GUIDELINE REVIEW
Depression in children and young
1
Psychiatry Core Trainee (CT3),
Edinburgh, UK
2
Lewisham CAMHS, South
London & the Maudsley NHS
Foundation Trust, London, UK
Correspondence to
Dr Andrew Lawton, Psychiatry
Core Trainee (CT3), Royal
Edinburgh Hospital, Morningside
Place, Edinburgh, EH10 5HF;
andrew.lawton@nhs.net
Received 25 May 2015
Revised 9 September 2015
Accepted 13 September 2015
Published Online First
12 October 2015
To cite: Lawton A,
Moghraby OS. Arch Dis Child
Educ Pract Ed 2016;101:
206–209.
206
people: identification and
management in primary,
community and secondary care
(NICE guideline CG28)
Andrew Lawton,1 Omer S Moghraby2
INTRODUCTION AND INFORMATION
ABOUT THE CURRENT GUIDELINE
The National Institute for Health and
Care Excellence (NICE) guideline CG28
‘Depression in children and young
people: Identification and management
in primary, community and secondary
care’ was recently updated and was pub-
lished in March 2015.1
This covers depression as defined by the
International Classification of Diseases
(ICD-10) in children (5–11 years) and
young people (12–18 years). It provides
specific recommendations on assessment
and treatment stratified by severity and
includes risk profiling, the role of special-
ist Child and Adolescent Mental Health
Services (CAMHS) and the use of psycho-
logical and pharmacological interventions.
Table 1 outlines some important
definitions.
PREVIOUS GUIDELINES
The original NICE guideline CG28 was
published in 2005. This revision includes
updated recommendations for some
interventions and for future research. See
box 1 for a link to this guidance and
further resources.
KEY ISSUES THAT THE GUIDELINE
ADDRESSES
Risk profiling
A child/young person exposed to a single
recent undesirable life event should be
assessed for symptoms and risk factors
for depression with a risk profile docu-
mented in their records. The assessment
should ALWAYS consider possible child
maltreatment (abuse may coexist with
depression), self-harm or any suicidal
Lawton A, Moghraby OS. Arch Dis Child Educ Pract Ed 2016;101:206–209. doi:10.1136/archdischild-2015-308680
thoughts and, in young people, directly
address alcohol and drug use.
Children and young people referred to
CAMHS without a diagnosis of depres-
sion should be screened with a self-report
questionnaire such as Mood and Feelings
Questionnaire (MFQ). The MFQ can
also be used as an adjunct to clinical
judgement when monitoring response to
treatment.
Referral guidance
Mild depression without comorbidity can
be managed by primary care by appropri-
ately trained professionals. Referral
should be made to CAMHS where a
child/young person has any other depres-
sive illness. Other criteria for referral are
listed in box 2.
MANAGEMENT
Mild depression
Children and young people with mild
depression without features in box 2
should be offered individual supportive
therapy, group Cognitive Behavioural
Therapy (CBT) or guided self-help
(according to availability) for 2–
3 months, provided by tier 1, tier 2 or
the voluntary sector. It should be
explained to children/young people and
their family/carers that no one type of
therapy is better than the others.
Treatment may be deferred if it is
declined or the healthcare professional
believes the child/young person may
recover without it. However, they must
be offered a further assessment, that is,
‘watchful waiting’, within 4 weeks
(ideally within 2) and should be actively
pursued if they do not (re)attend.
 Guideline review

Table 1 Important definitions

Child An individual aged 5–11 years
Young person An individual aged 12–18 years
Typical symptoms of depression Low mood or irritability, loss of interest or enjoyment and increased fatigability for at least 2 weeks, at least half the
time and with impairment
Other symptoms of depression Poor concentration and attention;
reduced self-esteem or self-confidence;
ideas of guilt or worthlessness;
agitation;
ideas or acts of self-harm or suicide (including bleak outlook for future);
disturbed sleep (increased or decreased);
significant change in appetite (with weight gain/loss)
Mild depressive episode At least two typical and two other symptoms for at least 2 weeks
Moderate depressive episode At least two typical and three to four other symptoms for at least 2 weeks, usually with significant functional impairment
Severe depressive episode All three typical and at least four other symptoms, some of which should be of severe intensity
Tier 1 Primary care services, including general practitioners, teachers and voluntary agencies
2
Tiers 2 and 3 CAMHS sole practitioners in the community and community paediatricians and CAMHS multidisciplinary specialist
outpatient services
Tier 4 CAMHS highly specialist outpatient and inpatient services
CAMHS, Child and Adolescent Mental Health Services.

Moderate-to-severe depression required for adverse effects. Medication could be

Children and young people should be seen by tier 2 or
3 CAMHS and offered at least 3 months of a specific
psychological therapy. For young people (12–
18 years), combined fluoxetine and psychological
therapy can be considered as an initial treatment.
Where moderate/severe depression in a young person
does not improve after four to six sessions of psycho-
logical therapy, or they decline that therapy, offer flu-
oxetine. Where moderate/severe depression in a child
(5–11 years) does not improve after four to six sessions
of psychological therapy, fluoxetine can be considered.
started where psychological interventions are declined
or not improving symptoms. It is recommended that
fluoxetine should be used in the first instance, at
10 mg, with sertraline and citalopram only used if this
has not worked. The evidence for use is limited.
Medication should be continued for at least 6 months
after remission of symptoms. St John’s Wort is specif-
ically advised against due to an absence of trial evi-
dence, unknown side-effect profile and risk of
interaction with prescribed medication (including the
oral contraceptives).

Antidepressants UNDERLYING EVIDENCE BASE/METHODOLOGY

Antidepressants should only be prescribed after an In reviewing the most effective psychological interven-
assessment and diagnosis by a child and adolescent tion, 40 randomised trials were included. Of these, six
psychiatrist. They should be offered in combination involved children and six included children/young
with psychological therapy and careful monitoring is

Box 2 Criteria for referral to Child and Adolescent

Box 1 Resources Mental Health Services (CAMHS) (tier 2 or 3)

▸ http://www.nice.org.uk/guidance/cg28/resources/guida ▸ Depression with 2+ other risk factors for depression

nce-depression-in-children-and-young-people-identifica ▸ Depression with family history of depression
tion-and-management-in-primary-community-and- ▸ Mild depression not responding to tier 1 interven-
secondary-care-pdf tions after 2–3 months
Link to the National Institute for Health and Care ▸ Moderate or severe depression
Excellence (NICE) full guideline ▸ Signs of recurrence in those with previous moderate
▸ http://www.nice.org.uk/guidance/cg28/ifp/chapter/defi or severe depression
nitions-of-psychological-treatments ▸ Unexplained self-neglect for 1 month that might be
Link to public information on guideline harmful to their physical health
▸ Hopkins, et al 20153 ▸ Active suicidal thoughts
Summary of the guidance by the Clinical Guidelines ▸ Referral requested by child/young person or their
Update Committee parent(s)/carer(s)

Lawton A, Moghraby OS. Arch Dis Child Educ Pract Ed 2016;101:206–209. doi:10.1136/archdischild-2015-308680 207
 Guideline review
people from the UK. Recommendations regarding the
relative efficacy of different antidepressants or differ-
ent psychological therapies separately or in combin-
ation were based on a Cochrane Systematic Review.4
No suitable evidence was identified to recommend
which monotherapy should be initially offered (ie,
either psychological or antidepressant therapy),
although suicidal ideation may be greater with the
latter. However, it is generally considered safer to
treat than not even if this is the case and the more
severe the depression, the more likely it is that
the benefits/risks trade-off will favour intervention.
The Improving Mood with Psychoanalytical and
Cognitive Therapy (IMPACT) study is due to report
in 2016 and may provide some information on which
therapies work best.
WHAT DO I NEED TO KNOW?
What should I stop doing?
▸ Don’t automatically refer to CAMHS: a single undesir-
able life event without other risk factors may not require
specific intervention.
▸ Don’t prescribe antidepressants until advised by a child
and adolescent psychiatrist.
▸ Don’t prescribe antidepressants for initial treatment of
mild depression.
What should I be doing?
▸ Assessment of risk following any undesirable life event;
this should include screening for possible mood
disorder.
▸ Always consider external factors in assessment, especially
child maltreatment.
▸ For mild depression not requiring CAMHS referral:
– If you think it might resolve—wait and reassess in
2–4 weeks.
– Do suggest therapy for 2–3 months and monitor
response.
– Discuss available choice of therapy with child/young
person and family/carers do explain that there is no
evidence that any specific mode of therapy is superior.
– If it is more severe or doesn’t respond, then refer to
CAMHS.
UNRESOLVED CONTROVERSIES
Since 2010, two-thirds of local authorities in England
have reduced their CAMHS budget5 and access to
psychological therapies remains difficult and subject
to long delays in many parts of the UK. However, the
NICE guidance recommends offering psychological
therapy of one form or other in most cases while also
recommending that medication should not be offered
‘except in combination with a concurrent psycho-
logical therapy’ and should only be prescribed after
assessment and diagnosis by a child and adolescent
psychiatrist.1 This would leave many young people
without any intervention for many months.
208 Lawton A, Moghraby OS. Arch Dis Child Educ Pract Ed 2016;101:206–209. doi:10.1136/archdischild-2015-308680
A separate point is the limited trial evidence regard-
ing the use of antidepressants at all in children (with
no UK licence for use under 8 years) and regarding the
use of antidepressants other than fluoxetine in young
people (there is also limited high-quality evidence for
psychological therapies, including CBT). The
Cochrane Review used in preparing this guideline
could only identify 19 trials and its authors express
reservations about the validity and potential bias of all
of them. The lack of high-quality research in this area
leaves fluoxetine as first choice and any deviation must
be clearly documented. In contrast, a meta-analysis for
adults6 reviewed 117 randomised controlled trials
finding clinically significant differences between anti-
depressants in terms of efficacy and acceptability with
escitalopram and sertraline favoured for both. The
guideline calls for further blinded, randomised trials to
assess the efficacy of the various therapies against each
other and placebo. This may identify incremental ben-
efits between medications, including in combination.
Clinical bottom line
▸ Risk assessment of all children/young people experi-
encing an undesirable life event (including screening
for depression).
▸ Watchful waiting for up to 4 weeks in uncomplicated
mild depression followed by limited psychological
intervention and monitor response.
▸ All other children/young people with depression,
active suicidal thoughts or self-harm compromising
physical health should be referred to Child and
Adolescent Mental Health Services (CAMHS).
▸ Initial treatment for mild depression should not be
antidepressants.
▸ Antidepressants should not be commenced prior to
review by CAMHS psychiatrist.
Twitter Follow Andrew Lawton at @DrALawton and Omer
Moghraby at @moghraby
Contributors AL and OSM reviewed the subject guideline and
the evidence supporting the guidelines. AL drafted and revised
the review article. OSM reviewed, amended, revised and added
to the draft article.
Competing interests None declared.
Provenance and peer review Not commissioned; externally
peer reviewed.
REFERENCES
1 National Institute for Health and Clinical Excellence.
Depression in children and young people: Identification and
management in primary, community and secondary care (NICE
Clinical Guideline CG28). London: National Institute for
Health and Care Excellence (UK), 2015.
2 NHS England. Model specification for child and adolescent
mental health services: targeted and specialist levels (Tiers 2/3),
2015. (accessed 20 May 2015). http://www.england.nhs.uk/
wp-content/uploads/2015/01/mod-camhs-tier-2-3-spec.pdf

3 Hopkins K, Crosland P, Elliott N, et al. Clinical guidelines
update committee B. Diagnosis and management of depression
in children and young people: summary of updated NICE
guidance. BMJ 2015;350:h824.
4 Hetrick SE, McKenzie JE, Cox GR, et al. (2012) Newer
generation antidepressants for depressive disorders in children
and adolescents. Cochrane Database Syst Rev 2012;11:
CD004851.
Lawton A, Moghraby OS. Arch Dis Child Educ Pract Ed 2016;101:206–209. doi:10.1136/archdischild-2015-308680
Guideline review
5 YoungMinds. Local authorities and CAMHS budgets 2012/
2013. 2013. http://http://www.youngminds.org.uk/assets/0000/
7313/CAMHS_2012.13_briefing_local_authorities.doc
(accessed 17 Apr 2015).
6 Cipriani A, Furukawa T, Salanti G, et al. Comparative efficacy
and acceptability of 12 new-generation antidepressants:
a multiple-treatments meta-analysis. Lancet 2009;373:
746–58.
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