Depression in children and young people: identification and management

Depression is a common illness; it is estimated that more than 300 million people worldwide are affected^[1]
. It is different from usual mood swings and short-lived emotional responses to everyday challenges and may become a serious health disorder when it is long-lasting and with moderate or severe intensity. Not only can it cause the affected person to suffer significantly and perform poorly at work, school or in the family but, if left untreated, depression can also lead to suicide. According to the World Health Organization (WHO), more than 800,000 people die by suicide each year and it is the second leading cause of death in 15–29-year-olds^[1]
.

People of any age, ethnicity or social background can suffer from depression. It is estimated that 1% of pre-pubertal children and around 3% of post-pubertal young people are diagnosed with depression^[2]
. Depression is more common in older adolescents, and twice as many adolescent females are affected compared with adolescent males. The prevalence of childhood depression appears to be increasing; however, this may be owing to greater awareness and improved diagnosis^[2]
.

A young person with depression may experience major difficulties with feelings and behaviour. This may cause problems at home, at school and in relationships. Some young people may be more likely to engage in riskier behaviours, such as missing school, harming themselves, misusing drugs or alcohol, and having inappropriate sexual relationships. Sometimes young people with untreated depression may have suicidal ideation.

Some young people with severe depression may develop psychotic symptoms, causing them to perceive or interpret things differently from those around them. For example, they may hear voices or see things that do not exist outside of their mind. A small number of young people also experience episodes of depression followed by symptoms of mania. In these cases, they may actually be suffering from bipolar affective disorder^[3]
.

Depression is a treatable illness. Overall, 10% of children and young people with depression recover spontaneously within three months, and 50% recover within the first year^[4]
. The first step towards getting help is to recognise that there might be a problem. Pharmacists and healthcare professionals in primary care should be able to recognise the symptoms of depression, and be able to assess children and young people who may be at risk. If necessary, they can then make a referral to the local Child and Adolescent Mental Health Service (CAMHS), which can offer specialist help.

This article outlines the four-tier strategic framework of CAMHS, how to diagnose depression, the various treatment options available (both pharmacological and non-pharmacological), and the role of the pharmacist and pharmacy team in managing and supporting children or young people and their carers.

The Child and Adolescent Mental Health Service

CAMHS usually provides coordinated care involving professionals in both primary and secondary care. There are four tiers within CAMHS, offering different areas of specialism^[5]
:

• 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 is provided by professionals working with 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 or 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 or nurse specialists (community or hospital based), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists;
• Tier 4: Tertiary-level services (e.g. day units, highly specialised outpatient teams and inpatient units). The availability of services will vary depending on locality but all children should be seen by a specialist with experience in child and adolescent mental health.

When to refer

Pharmacists, pharmacy teams and other healthcare professionals should refer any child or young person to tier 2 or 3 CAMHS when:

• They are at risk of self-harm or suicide (with active suicidal plans or ideas);
• There is unexplained self-neglect (e.g. poor personal hygiene or weight loss owing to restrictive eating) with a minimum duration of one month that could be harmful to their physical health;
• They have mild depression and:
  • Two or more risk factors for depression (e.g. family history of depression, alcohol or drug abuse, negative life events, other comorbidities etc);
  • One or more family member with multiple-risk histories for depression;
  • No improvement after four weeks of watchful waiting;
• They have moderate or severe depression (including psychotic depression);
• They have previously recovered from moderate or severe depression but begin to show signs of recurrence of depression;
• There is severe impairment of functioning at school or within the family and relationships.

Refer any child or young person to tier 4 CAMHS when:

• There is a high recurrent risk of acts of self-harm or suicide;
• There is significant ongoing self-neglect (e.g. poor personal hygiene or significant weight loss owing to restrictive eating that could be harmful to their physical health);
• They require a level of intensity of assessment or treatment and/or level of supervision that is not available in tier 2 or 3.

Diagnostic criteria, signs and symptoms

Depression is thought to involve both genetic and environmental factors^[6]
. Children or young people with parents or siblings who have depression are likely to be more susceptible to depression. Although there is no single factor that will lead to the onset of depression, there are factors that can act as potential triggers: comorbidities (e.g. anxiety or conduct disorder), alcohol and/or drug misuse, history of bullying or abuse, and recent negative life events (e.g. parental divorce or bereavement).

Chemical or organic causes of depression should also be ruled out and treated prior to diagnosis. For example, corticosteroids may cause or worsen depressive illness, and low levels of thyroid hormone may cause symptoms of depression. Further lists of psychiatric side effects of medicines are found in Maudsley Prescribing Guidelines^[7]
and Psychotropic Drug Directory^[8]
.

Depression is a broad diagnosis and different people may experience different symptoms. However, depressed mood and loss of pleasure in most activities are the main signs of depression. Depressive symptoms are frequently accompanied by symptoms of anxiety but may also occur on their own. The International Statistical Classification of Diseases (ICD-10) uses an agreed list of 10 depressive symptoms for the diagnosis of depression (see Box 1)^[9]
.

For a diagnosis of depression, symptoms should be present for at least two weeks and at least two key symptoms should be present for most of the day. ICD-10 divides depressive episodes into four categories:

• Not depressed (if there are fewer than four symptoms);
• A mild depressive episode (if there are four symptoms);
• A moderate-to-severe depressive episode (if there are five or six symptoms);
• A severe depressive episode (if there are seven or more symptoms, with or without psychosis).

It is important to consider that depression in children and young people may have a more insidious onset than in adults. Irritability may be more prominent than sadness and often occurs contemporarily with other behavioural disorders. It is crucial to record the signs and symptoms in detail and accurately in the clinical notes, as the symptoms may not all be present at the same time and may fluctuate in severity.

Treatment

The goal of treatment is to improve symptoms, prevent the illness from returning and help the child or young person reintegrate into regular life. Families play an important role in recognising the illness and supporting the individual through treatment.

Based on the severity of the depression, treatment should be tailored to meet the individual needs of the child or young person. If they exhibit severe symptoms or difficulties (e.g. having active suicidal thoughts or other risky behaviours), they may require medication and admission to hospital.

Psychotherapies

Psychotherapy, particularly cognitive behavioural therapy (CBT) and interpersonal therapy (IPT), is effective and generally recommended as first-line treatment for depression in children and young people^[5]
. 

Therefore, psychotherapy should be tried before considering other treatment options (e.g. medicines). However, this depends on the individual’s symptoms, and their personal circumstances and preferences.

Pharmacological treatments

Selective serotonin reuptake inhibitors (SSRIs) are indicated for moderate-to-severe depressive disorders in children and young people where effective psychological interventions are impractical or depression fails to respond to an adequate trial (at least three months) of psychotherapy. In practice, around 60% of young people with depression will have an adequate response to initial treatment with an SSRI^[10]
. Switching to another SSRI and/or adding CBT is beneficial for many who do not respond to the first SSRI. Antidepressant medicines should not be used for the initial treatment of children and young people with mild depression, should not be used as the sole intervention and should only be initiated after specialist consultation.

Both United States (US) and European authorities warn about the increased risk of suicidal thoughts and behaviour in patients aged under 18 years being treated with antidepressants. However, an increased risk of completed suicide has not been demonstrated^[11]
.

Nevertheless, the National Institute for Health and Care Excellence (NICE) suggests that prescribers should review treatment on a weekly basis, especially during the first four weeks of drug treatment.

Before starting treatment, informed consent must be sought from the child or young person and/or someone with parental responsibility for them. If the individual is aged over 16 years, they alone can give consent, if deemed competent (see Box 2).

SSRIs are the most widely prescribed type of antidepressants. They are believed to increase the extracellular serotonin concentration by inhibiting its reabsorption into the presynaptic cell. This causes an increase in serotonin availability at the synaptic cleft to bind to the postsynaptic receptors. SSRIs have weak but varying degrees of affinity for the noradrenaline and dopamine transporters, which is why some people may respond to one SSRI and not another.

SSRIs are generally well tolerated but they are not free from side effects. The most common side effects (e.g. nausea, diarrhoea, insomnia and increased agitation) are usually transient and self-limiting, disappearing after a few days or weeks. It is important that the child or young person and their carers are informed about this and told not to stop the medication abruptly. Furthermore, they should be informed about the possibility of more serious adverse effects (e.g. suicidal ideation, gastrointestinal bleeding and serotonin syndrome^[12]
) and be advised to seek medical attention immediately if these complications are suspected.

If a child or young person is responding to an antidepressant, treatment should be continued for at least six months after remission, where remission is defined as no symptoms and full functioning for at least eight weeks^[5]
.

The use of antidepressants in the management of conditions other than depression is outside the remit of this article. For further advice, pharmacists and healthcare professionals should refer to specialist reference sources and their local mental health pharmacy team.

Fluoxetine

This is the only antidepressant licensed for the treatment of depression in children aged over 8 years, and evidence suggests that the benefits outweigh the risks in this population^[5],[13]
. The starting dose should be 10mg daily; this can be increased to 20mg daily after one week if clinically necessary^[14]
. There is little evidence regarding the effectiveness of doses of fluoxetine higher than 20mg daily, but higher doses may be considered in older children of higher body weight or when the illness is severe^[5]
.

Fluoxetine is available as capsules, tablets, oral solution and dispersible tablets^[14]
. The choice of formulation should be made on an individual basis taking into account the child or young person’s preference, the practicalities of administration, and the cost. For example, some young people are unable to take medicines in solid oral dosage forms because they have swallowing difficulties or feeding tubes. In these circumstances, the use of an oral solution or dispersible tablet may be more appropriate.

Fluoxetine can be offered in combination with psychological therapy^[5]
. However, before doing this, several considerations should be made (see Box 3).

Sertraline and citalopram

If treatment with fluoxetine is unsuccessful or is not tolerated because of adverse effects, sertraline and citalopram are recommended as second-line treatments^[5]
(off-licensed use for the treatment of depression in anyone aged under 18 years). These should only be used when the following criteria have been met^[5]
:

• The potential benefits and risks of the new treatment have been documented and discussed with the child or young person and their carers;
• The child or young person’s depression is severe and/or causing serious symptoms (e.g. weight loss or suicidal behaviour) to justify a trial of another antidepressant;
• There has been a fair trial of the combination of fluoxetine and a psychological therapy, and all efforts have been made to ensure adherence to the recommended treatment regimen;
• The likely causes of the depression and of treatment resistance have been reassessed (e.g. other diagnoses such as bipolar disorder or substance misuse);
• Appropriate and up-to-date written information has been provided. This should cover the rationale for the drug treatment, the delay in onset of effect, the anticipated duration of treatment, the possible adverse effects, and the need to take medicines as prescribed.

There is little evidence regarding the effectiveness of high doses for children and young people, but these may be considered in older children of higher body weight or when the illness is severe.

Paroxetine and venlafaxine

Evidence available suggests that both paroxetine (SSRI) and venlafaxine have little impact on response to treatment, symptom levels, functional status, or clinical improvement in children and young people with depression^[5],[15]
. Therefore, these medicines should not be used in patients aged under 18 years.

Tricyclic antidepressants

There is limited evidence to support the use of tricyclic antidepressants (TCAs) in the treatment of depression in children and young people. Owing to their propensity to cause side effects and toxicity in overdose^[16]
, it is recommended that TCAs should not be used for the treatment of depression in this patient group^[5]
.

Electroconvulsive therapy

This should only be considered for young people (aged 12–18 years) with very severe depression and either life-threatening symptoms or intractable and severe symptoms that have not responded to other treatments^[13]
. NICE does not recommend electroconvulsive therapy for the treatment of depression in children aged under 11 years^[5]
.

The role of the pharmacy team

A study has shown that around 50% of patients prematurely discontinued their antidepressant therapy within six months of initiation^[17]
. Children, young people, and their parents and carers may have concerns that these medicines are addictive and have been linked with suicidal thoughts and behaviour, which may be a reason for the non-adherence to the prescribed medicine.

As experts in pharmacotherapy, pharmacists provide specialised skills and knowledge to other healthcare professionals within a multidisciplinary team, and contribute towards the improvement of patient outcomes by detecting and resolving or preventing drug-related interventions. In addition, pharmacists and pharmacy technicians play a vital role in supporting young people and their families in taking antidepressants, helping them to understand the benefits of taking the medicine, which subsequently improves medicine adherence. If the child or young person has achieved full remission, treatment should be reviewed and discussed between the multidisciplinary team, the child and their carers. If appropriate, support should be provided when weaning off the antidepressant, and the individual should be encouraged to discuss any discontinuation symptoms or any recurring depression symptoms.

Children or young people and their carers should also be reassured that antidepressants are safe and effective when they are monitored appropriately, particularly at the beginning of the treatment or if the dose has changed. In patients with moderate or severe depression, medicines can play an important part in managing this disabling condition.

Furthermore, pharmacists are in a unique position to assist in opportunistic screening for depression in the community setting as they are easily accessible to the public. Previous research has concluded that trained pharmacists may be equipped with the skills and knowledge to assist in the identification and support of people with a mental illness such as depression^{[18],[19],[20]}
. Depression screening (e.g. the Patient Health Questionnaire or the WHO-5 Well-being Index)^{[21],[22],[23]}
and risk assessment have the potential to increase early identification of the signs and symptoms of depression, and prompt a referral to the appropriate healthcare professional if necessary.

Conclusion

Depression is a common mental health disorder that all healthcare professionals will come into contact with. Therefore, pharmacists and healthcare professionals, especially those in primary care, should be able to detect the symptoms of depression, assess children and young people who may be at risk, and refer them to a specialist (i.e. CAMHS) if appropriate.

Mild depression is best treated with psychotherapies, while moderate or severe forms may require pharmacological treatments. Antidepressants are used for a variety of disorders, but only fluoxetine is currently licensed in the UK for treatment of moderate-to-severe depressive disorder in children and adolescents aged 8 years and older. Pharmacological treatment may be considered when patients are unresponsive to psychological therapy after 4–6 sessions, and only in combination with a concurrent psychological therapy.

Pharmacists and pharmacy technicians have an important role in engaging with patients, supporting their treatment, and assessing and promoting the importance of medicine adherence. Parents or carers should also be supported and encouraged to get involved in the child or young person’s medicine administration process. This is essential in achieving remission, restoring previous levels of functioning and preventing reoccurrence of depression.