Treatment

Refer for specialist advice.

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

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

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

• antidepressant treatment in children and young people how to use antidepressants in children and young people:
  • children and young people presenting with moderate to severe depression should be reviewed by a CAMHS team (1)
    
    
  • combined therapy (fluoxetine and psychological therapy) should be considered for initial treatment of moderate to severe depression in young people (12-18 years), as an alternative to psychological therapy followed by combined therapy
  • if psychological therapy as initial treatment
    • following multidisciplinary review, offer fluoxetine if moderate to severe depression in a young person (12-18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions
    • following multidisciplinary review, cautiously consider fluoxetine if moderate to severe depression in a child (5-11 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions, although the evidence for fluoxetine's effectiveness in this age group is not established
      
      
  • if an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist
    
    
  • when an antidepressant is prescribed to a child or young person with moderate to severe depression
    • fluoxetine should be used as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks
      
      
  • when fluoxetine is prescribed for a child or young person with depression, the starting dose should be 10 mg daily
    • can be increased to 20 mg daily after 1 week if clinically necessary, although lower doses should be considered in children of lower body weight
    • little evidence regarding the effectiveness of doses higher than 20 mg daily. However, higher doses may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority
      
      
  • when a child or young person responds to treatment with fluoxetine
    • fluoxetine should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks); in other words, for 6 months after this 8-week period
      
      
  • if treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, an alternative antidepressant should be considered. In this case sertraline or citalopram are the recommended second-line treatments
    • when a child or young person responds to treatment with citalopram or sertraline, medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks)
      
      
  • paroxetine and venlafaxine should not be used for the treatment of depression in children and young people
    
    
  • tricyclic antidepressants should not be used for the treatment of depression in children and young people
    
    
  • where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks
    • exact dose of the antidepressant being titrated against the level of discontinuation/withdrawal symptoms

Notes:

• at the time of NICE publication (June 2019), fluoxetine did not have UK marketing authorisation for use in young people (aged 12-18), without a previous trial of psychological therapy that was ineffective. For combined antidepressant treatment and psychological therapy as an initial treatment, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented
• at the time of NICE publication (June 2019), sertraline and citalopram did not have a UK marketing authorisation for use in young people under the age of 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented
• study evidence has examined the long-term effectiveness of SSRIs in adolescents with depression (2,3):
  • for adolescents with a major depression, the Treatment for Adolescents with Depression Study (TADS) suggests that treatment with a combination of fluoxetine and cognitive behavioural therapy (CBT) is superior to either treatment approach on its own
  • fluoxetine as a maintenance therapy for depression is associated with an increased risk for suicidal ideation which may be minimised by combining treatment with CBT
    
    
• Tier 1
  • primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services
    
    
• Tier 2 CAMHS
  • services provided by professionals relating to workers in primary care including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists
    
    
• Tier 3 CAMHS
  • specialised services for more severe, complex or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community or inpatient), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists
    
    
• Tier 4 CAMHS
  • tertiary-level services such as day units, highly specialised outpatient teams and inpatient units

Reference:

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