved psychosocial interventions for improved adherence. In an evidence review on asthma adherence, Lemanek et al95 suggested that some educational and behavioral strategies are probably efficacious in creating change. In addition, a study in which researchers used cognitive behavioral strategies revealed that diabetic adherence can also be improved.95
For this update, our team searched the Cochrane Database of Systematic Reviews for all types of interventions that were implemented in the adherence arena. These reviews96–98 revealed that only complex, multifaceted approaches that include convenient care, patient education, reminders, reinforcement, counseling, and additional supervision by a member of the care team were effective in improving adherence in different chronic medical conditions, including asthma, hypertension, diabetes, and adult depression. In the pediatric literature, research regarding adherence commonly involved interventions that targeted both patients and their families.99 Several key components have been identified that may improve compliance and/or adherence, including patient self-management and/or monitoring, patient and/or family education and/or support, and the setting and supervision of management goals.100,101 The identification and periodic review of short- and long-term goals provides an individualized plan that both the provider and the patient and family can follow over time.100,101 Specifically in the area of youth depression, however, current research evidence reveals that only more complex interventions are likely to have the greatest impact on both adherence and treatment outcomes. This kind of coordinated care, which is often described as collaborative care or integrated behavioral health, is discussed further in the accompanying report on depression treatment and ongoing management.102
Depression in children and young people: identification and management
1.1 Care of all children and young people with depression Good information, informed consent and support
1.1.1 Children and young people and their families need good information, given as part of a collaborative and supportive relationship with healthcare professionals, and need to be able to give fully informed consent. [2005]
1.1.2 Healthcare professionals involved in the detection, assessment or treatment of children or young people with depression should ensure that information is provided to the patient and their parents and carers at an appropriate time. The information should be age appropriate and should cover the nature, course and treatment of depression, including the likely side effect profile of medication should this be offered. [2005]
1.1.3 Healthcare professionals involved in the treatment of children or young people with depression should take time to build a supportive and collaborative relationship with both the patient and the family or carers. [2005]
1.1.4 Healthcare professionals should make all efforts necessary to engage the child or young person and their parents or carers in treatment decisions, taking full account of patient and parental/carer expectations, so that the patient and their parents or carers can give meaningful and properly informed consent before treatment is initiated. [2005]
1.1.5 Families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate. [2005]
Language and black, Asian and minority ethnic groups
1.1.6 Where possible, all services should provide written information or audiotaped material in the language of the child or young person and their family or carers, and professional interpreters should be sought for those whose preferred language is not English. [2005]
1.1.7 Consideration should be given to providing psychological therapies and information about medication and local services in the language of the child or young person and their family or carers where the patient's and/or their family's or carer's first language is not English. If this is not possible, an interpreter should be sought. [2005]
1.1.8 Healthcare professionals in primary, secondary and relevant community settings should be trained in cultural competence to aid in the diagnosis and treatment of depression in children and young people from black, Asian and minority ethnic groups. This training should take into consideration the impact of the patient's and healthcare professional's racial identity status on the patient's depression. [2005]
1.1.9 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. [2005]
1.1.10 The development and evaluation of services for children and young people with depression should be undertaken in collaboration with stakeholders involving patients and their families and carers, including members of black, Asian and minority ethnic groups. [2005]
Assessment and coordination of care
1.1.11 When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient's notes, 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. [2005]
1.1.12 In the assessment of a child or young person with depression, healthcare professionals should always ask the patient and their parents or carers 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. [2005]
1.1.13 If a child or young person with depression presents acutely having self‑harmed, the immediate management should follow NICE's guideline on self-harm as this applies to children and young people, paying particular attention to the guidance on consent and capacity. Further management should then follow this depression guideline. [2005]
1.1.14 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 parents or carers. This may include educational leaflets, helplines, self‑diagnosis tools, peer, social and family support groups, complementary therapies and faith groups. [2005]
1.1.15 Healthcare professionals should only recommend self‑help materials or strategies as part of a supported and planned package of care. [2005]
1.1.16 For any child or young person with suspected mood disorder, a family history should be obtained to check for unipolar or bipolar depression in parents and grandparents. [2005]
1.1.17 When a child or young person has been diagnosed with depression, 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 treatment offered to the child or young person. [2005]
1.1.18 When the clinical progress of children and young people with depression is being monitored in secondary care, the self‑report Mood and Feelings Questionnaire (MFQ) should be considered as an adjunct to clinical judgement. [2005]
1.1.19 In the assessment and treatment of depression in children and young people, special attention should be paid to the issues of:
confidentiality
the young person's consent (including Gillick competence)
parental consent
child protection
the use of the Mental Health Act in young people
the use of the Mental Capacity Act in young people
the use of the Children Act. [2005, amended 2019]
1.1.20 The form of assessment should take account of cultural and ethnic variations in communication, family values and the place of the child or young person within the family. [2005]
The organisation and planning of services
1.1.21 Healthcare professionals specialising in depression in children and young people should work with local child and adolescent mental health services (CAMHS)[] to enhance specialist knowledge and skills regarding depression in these existing services. This work should include providing training and help with guideline implementation. [2005]
1.1.22 CAMHS and local healthcare commissioning organisations should consider introducing a primary mental health worker (or CAMHS link worker) into each secondary school and secondary pupil referral unit as part of tier 2[] provision within the locality. [2005]
1.1.23 Primary mental health workers (or CAMHS link workers) should establish clear lines of communication between CAMHS and tier 1 or 2, with named contact people in each tier or service, and develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2[]. [2005]
1.1.24 CAMHS and local healthcare commissioning organisations should routinely monitor the rates of detection, referral and treatment of children and young people, from all ethnic groups, with mental health problems, including those with depression, in local schools and primary care. This information should be used for planning services and made available for local, regional and national comparison. [2005]
1.1.25 All healthcare and CAMHS professionals should routinely use, and record in the notes, appropriate outcome measures (such as those self‑report measures used in screening for depression or generic outcome measures used by particular services, for example Health of the Nation Outcome Scale for Children and Adolescents [HoNOSCA] or Strengths and Difficulties Questionnaire [SDQ]), for the assessment and treatment of depression in children and young people. This information should be used for planning services, and made available for local, regional and national comparison. [2005]
Treatment and considerations in all settings
1.1.26 Most children and young people with depression should be treated on an outpatient or community basis. [2005]
1.1.27 Before any treatment is started, healthcare professionals should assess, 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 or negatively 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. [2005]
1.1.28 When bullying is considered to be a factor in a child or young person's depression, CAMHS, primary care and educational professionals should work collaboratively to prevent bullying and to develop effective antibullying strategies. [2005]
1.1.29 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. [2005]
1.1.30 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. [2005]
1.1.31 Therapists should develop a treatment alliance with the family. If this proves difficult, consideration should be given to providing the family with an alternative therapist. [2005]
1.1.32 Comorbid diagnoses and developmental, social and educational problems should be assessed and managed, either in sequence or in parallel, with the treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care. [2005]
1.1.33 Attention should be paid to the possible need for parents' own psychiatric problems (particularly depression) to be treated in parallel, if the child or young person's mental health is to improve. If such a need is identified, then a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services. [2005]
1.1.34 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. [2005]
1.1.35 A child or young person with depression should be offered advice about sleep hygiene and anxiety management. [2005]
1.1.36 A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet. [2005]
1.2 Stepped care
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 patients and their parents or carers in identifying and accessing the most effective interventions (see table 1).
Table 1 The stepped-care model
Focus
Action
Responsibility 1
Detection
Risk profiling
Tier 1
Recognition
Identification in presenting children or young people
Tiers 2 to 4
Mild depression (including dysthymia)
Watchful waiting
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
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
Tier 2 or 3
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
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.
1June 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.
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 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 3[] CAMHS – moderate to severe depression.
5. Managing recognised depression in tier 3 or 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.
1.3 Step 1: Detection, risk profiling and referral Detection and risk profiling
See also the recommendations on psychological and social issues in children and young people with type 1 or type 2 diabetes in the NICE guideline on diabetes (type 1 and type 2) in children and young people.
1.3.1 Healthcare professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression, and to assess children and young people who may be at risk of depression. Training should include the evaluation of recent and past psychosocial risk factors, such as age, gender, family discord, bullying, physical, sexual or emotional abuse, comorbid disorders, including drug and alcohol use, and a history of parental depression; the natural history of single loss events; the importance of multiple risk factors; ethnic and cultural factors; and factors known to be associated with a high risk of depression and other health problems, such as homelessness, refugee status and living in institutional settings. [2005]
1.3.2 Healthcare professionals in primary care, schools and other relevant community settings should be trained in communications skills such as 'active listening' and 'conversational technique', so that they can deal confidently with the acute sadness and distress ('situational dysphoria') that may be encountered in children and young people following recent undesirable events. [2005]
1.3.3 Healthcare professionals in primary care settings should be familiar with screening for mood disorders. They should have regular access to specialist supervision and consultation. [2005]
1.3.4 Healthcare professionals in primary care, schools and other relevant community settings who are providing support for a child or young person with situational dysphoria should consider ongoing social and environmental factors if the dysphoria becomes more persistent. [2005]
1.3.5 CAMHS tier 2 or 3[] should work with health and social care professionals in primary care, schools and other relevant community settings to provide training and develop ethnically and culturally sensitive systems for detecting, assessing, supporting and referring children and young people who are either depressed or at significant risk of becoming depressed. [2005]
1.3.6 In the provision of training by CAMHS professionals for healthcare professionals in primary care, schools and relevant community settings, priority should be given to the training of pastoral support staff in schools (particularly secondary schools), community paediatricians and GPs. [2005]
1.3.7 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, healthcare professionals in primary care, schools and other relevant community settings should undertake an assessment of the risks of depression associated with the event and make contact with their parents or carers to help integrate parental/carer and professional responses. The risk profile should be recorded in the child or young person's records. [2005]
1.3.8 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, in the absence of other risk factors for depression, healthcare professionals in primary care, schools and other relevant community settings should offer support and the opportunity to talk over the event with the child or young person. [2005]
1.3.9 Following an undesirable event, a child or young person should not normally be referred for further assessment or treatment, as single events are unlikely to lead to a depressive illness. [2005]
1.3.10 A child or young person who has been exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience and is identified to be at high risk of depression (the presence of 2 or more other risk factors for depression), should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1[] and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. [2005]
1.3.11 When a child or young person is exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, and where 1 or more family members (parents or children) have multiple risk histories for depression, they should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1[] and assessed for depression. Early referral should be considered if there is evidence of depression and/or self-harm. [2005]
1.3.12 If children and young people who have previously recovered from moderate or severe depression begin to show signs of a recurrence of depression, healthcare professionals in primary care, schools or other relevant community settings should refer them to CAMHS tier 2 or 3[] for rapid assessment. [2005]
Referral criteria
1.3.13 For children and young people, the following factors should be used by healthcare professionals as indications that management can remain at tier 1[]:
exposure to a single undesirable event in the absence of other risk factors for depression
exposure to a recent undesirable life event in the presence of 2 or more other risk factors with no evidence of depression and/or self‑harm
exposure to a recent undesirable life event, where 1 or more family members (parents or children) have multiple‑risk histories for depression, providing that there is no evidence of depression and/or self‑harm in the child or young person
mild depression without comorbidity. [2005]
1.3.14 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 2 or 3[] CAMHS:
depression with 2 or more other risk factors for depression
depression where 1 or more family members (parents or children) have multiple‑risk histories for depression
mild depression in those who have not responded to interventions in tier 1[] after 2–3 months
moderate or severe depression (including psychotic depression)
signs of a recurrence of depression in those who have recovered from previous moderate or severe depression
unexplained self‑neglect of at least 1 month's duration that could be harmful to their physical health
active suicidal ideas or plans
referral requested by a young person or their parents or carers. [2005]
1.3.15 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 4[] services:
high recurrent risk of acts of self‑harm or suicide
significant ongoing self‑neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health)
requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3[]. [2005]
1.4.1 Children and young people of 11 years or older referred to CAMHS without a diagnosis of depression should be routinely screened with a self‑report questionnaire for depression as part of a general assessment procedure. [2005]
1.4.2 Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer‑based instruments (such as Kiddie‑Sads [K‑SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) could be used for this purpose but will require modification for regular use in busy routine CAMHS settings. [2005]
1.4.3 Within tier 3[] CAMHS, professionals who specialise in the treatment of depression should have been trained in interviewer‑based assessment instruments (such as K‑SADS and CAPA) and have skills in non‑verbal assessments of mood in younger children. [2005]
1.5 Step 3: Managing mild depression Watchful waiting
1.5.1 For children and young people with diagnosed mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks ('watchful waiting'). [2005]
1.5.2 Healthcare professionals should make contact with children and young people with depression who do not attend follow‑up appointments. [2005]
Treatments for mild depression
For children and young people with learning disabilities, see the recommendations on psychological interventions in the NICE guideline on mental health problems in people with learning disabilities.
1.5.3 Antidepressant medication should not be used for the initial treatment of children and young people with mild depression. [2005]
1.5.4 Discuss the choice of psychological therapies with children and young people with mild depression and their family members or carers (as appropriate). Explain:
what the different therapies involve
the evidence for each age group (including the limited evidence for 5- to 11‑year‑olds)
how the therapies could meet individual needs, preferences and values. [2019]
1.5.5 Base the choice of psychological therapy on:
a full assessment of needs, including:
the circumstances of the child or young person and their family members or carers
their clinical and personal/social history and presentation
their maturity and developmental level
the context in which treatment is to be provided
comorbidities, neurodevelopmental disorders, communication needs (language, sensory impairment) and learning disabilities
patient and carer preferences and values (as appropriate). [2019]
1.5.6 For 5- to 11‑year‑olds with mild depression continuing after 2 weeks of watchful waiting, and without significant comorbid problems or active suicidal ideas or plans, consider the following options adapted to developmental level as needed:
digital cognitive–behavioural therapy (CBT)
group CBT
group non-directive supportive therapy (NDST)
group interpersonal psychotherapy (IPT).
If these options would not meet the child's clinical needs or are unsuitable for their circumstances, consider the following adapted to developmental level as needed:
attachment-based family therapy
individual CBT. [2019]
1.5.7 For 12- to 18‑year‑olds with mild depression continuing after 2 weeks of watchful waiting, and without significant comorbid problems or active suicidal ideas or plans, offer a choice of the following psychological therapies for a limited period (approximately 2 to 3 months):
digital CBT
group CBT
group NDST
group IPT. [2019]
1.5.8 If the options in recommendation 1.5.7 would not meet the clinical needs of a 12- to 18‑year‑old with mild depression or are unsuitable for their circumstances, consider:
1.5.9 Provide psychological therapies in settings such as schools and colleges, primary care, social services and the voluntary sector. [2019]
1.5.10 If mild depression in a child or young person has not responded to psychological therapy after 2 to 3 months (recommendations 1.5.6 to 1.5.8 and table 1), refer the child or young person for review by a CAMHS team. [2019]
1.5.11 Follow the recommendations on treating moderate to severe depression for children and young people who have continuing depression after 2 to 3 months of psychological therapy (see section 1.6 on moderate to severe depression). [2019]
To find out why the committee made the 2019 recommendations on treatments for mild depression and how they might affect practice, see rationale and impact.
1.6 Steps 4 and 5: Managing moderate to severe depression Treatments for moderate to severe depression
For children and young people with learning disabilities, see the recommendations on psychological interventions in the NICE guideline on mental health problems in people with learning disabilities.
1.6.1 Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS team. [2019]
1.6.2 Discuss the choice of psychological therapies with children and young people with moderate to severe depression and their family members or carers (as appropriate). Explain:
what the different therapies involve
the evidence for each age group (including the limited evidence for 5- to 11‑year‑olds)
how the therapies could meet individual needs, preferences and values. [2019]
1.6.3 Base the choice of psychological therapy on:
a full assessment of needs, including:
the circumstances of the child or young person and their family members or carers
their clinical and personal/social history and presentation
their maturity and developmental level
the context in which treatment is to be provided
comorbidities, neurodevelopmental disorders, communication needs (language, sensory impairment) and learning disabilities
patient and carer preferences and values (as appropriate). [2019]
1.6.4 For 5- to 11‑year‑olds with moderate to severe depression, consider the following options adapted to developmental level as needed:
family-based IPT
family therapy (family-focused treatment for childhood depression and systems integrative family therapy)
psychodynamic psychotherapy
individual CBT. [2019]
1.6.5 For 12- to 18‑year‑olds with moderate to severe depression, offer individual CBT for at least 3 months. [2019]
1.6.6 If individual CBT would not meet the clinical needs of a 12- to 18‑year‑old with moderate to severe depression or is unsuitable for their circumstances, consider the following options:
To find out why the committee made the 2019 recommendations on treatments for moderate to severe depression and how they might affect practice, see rationale and impact.
Combined treatments for moderate to severe depression
1.6.7 Consider combined therapy (fluoxetine[] and psychological therapy) for initial treatment of moderate to severe depression in young people (12–18 years), as an alternative to psychological therapy followed by combined therapy and to recommendations 1.6.8 to 1.6.10. [2015]
1.6.8 If moderate to severe depression in a child or young person is unresponsive to psychological therapy after 4 to 6 treatment sessions, a multidisciplinary review should be carried out. [2005]
1.6.9 Following multidisciplinary review, if the child or young person's depression is not responding to psychological therapy as a result of other coexisting factors such as the presence of comorbid conditions, persisting psychosocial risk factors such as family discord, or the presence of parental mental ill‑health, alternative or perhaps additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient, should be considered. [2005]
1.6.10 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. [2015]
1.6.11 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. [2015]
Depression unresponsive to combined treatment
1.6.12 If moderate to severe depression in a child or young person is unresponsive to combined treatment with a specific psychological therapy and fluoxetine after a further 6 sessions, or the patient and/or their parents or carers have declined the offer of fluoxetine, the multidisciplinary team should make a full needs and risk assessment. This should include a review of the diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family. [2005]
1.6.13 Following multidisciplinary review, the following should be considered:
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
psychodynamic psychotherapy (approximately 30 weekly sessions). [2005]
1.6.14 Do not offer antidepressant medication to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy. Specific arrangements must be made for careful monitoring of adverse drug reactions, as well as for reviewing mental state and general progress; for example, weekly contact with the child or young person and their parents or carers for the first 4 weeks of treatment. The precise frequency will need to be decided on an individual basis, and recorded in the notes. In the event that psychological therapies are declined, medication may still be given, but as the young person will not be reviewed at psychological therapy sessions, the prescribing doctor should closely monitor the child or young person's progress on a regular basis and focus particularly on emergent adverse drug reactions. [2015]
1.6.15 If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist. [2005]
1.6.16 When an antidepressant is prescribed to a child or young person with moderate to severe depression, it should be fluoxetine[] as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks. [2005]
1.6.17 If a child or young person is started on antidepressant medication, they (and their parents or carers, as appropriate) should be informed about the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed. Discussion of these issues should be supplemented by written information appropriate to the child or young person's and parents' or carers' needs that covers the issues described above and includes the latest patient information advice from the relevant regulatory authority. [2005]
1.6.18 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. [2005]
1.6.19 When fluoxetine[] is prescribed for a child or young person with depression, the starting dose should be 10 mg daily. This 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. There is 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. [2005]
1.6.20 When an antidepressant is prescribed in the treatment of a child or young person with depression and a self‑report rating scale is used as an adjunct to clinical judgement, this should be a recognised scale such as the MFQ. [2005]
1.6.21 When a child or young person responds to treatment with fluoxetine[], medication 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. [2005]
1.6.22 If treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, consideration should be given to the use of another antidepressant. In this case sertraline or citalopram are the recommended second‑line treatments[]. [2005]
1.6.23 Sertraline or citalopram[] should only be used when the following criteria have been met[]:
The child or young person and their parents or carers have been fully involved in discussions about the likely benefits and risks of the new treatment and have been provided with appropriate written information. This information should cover the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed; it should also include the latest patient information advice from the relevant regulatory authority.
The child or young person's depression is sufficiently severe and/or causing sufficiently serious symptoms (such as weight loss or suicidal behaviour) to justify a trial of another antidepressant.
There is clear evidence that there has been a fair trial of the combination of fluoxetine and a psychological therapy (in other words, that all efforts have been made to ensure adherence to the recommended treatment regimen).
There has been a reassessment of the likely causes of the depression and of treatment resistance (for example other diagnoses such as bipolar disorder or substance misuse).
There has been advice from a senior child and adolescent psychiatrist – usually a consultant.
The child or young person and/or someone with parental responsibility for the child or young person (or the young person alone, if over 16 or deemed competent) has signed an appropriate and valid consent form. [2005]
1.6.24 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). [2005]
1.6.25 When an antidepressant other than fluoxetine[] is prescribed for a child or young person with depression, the starting dose should be half the daily starting dose for adults. This can be gradually increased to the daily dose for adults over the next 2 to 4 weeks if clinically necessary, although lower doses should be considered in children with lower body weight. 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. [2005]
1.6.26 Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people. [2005]
1.6.27 Tricyclic antidepressants should not be used for the treatment of depression in children and young people. [2005]
1.6.28 Where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks with the exact dose being titrated against the level of discontinuation/withdrawal symptoms. [2005]
1.6.29 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. [2005]
1.6.30 Although there is some evidence that St John's wort may be of some benefit in adults with mild to moderate depression, this cannot be assumed for children or young people, for whom there are no trials upon which to make a clinical decision. Moreover, it has an unknown side‑effect profile and is known to interact with a number of other drugs, including contraceptives. Therefore St John's wort should not be prescribed for the treatment of depression in children and young people. [2005]
1.6.31 A child or young person with depression who is taking St John's wort as an over-the-counter preparation should be informed of the risks and advised to discontinue treatment while being monitored for recurrence of depression and assessed for alternative treatments in accordance with this guideline. [2005]
The treatment of psychotic depression
1.6.32 For children and young people with psychotic depression, augmenting the current treatment plan with a second-generation antipsychotic medication[] should be considered, although the optimum dose and duration of treatment are unknown. [2005]
1.6.33 Children and young people prescribed a second-generation antipsychotic medication should be monitored carefully for side effects. [2005]
See also the recommendations on choice of antipsychotics and how to use them in the NICE guideline on psychosis and schizophrenia in children and young people.
Inpatient care
1.6.34 Inpatient treatment should be considered for children and young people who present with a high risk of suicide, high risk of serious self‑harm or high risk of self‑neglect, and/or when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated. [2005]
1.6.35 When considering admission for a child or young person with depression, the benefits of inpatient treatment need to be balanced against potential detrimental effects, for example loss of family and community support. [2005]
1.6.36 When inpatient treatment is indicated, CAMHS professionals should involve the child or young person and their parents or carers in the admission and treatment process whenever possible. [2005]
1.6.37 Commissioners should ensure that inpatient treatment is available within reasonable travelling distance to enable the involvement of families and maintain social links. [2005]
1.6.38 Commissioners should ensure that inpatient services are able to admit a young person within an appropriate timescale, including immediate admission if necessary. [2005]
1.6.39 Inpatient services should have a range of interventions available including medication, individual and group psychological therapies and family support. [2005]
1.6.40 Inpatient facilities should be age appropriate and culturally enriching, with the capacity to provide appropriate educational and recreational activities. [2005]
1.6.41 Planning for aftercare arrangements should take place before admission or as early as possible after admission and should be based on the Care Programme Approach. [2005]
1.6.42 Tier 4[] CAMHS professionals involved in assessing children or young people for possible inpatient admission should be specifically trained in issues of consent and capacity, the use of current mental health legislation and the use of childcare laws, as they apply to this group of patients. [2005]
Electroconvulsive therapy (ECT)
1.6.43 ECT should only be considered for young people with very severe depression and either life‑threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments. [2005]
1.6.44 ECT should be used extremely rarely in young people and only after careful assessment by a practitioner experienced in its use and only in a specialist environment in accordance with NICE recommendations. [2005]
1.6.45 ECT is not recommended in the treatment of depression in children (5–11 years). [2005]
Discharge after a first episode
1.6.46 When a child or young person is in remission (fewer than 2 symptoms and full functioning for at least 8 weeks), they should be reviewed regularly for 12 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parents or carers and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. [2005]
1.6.47 CAMHS should keep primary care professionals up to date about progress and the need for monitoring of the child or young person in primary care. CAMHS should also inform relevant primary care professionals within 2 weeks of a patient being discharged and should provide advice about whom to contact in the event of a recurrence of depressive symptoms. [2005]
1.6.48 Children and young people who have been successfully treated and discharged but then re‑referred should be seen as soon as possible rather than placed on a routine waiting list. [2005]
Recurrent depression and relapse prevention
1.6.49 Specific follow‑up psychological therapy sessions to reduce the likelihood of, or at least detect, a recurrence of depression should be considered for children and young people who are at a high risk of relapse (for example individuals who have already experienced 2 prior episodes, those who have high levels of subsyndromal symptoms, or those who remain exposed to multiple‑risk circumstances). [2005]
1.6.50 CAMHS specialists should teach recognition of illness features, early warning signs, and subthreshold disorders to tier 1[] professionals, children or young people with recurrent depression and their families and carers. Self‑management techniques may help individuals to avoid and/or cope with trigger factors. [2005]
1.6.51 When a child or young person with recurrent depression is in remission (fewer than 2 symptoms and full functioning for at least 8 weeks), they should be reviewed regularly for 24 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parents or carers and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. [2005]
1.6.52 Children and young people with recurrent depression who have been successfully treated and discharged but then re‑referred should be seen as a matter of urgency. [2005]
1.7 Transfer to adult services
See also the NICE guideline on transition from children's to adults' services for young people using health or social care services.
1.7.1 The CAMHS team currently providing treatment and care for a young person aged 17 who is recovering from a first episode of depression should normally continue to provide treatment until discharge is considered appropriate in accordance with this guideline, even when the person turns 18 years of age. [2005]
1.7.2 The CAMHS team currently providing treatment and care for a young person aged 17–18 who either has ongoing symptoms from a first episode that are not resolving or has, or is recovering from, a second or subsequent episode of depression, should normally arrange for a transfer to adult mental health services, informed by the Care Programme Approach. [2005]
1.7.3 A young person aged 17–18 with a history of recurrent depression who is being considered for discharge from CAMHS should be provided with comprehensive information about the treatment of depression in adults (including NICE's information for the public) and information about local services and support groups suitable for young adults with depression. [2005]
1.7.4 A young person aged 17–18 who has successfully recovered from a first episode of depression and is discharged from CAMHS should not normally be referred on to adult services, unless they are considered to be at high risk of relapse (for example, if they are living in multiple‑risk circumstances). [2005]
AI that can shoot down fighter planes helps treat bipolar disorder
The artificial intelligence that can blow human pilots out of the sky in air-to-air combat accurately predicted treatment outcomes for bipolar disorder, according to a new medical study by the University of Cincinnati.
The findings open a world of possibility for using AI, or machine learning, to treat disease, researchers said.
David Fleck, an associate professor at the UC College of Medicine, and his co-authors used artificial intelligence called "genetic fuzzy trees" to predict how bipolar patients would respond to lithium.
Bipolar disorder, depicted in the TV show "Homeland" and the Oscar-winning "Silver Linings Playbook," affects as many as six million adults in the United States or 4 percent of the adult population in a given year.
"In psychiatry, treatment of bipolar disorder is as much an art as a science," Fleck said. "Patients are fluctuating between periods of mania and depression. Treatments will change during those periods. It's really difficult to treat them appropriately during stages of the illness."
The study authors found that even the best of eight common models used in treating bipolar disorder predicted who would respond to lithium treatment with 75 percent accuracy. By comparison, the model UC researchers developed using AI predicted how patients would respond to lithium 100 percent of the time. Even more impressively, the UC model predicted the actual reduction in manic symptoms after lithium treatment with 92 percent accuracy.
The study authors found that even the best of the eight most common treatments was only effective half the time. But the model UC researchers developed using AI predicted how patients would respond to lithium treatment with 88 percent accuracy and 80 percent accuracy in validation.
It turns out that the same kind of artificial intelligence that outmaneuvered Air Force pilots last year in simulation after simulation at Wright-Patterson Air Force Base is equally adept at making beneficial decisions that can help doctors treat disease. The findings were published this month in the journal Bipolar Disorders.
"What this shows is that an effort funded for aerospace is a game-changer for the field of medicine. And that is awesome," said Kelly Cohen, a professor in UC's College of Engineering and Applied Science.
Cohen's doctoral graduate Nicholas Ernest is founder of the company Psibernetix, Inc., an artificial intelligence development and consultation company. Psibernetix is working on applications such as air-to-air combat, cybersecurity and predictive analytics. Ernest's fuzzy logic algorithm is able to sort vast possibilities to arrive at the best choices in literally the blink of an eye.
"Normally the problems our AIs solve have many, many googolplexes of possible solutions -- effectively infinite," study co-author Ernest said.
His team developed a genetic fuzzy logic called Alpha capable of shooting down human pilots in simulations, even when the computer's aircraft intentionally was handicapped with a slower top speed and less nimble flight characteristics. The system's autonomous real-time decision-making shot down retired U.S. Air Force Col. Gene Lee in every engagement.
"It seemed to be aware of my intentions and reacting instantly to my changes in flight and my missile deployment," Lee said last year. "It knew how to defeat the shot I was taking. It moved instantly between defensive and offensive actions as needed."
The American Institute of Aeronautics and Astronautics honored Cohen and Ernest this year for their "advancement and application of artificial intelligence to large scale, meaningful and challenging aerospace-related problems."
Cohen spent much of his career working with fuzzy-logic based AI in drones. He used a sabbatical from the engineering college to approach the UC College of Medicine with an idea: What if they could apply the amazing predictive power of fuzzy logic to a particularly nettlesome medical problem?
Medicine and avionics have little in common. But each entails an ordered process -- a vast decision tree -- to arrive at the best choices. Fuzzy logic is a system that relies not on specific definitions but generalizations to compensate for uncertainty or statistical noise. This artificial intelligence is called "genetic fuzzy" because it constantly refines its answer, tossing out the lesser choices in a way analogous to the genetic processes of Darwinian natural selection.
Cohen compares it to teaching a child how to recognize a chair. After seeing just a few examples, any child can identify the object people sit in as a chair, regardless of its shape, size or color.
"We do not require a large statistical database to learn. We figure things out. We do something similar to emulate that with fuzzy logic," Cohen said.
Cohen found a receptive audience in Fleck, who was working with UC's former Center for Imaging Research. After all, who better to tackle one of medical science's hardest problems than a rocket scientist? Cohen, an aerospace engineer, felt up to the task.
Ernest said people should not conflate the technology with its applications. The algorithm he developed is not a sentient being like the villains in the "Terminator" movie franchise but merely a tool, he said, albeit a powerful one with seemingly endless applications.
"I get emails and comments every week from would-be John Connors out there who think this will lead to the end of the world," Ernest said.
Ernest's company created EVE, a genetic fuzzy AI that specializes in the creation of other genetic fuzzy AIs. EVE came up with a predictive model for patient data called the LITHium Intelligent Agent or LITHIA for the bipolar study.
"This predictive model taps into the power of fuzzy logic to allow you to make a more informed decision," Ernest said.
And unlike other types of AI, fuzzy logic can describe in simple language why it made its choices, he said.
The researchers teamed up with Dr. Caleb Adler, the UC Department of Psychiatry and Behavioral Neuroscience vice chairman of clinical research, to examine bipolar disorder, a common, recurrent and often lifelong illness. Despite the prevalence of mood disorders, their causes are poorly understood, Adler said.
"Really, it's a black box," Adler said. "We diagnose someone with bipolar disorder. That's a description of their symptoms. But that doesn't mean everyone has the same underlying causes."
Selecting the appropriate treatment can be equally tricky.
"Over the past 15 years there has been an explosion of treatments for mania. We have more options. But we don't know who is going to respond to what," Adler said. "If we could predict who would respond better to treatment, you would save time and consequences."
With appropriate care, bipolar disorder is a manageable chronic illness for patients whose lives can return to normal, he said.
UC's new study, funded in part by a grant from the National Institute of Mental Health, identified 20 patients who were prescribed lithium for eight weeks to treat a manic episode. Fifteen of the 20 patients responded well to the treatment.
The algorithm used an analysis of two types of patient brain scans, among other data, to predict with 100 percent accuracy which patients responded well and which didn't. And the algorithm also predicted the reductions in symptoms at eight weeks, an achievement made even more impressive by the fact that only objective biological data were used for prediction rather than subjective opinions from experienced physicians.
"This is a huge first step and ultimately something that will be very important to psychiatry and across medicine," Adler said.
How much potential does this have to revolutionize medicine?
"I think it's unlimited," Fleck said. "It's a good result. The best way to validate it is to get a new cohort of individuals and apply their data to the system."
Cohen is less reserved in his enthusiasm. He said the model could help personalize medicine to individual patients like never before, making health care both safer and more affordable. Fewer side-effects means fewer hospital visits, less secondary medication and better treatments.
Now the UC researchers and Psibernetix are working on a new study applying fuzzy logic to diagnosing and treating concussions, another condition that has bedeviled doctors.
"The impact on society could be profound," Cohen said.
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