NICE 2019 Guidelines for management of moderate to severe depression in children and young

Treatments for moderate to severe depression

• Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS team. [2019]


• 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]

• Base the choice of psychological therapy on:

• a full assessment of needs, including:

• For 5- to 11‑year‑olds with moderate to severe depression, consider the following options adapted to developmental level as needed:

• For 12- to 18‑year‑olds with moderate to severe depression, offer individual CBT for at least 3 months. [2019]


• 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:

• 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. [2015]


• 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]


• 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]


• 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]


• 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

• 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]


• Following the multidisciplinary review, the following should be considered:

How to use antidepressants in children and young people

• 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]


• If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist. [2005]


• 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]


• 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]


• 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]


• 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]


• 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]


• 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]


• 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]


• Sertraline or citalopram should only be used when the following criteria have been met:

• 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]


• 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]


• Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people. [2005]


• Tricyclic antidepressants should not be used for the treatment of depression in children and young people. [2005]


• 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]


• 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]


• 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]


• 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

• 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]


• Children and young people prescribed a second-generation antipsychotic medication should be monitored carefully for side effects. [2005]

Inpatient care

• 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]


• 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]


• 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]


• Commissioners should ensure that inpatient treatment is available within reasonable travelling distance to enable the involvement of families and maintain social links. [2005]


• Commissioners should ensure that inpatient services are able to admit a young person within an appropriate timescale, including immediate admission if necessary. [2005]


• Inpatient services should have a range of interventions available including medication, individual and group psychological therapies and family support. [2005]


• Inpatient facilities should be age appropriate and culturally enriching, with the capacity to provide appropriate educational and recreational activities. [2005]


• 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]


• 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)

• 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]


• 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]


• ECT is not recommended in the treatment of depression in children (5–11 years). [2005]

Discharge after a first episode

• 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]


• 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]


• 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

• 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]


• 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]


• 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]


• 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]