NICE support for commissioning for

depression in children and young people

September 2013

1 Introduction
Implementing the recommendations from NICE guidance and other
NICE-accredited guidance is the best way to support improvements in the
quality of care or services, in line with the statements and measures that
comprise the NICE quality standards. This report:

 considers the cost of implementing the quality standard at a local level

 identifies where potential cost savings can be made
 highlights the statements in the quality standard that have potential
implications for Clinical Commissioning Groups (CCGs) and Local authority
commissioners
 directs commissioners and service providers to support tools that can help
them implement NICE guidance and redesign services.

NICE quality standards describe high-priority areas for quality improvement in

a defined care or service area. Each standard consists of a prioritised set of
specific, concise and measurable statements. The statements draw on
existing guidance, which provides an underpinning, comprehensive set of
recommendations, and are designed to support the measurement of
improvement. For more information see NICE quality standards.

NHS England's CCG outcomes indicator set is part of a systematic approach

to promoting quality improvement. The outcomes indicator set provides
Clinical Commissioning Groups (CCGs) and health and wellbeing boards with
comparative information on the quality of health services commissioned by

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CCGs and the associated health outcomes. The set includes indicators
derived from NICE quality standards. By commissioning services in line with
the quality standards, commissioners can contribute to improvements in
health outcomes.

Commissioners can use the quality standards to improve services by

including quality statements and measures in the service specification of the
standard contract and establishing key performance indicators as part of
tendering. They can also encourage improvements in provider performance
by using quality standard measures in association with incentive payments
such as the NHS Commissioning Board’s Commissioning for quality and
innovation 2013/14 guidance. NICE quality standards provide a baseline
against which improvements can be measured and rewarded, enabling
commissioners to address gaps in service provision, support best practice
and encourage evidence-based care.

This report on the depression in children and young people quality standard
should be read alongside:

 Depression in children and young people (2013). NICE quality standard 48.
 Self-harm (2013). NICE quality standard 34.
 Patient experience in adult NHS services (2012). NICE quality standard 15.
 Depression in adults (2011). NICE quality standard 8.
 Depression in children and young people (2005). NICE clinical guideline
28.

2 Overview of depression in children and young

people
Depression is a broad and heterogeneous diagnostic grouping, central to
which is depressed mood and loss of pleasure in most activities. Depressive
symptoms are frequently accompanied by symptoms of anxiety, but may also
occur on their own. The ICD-10 Classification of Mental and Behavioural
Disorders (World Health Organization 1992) uses an agreed list of 10
depressive symptoms to divide the common form of major depressive episode

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into 4 groups. Symptoms should be present for at least 2 weeks and every
symptom should be present for most of the day. The 4 groups are:

 not depressed (fewer than 4 symptoms)

 mild depression (4 symptoms)
 moderate depression (5–6 symptoms)
 severe depression (7 or more symptoms, with or without psychotic
symptoms).

The prevalence of mental health problems increases in adolescence (see

section 2.1). More than half of all adults with mental health problems were
diagnosed in childhood, and fewer than half of them were treated
appropriately at the time1. The London School of Economics’ report How
mental illness loses out in the NHS reaffirms that the economic and human
costs of mental health problems are substantial. Mental health problems are
the single largest cause of disability in the UK, and account for up to 23% of
the total burden of disease and 13% of NHS health expenditure. The King’s
Fund report Long-term conditions and mental health: the cost of co-
morbidities (2012) also noted that comorbid mental health problems raise total
healthcare costs by at least 45% for each person with a long-term condition.
Between £8 billion and £13 billion of NHS spending in England is attributable
to co-morbid mental health problems among people with long-term conditions.

This document covers the commissioning for diagnosis and management of

depression in children and young people aged between 5 and 17 years (that
is, up to their 18th birthday). Depression is most often not confined to only 1
family member. Parental depression is a strong risk factor for the child or
young person’s depression, and the child or young person’s experience of
depression is best helped by their parents or carers. Parents and carers have
an important role to play in supporting the child or young person with
depression and should be engaged at all stages of assessment, diagnosis
and treatment. Commissioned services should be coordinated across all

1
Kim-Cohen J, Caspi A, Moffitt TE, et al. (2003) Prior juvenile diagnoses in adults with mental
disorder: developmental follow-back of a prospective-longitudinal cohort. Archives of General
Psychiatry 60: 709–17

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relevant agencies encompassing the whole care pathway for depression in
children and young people, and focused on early intervention and integrated
support. A person-centred and integrated approach to providing services is
fundamental to delivering high-quality care to children and young people with
depression. Commissioners will need to consider the particular needs of the
most vulnerable groups in their local population who may require targeted
services. These include:

 looked-after children
 children in special schools for behavioural, emotional and social difficulties
 children with learning difficulties or physical disabilities
 children in contact with the youth justice system
 teenage mothers.

Better links between Child and Adolescent Mental Health Services (CAMHS)
and tier 1 and tier 2 services are needed to improve the detection and
availability of treatment for depression in children and young people.
Commissioners need to ensure that service providers monitor detection rates
and record outcomes for local planning and local, regional and national
comparison.

2.1 Epidemiology of depression in children and young

people
The number of young people aged 15–16 years with depression nearly
doubled between the 1980s and the 2000s2. The prevalence of depression in
the UK in children is estimated to be 0.2% in children aged 5-10 years old and
1.4% in children aged 11-16 years old3. Between the ages of 5 and 16 years,
1 in 10 children has a clinically diagnosed mental health disorder3. The
incidence of depression was estimated in as 0.5–0.75% in children aged 5–

2
Nuffield Foundation (2013) Social trends and mental health: introducing the main findings.
London: Nuffield Foundation.
3
Green H, McGinnity A, Meltzer, H et al. (2005) Mental health of children and young people
in Great Britain 2004. London: Palgrave.

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11 years and 2–4% in young people aged 12–18 years4. This is between
around 125,100 and 239,400 children and young people.

3 Summary commissioning and resource

implications
In England, CCGs are responsible for commissioning for children’s healthcare
services including mental and physical health. NHS England is responsible for
commissioning specialised services (prescribed services) which includes
mental health. There will be care pathways for depression in children and
young people that cross over between CCG and NHS England commissioned
services. It is essential that service users receive seamless treatment and that
their care pathways are not adversely affected by these commissioning and
contracting boundaries. NHS England and CCGs will need to liaise with local
authority children's services (social care and education), which are key to
providing integrated CAMHS (see specialised commissioning resources
available from NHS England). Commissioners should also recognise the role
of CAMHS as integral to planning and coordinating care for vulnerable
children and young people.

CAMHS services are delivered in line with a four-tier strategic framework:

 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.

4
Full guideline Depression in children and young people: Identification and management in
primary, community and secondary care. National Collaborating Centre for Mental Health.
(2005)

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 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 Tertiary-level services such as day units, highly specialised

outpatient teams and inpatient units.

Using the quality standard, in conjunction with the guidance on which it is

based, should contribute to the improvements outlined in the NHS Outcomes
Framework 2013/14. The objectives of No health without mental health: a
cross-government mental health outcomes strategy for people of all ages are
consistent with the indicators from the NHS Outcomes Framework 2013/14.

The cost of achieving the quality standard for depression in children and
young people depends on current local practice and the progress
organisations have made in implementing NICE and NICE-accredited
guidance.

The Children and Young People's Improving Access to Psychological

Therapies (CYP IAPT) Project has a budget of £8 million per year (2011/12 to
2014/15). In 2012 it was announced that the project would receive an extra
investment of up to £22 million over the next 3 years5. In 2011/12, Primary
Care Trust (PCT) expenditure on child and adolescent mental health
disorders was estimated to be £713 million6. The changes involve improved
access, more precise categorisation of the nature and severity of the
difficulties on presentation, a recognition of complexity (such as being subject
to a care order or protection plan) and the effect on the child’s or young

5
Children and Young people's Improving Access to Psychological Therapies Newsletter -
June 2012
6
2011-12 programme Budgeting PCT Benchmarking Tool version 1.0

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person’s education, employment or training. There will also be a greater
emphasis on recording measures of recovery, change and satisfaction with
treatment7. Commissioners may also find it helpful to refer to Working with
under 18 year olds: guidance for commissioners, IAPT service providers and
those working in IAPT services.

Table 1 summarises the commissioning and resource implications for

commissioners working towards achieving the quality standard. See section 4
for more detail on commissioning and resource implications.

7
Royal College of General Practitioners (2013). Commissioning a good child health service.

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Table 1 Potential commissioning and resource implications of achieving
the quality standard for depression in children and young people
Quality statement Commissioning implications Estimated resource
impact
1 - Confirming and Specify and request evidence The cost impact will
recording a diagnosis of practice by monitoring the depend on current service
proportion of children and provision at a local level.
young people who presented
with suspected depression and
who have a diagnosis
confirmed and recorded in their
medical records.
2 - Information Specify and request evidence Cost impact not expected
appropriate to age of practice by monitoring the to be significant because
proportion of children and many of these resources
young people with depression are available on the
who are given information internet.
appropriate to their age about
the diagnosis and their
treatment options.
Measuring outcomes: evidence
from surveys and feedback
that children and young people
with depression understand the
diagnosis and their treatment
options.
Suspected severe Specify and request evidence Possible costs associated
depression: of practice by monitoring the with increasing capacity to
3 - at high risk of proportion of: enable assessments within
suicide children and young people with 24 hours and within
suspected severe depression 2 weeks of referrals made.
and at high risk of suicide who
are assessed by CAMHS
professionals within 24 hours
of referral,
4 - without high children and young people with
risk of suicide suspected severe depression
and at high risk of suicide who
are referred to CAMHS and
provided with a safe place if
necessary while waiting for an
assessment,
children and young people with
suspected severe depression
but not at high risk of suicide
who are assessed by CAMHS
professionals within 2 weeks of
referral.
5 - Monitoring Specify and request evidence The cost impact will
progress of practice by monitoring the depend on current service
proportion of children and provision at a local level

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 young people receiving but is not expected to be
treatment for depression who significant.
have their health outcomes
recorded at the beginning and
end of each step in treatment.

4 Commissioning implications and resource

impact
This section considers the commissioning implications and potential resource
impact of implementing the recommendations to achieve the NICE quality
standard for depression in children and young people.

4.1 Confirming and recording a diagnosis

Quality statement 1: Confirming and recording a diagnosis

Children and young people with suspected depression have a diagnosis

confirmed and recorded in their medical records.

Diagnosing depression in children and young people can be difficult.

Commissioners need to ensure that healthcare providers confirm a diagnosis
and accurately record it in the medical records of children and young people
with suspected depression so that appropriate treatment can be offered.
Based on available evidence, it is estimated that approximately 30% of
children and young people will recover fully within the first 3 months of a
depressive episode. However, without effective treatment, depressive
morbidity may persist into adulthood8. Early effective treatment is therefore
expected to reduce healthcare costs far beyond childhood.

The use of tools may be helpful in confirming a diagnosis of depression. NICE

clinical guideline 28 indicates that Kiddie-Sads (K-SADS) and Child and
Adolescent Psychiatric Assessment (CAPA) could be used to diagnose
8
Knapp M, McCrone P, Fombonne E et al (2000) The Maudsley long-term follow-up of child
and adolescent depression: 3. Impact of comorbid conduct disorder on service use and costs
in adulthood. British Journal of Psychiatry 180: 19–23

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depression in children and young people, but these would need to be modified
for regular use in busy routine CAMHS settings. Professionals within tier 3
CAMHS who specialise in the treatment of depression should be trained in
interviewer-based assessment instruments (such as K-SADS and CAPA, and
have skills in non-verbal assessments of mood in younger children in line with
recommendation 1.4.3.

Any cost impact will vary depending on how training will be delivered and
current service provision at a local level.

Commissioners may refer to the CAMHS secondary uses data set, which will
collect some data (on presenting problems and diagnoses)9.

Commissioners may find it helpful to refer to the NICE ‘referral advice’

recommendations database in accordance with the NICE guideline on
depression in children and young people, and also to Assessing the severity
of depression in primary care in Appendix E of the guideline.

4.2 Information appropriate to age

Quality statement 2: Information appropriate to age

Children and young people with depression are given information appropriate
to their age about the diagnosis and their treatment options.

Children and young people need age-appropriate information they can

understand about their diagnosis and treatment options, so that they can
participate in shared decision-making; such information also encourages
dialogue and collaboration between service users and healthcare
professionals. Commissioners need to ensure that healthcare professionals
involved in identifying, assessing or treating children and young people with

9
This statement is not specific to CAMHS. Other data sources may be necessary to evidence
achievement of this statement.

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depression provide information to them that is appropriate to their
developmental level, emotional maturity and cognitive capacity, and also
takes into account any learning disabilities, sight or hearing problems or
delays in language development.

In line with the NICE guideline on depression in children and young people
(recommendation 1.1.1.1), commissioners may wish to check that information
is provided at an appropriate time and covers the nature, course and
treatment of depression, including the likely side-effect profile of medication if
offered. Commissioners can specify that information should be accessible in a
variety of formats – for example, web-based resources and written
information. It should be tailored to the person's needs. Written information or
audiotaped material should be available in the language of the child or young
person and their family or carer(s), and professional interpreters should be
used if this is not possible. The national framework to improve mental health
and wellbeing (2012) highlights innovative use of information as essential in
implementing the mental health strategy and encourages mental health and
wellbeing services to use technology to provide self-care and peer support.
Commissioners may wish to work with providers to suggest a variety of
formats – for example, web resources such as MIND, OCD Youth, Royal
College of Psychiatrists and Young Minds10.

The cost impact of achieving this quality statement will depend on local
circumstances but is not expected to be significant because much of this
information is available on the internet.

4.3 Suspected severe depression

Quality statement 3: Suspected severe depression and at high risk of
suicide

Children and young people with suspected severe depression and at high
risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health

10
Examples are offered as suggestions of web resources that are available but are not
necessarily recommended. NICE makes no judgement on the compliance of these resources
with its guidance.

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 Services) professionals within a maximum of 24 hours of referral. If
necessary, children and young people are provided with a safe place while
waiting for the assessment.

Quality statement 4: Suspected severe depression without high risk of

suicide

Children and young people with suspected severe depression but not at high
risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health
Services) professionals within a maximum of 2 weeks of referral.

Although there have been considerable service improvements and much

progress in collaboration between agencies across the country, there remain
unacceptable variations and gaps to be addressed. Children, young people
and families are still waiting too long for interventions from more specialised
CAMHS11. Prompt access to services is essential if children and young people
are to receive the right treatment at the right time. Commissioners need to
ensure that referral pathways are in place for children and young people
presenting with moderate to severe depression to be reviewed by a CAMHS
tier 2 or 3 team in line with the NICE guideline on depression in children and
young people (recommendation 1.6.1.1). Commissioners should also ensure
that healthcare professionals who make the referral, are assessing the need
for a safe place for the child or young person until the CAMHS assessment is
carried out. This should be done at the time of the referral to help prevent
injury or worsening of symptoms.

Commissioners need to ensure that there is sufficient service and workforce

capacity for children and young people to be assessed within the following
time frames:

11
Department for Children, Schools and Families and the Department of Health (2010)
Keeping children and young people in mind: the Government’s full response to the
independent review of CAMHS.

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 As an emergency within a maximum of 24 hours of referral if they have
suspected severe depression and are at high risk of suicide. The time
frame for face-to-face assessment within 24 hours of referral is based on
consensus of expert opinion.
 Within a maximum of 2 weeks of referral if they have suspected severe
depression but are not at high risk of suicide. The time frame of 2 weeks is
based on consensus of expert opinion, and is to prevent injury or
worsening of symptoms.

Children and young people at high risk of suicide could include, but are not
limited to, those who have a previous history of self-harm or attempted
suicide, current active suicidal plans and coexisting mental health problems12.
An assessment by CAMHS professionals is likely to include, but is not limited
to, making a diagnosis and starting treatment. Commissioners may need to
specify that there are facilities so that a safe place can be provided for
children and young people at high risk of suicide, until the assessment is
carried out. Commissioners may find it helpful to refer to NICE quality
standard 34 for self harm (statement 5) and the related commissioning
support. Commissioners may need to work with providers to also check that
timely treatment for children and young people is available after assessment
to avoid delays.

Access to CAMHS professionals within the recommended timescales

dependent on suicide risk may already be in place in many areas. Where it is
not, there may be a cost impact in increasing service capacity. Because
current practice varies across the country, the cost impact should be
assessed locally. The hourly cost of staff that may be involved in these initial
assessments are given in table 2 below. These costs can be used to help
commissioners and providers when the capacity of services needs to be
increased.

12
NICE clinical guideline 28 defines suicidal ideation as thoughts about suicide or of taking
action to end one’s own life.

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Table 2 Hourly cost of staff in a CAMHS team who may perform initial
assessments
Job title Hourly cost (£)13 Hourly cost (face-to-face
14
contact) (£)
Consultant: psychiatric 72 186
Clinical psychologist 32 72
Nurse (mental health) 18 34
Child and adolescent 26 34
psychotherapist
NHS Community 18 2315
Occupational therapist
Community speech and 18 2315
language therapist

Commissioners may refer to the CAMHS secondary uses data set, which
collects data on waiting times and referrals to CAMHS.

Commissioners may also find it helpful to refer to the Quality and Productivity
examples Improving the efficiency of mental health services: an outcome
orientated model (2012) and Joint commissioning of child and adolescent
mental health services (2009).

Commissioners may also consider the NICE ‘referral advice’

recommendations database in accordance with the NICE guideline on
depression in children and young people.

13
All costs in Table 2 are taken from 2013-14 Agenda for Change midpoint pay rates except
the Consultant: psychiatrist which is taken from Pay Circular (M&D) 1/2013. Employer
pension contributions and employer national insurance contributions were added to these pay
rates. The hourly rate was worked out by dividing the total annual pay and contributions by 44
(annual number of weeks worked) and 37.5 (hours worked per week, except Consultant:
psychiatrists who work 40 hours per week).
14
The hourly cost of face-to-face contact was calculated using the ratios provided in the Unit
Costs of Health and Social Care (2012) document.
15
The hourly cost for face-to-face contact was worked out by increasing the hourly cost by
30% which is the same percentage increase in the Child and adolescent psychotherapist’s
normal hourly cost and hourly cost of face-to-face time.

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4.4 Monitoring progress
Quality statement 5: Monitoring progress

Children and young people receiving treatment for depression have their
health outcomes recorded at the beginning and end of each step in
treatment.

It is important to monitor the mood and feelings of children and young people
who are receiving treatment for depression so that the effectiveness of
treatment can be assessed and adjustments made to ensure maximum
benefit. Commissioners need to ensure that CAMHS professionals are
recording the health outcomes of children and young people who are
receiving treatment for depression at the beginning and end of each step in
treatment. A ‘step’ in treatment is defined as the movement between steps of
the stepped-care model as described in the NICE guideline on depression in
children and young people. The stepped-care model provides a framework in
which to organise the provision of services that support both healthcare
professionals and service users and their parent(s) or carer(s) in identifying
and accessing the most effective interventions. The model describes the
different needs that children and young people with depression may have –
depending on the characteristics of their depression and their personal and
social circumstances – and the responses that are required from services.

Commissioners may note that methods to record and monitor health

outcomes may include the use of self-report measures, as used in screening
for depression (for example, the Mood and Feelings Questionnaire [MFQ]) or
generic outcome measures (for example, Health of the National Outcome
Scale for Children and Adolescents [HoNOSCA] or the Strengths and
Difficulties Questionnaire [SDQ]) in line with the NICE guideline on depression
in children and young people (recommendations 1.1.3.8 and 1.1.4.5).
Commissioners need to be sure that the information collected is used to
improve the treatment pathway. It can also be used for planning services, and
made available for local, regional and national comparison.

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The cost impact of implementing this statement will depend on current service
provision at a local level but is not expected to be significant.

Commissioners may refer to the CAMHS secondary uses data set, which
collects data on outcome measurement.

Routine outcome monitoring is being specified as part of CYP IAPT which

could be used by tier 2 and 3 community services locally. The aim is to
encourage the use of routine patient reported outcome measurement to
improve the quality and experience of service users16.

Commissioners may wish to consider the use of Commissioning for quality

and innovation targets to encourage and support providers to implement the
use of outcomes measures.

Commissioners can also refer to the NICE ‘referral advice’ recommendations

database in accordance with the NICE guideline on depression in children
and young people.

5 Other useful resources

5.1 Policy documents

 Department for Education (updated 2013) Working together to safeguard
children.
 Department of Health (2012) No health without mental health:
implementation framework.
 Department of Health (2012) Preventing suicide in England: a cross-
government outcomes strategy to save lives.
 Department of Health (2011) Delivering better mental health outcomes for
people of all ages.

16
All year 1 IAPT sites began to submit data from all community CAMHS from December
2012.

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 Royal College of Psychiatrists (2011) National audit of psychological
therapies for anxiety and depression.
 Department of Health (2011) Talking therapies: a 4 year plan of action.
 Department for Children, Schools and Families and the Department of
Health (2010) Keeping children and young people in mind: the
Government’s full response to the independent review of CAMHS.
 Department of Health (2009) Improving access to child and adolescent
mental health services.
 Department of Health, Department for Children, Schools and Families
(2009) Healthy lives, brighter futures: the strategy for children and young
people’s health.
 HM Government (2009) New horizons: a shared vision for mental health.

5.2 Useful resources

 Royal College of General Practitioners (2013) Commissioning a good child
health service..
 NICE quality standard 31 (2013) Health and wellbeing of looked-after
children and young people.
 NICE (2013) Development sources for the quality standard for the health
and wellbeing of looked after children and young people.
 Department of Health (2011) You're welcome - quality criteria for young
people friendly services.
 World Health Organisation (2010) ICD-10 classification of mental and
behavioural disorders.
 NICE public health guidance 28/ SCIE guide 40 (2010) Looked-after
children and young people.

5.3 NICE implementation support

 Health and wellbeing of looked-after children and young people. NICE
support for commissioning (2013).
 Promoting the quality of life of looked after children and young people.
NICE costing report (2010).

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 Promoting the quality of life of looked after children and young people.
NICE guide to resources (2010).
 Promoting the quality of life of looked after children and young people.
NICE self assessment tool (2010).
 Promoting the quality of life of looked after children and young people.
NICE slide set (2010).
 Depression in children and young people. NICE costing report (2005).
 Depression in children and young people. NICE costing template (2005).
 Depression in children and young people. NICE slide set (2005).
 Depression in children and young people. NICE implementation advice
(2005).

5.4 NICE pathways

 Depression
 Looked-after babies, children and young people

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