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NATIONAL INSTITUTE FOR HEALTH AND CARE
EXCELLENCE
Health and social care directorate
Quality standards and indicators
Briefing paper
Quality standard topic: Depression in children and young people
Output: Prioritised quality improvement areas for development.
Date of Quality Standards Advisory Committee meeting: 8 January 2013
Contents
1 Introduction .......................................................................................................... 2 2 Overview .............................................................................................................. 3 3 Summary of suggestions ..................................................................................... 6 4 Suggested improvement area: Early recognition ................................................. 9 5 Suggested improvement area: Assessment and diagnosis ............................... 11 6 Suggested improvement area: Decision making................................................ 13 7 Suggested improvement area: Access to services ............................................ 14 8 Suggested improvement area: Nutrition ............................................................ 18 9 Suggested improvement area: Psychological therapies .................................... 19 10 Suggested improvement area: Anti-depressants............................................ 20 11 Suggested improvement area: Routine outcome measurement ..................... 22 12 Suggested improvement area: Inappropriate admissions............................... 23 13 Suggested improvement area: Transition to adult services ............................ 25 Appendix 1 Key priorities for implementation recommendations (CG28) ............. 27 Appendix 2 Suggestions from stakeholder engagement exercise ........................ 29
1 Introduction
This briefing paper presents a structured overview of potential quality improvement areas for a NICE quality standard on depression in children and young people. It provides the Committee with a basis for discussion and prioritising quality improvement areas for developing quality statements and measures, which will be drafted for public consultation.
Structure
This includes a brief overview of the topic followed by a summary of each of the suggested quality improvement areas followed with supporting information.
Where relevant, guideline recommendations selected from the key development source below are presented to aid the Committee when considering specific aspects for which statements and measures should be considered.
Development source
Unless otherwise stated, the key development source referenced in this briefing paper as follows:
Depression in children and young people. NICE clinical guideline 28 (2005).
The guideline was reviewed in 2011, and the decision made not to update at that time. Several ongoing clinical trials (publication dates unknown) were identified focusing on antidepressant treatment and efficacy of psychological therapies for depression in children and young people. The results of these trials may contribute towards the evidence base relating to management of depression in children and young people in the next update review (next review date: September 2013).
Where relevant, guideline recommendations from the key development source are presented alongside each of the suggested areas for quality improvement within the main body of the report.
2.4 Management
Support is provided by four tiers of service following national frameworks in place since 1995 for the delivery of mental health services for children and young people (table one). These tiers provide a framework in which to organise the provision of services that supports people to identify and access the most effective interventions.
A stepped care model outlined in CG28 details the detection, recognition and management of depression in children and young people and prescribes responsibility for each tier (table two).
Children and young people at risk of or with recognised with depression do not automatically get referred to CAMHS services, and instead can be treated at Tier 1. This commonly includes milder cases of depression or those with fewer risk factors for depression.
See appendix 1 for key priority for implementation recommendations from CG 28.
Tiers of service (Table one):
Tier Service
1 Services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services. Universal services in the community (not mental health specialists).
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. Mental health professionals delivering CAMHS services in primary care or a community mental health setting.
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. Specialised mental health professionals delivering CAMHS services in a community mental health setting or specialist outpatient setting.
4 CAMHS services at a tertiary-level such as day units, highly specialised outpatient teams and inpatient units. Specialised mental health professionals (same as Tier 3) delivering CAMHS services in a specialist setting.
Stepped care model (Table two):
Step Action Responsible
1 Detection Risk profiling Tier 1
2 Recognition Identification in presenting children or young people
Tier 1 to 4
3 Management of mild depression
Watchful waiting Non-directive supportive therapy / group CBT / guided self-help
Tier 1 Tier 1 or 2
4 Management of moderate to severe depression
Brief psychological therapy +/- pharmacological therapy (fluoxetine)
Tier 2 or 3
5 Depression unresponsive to treatment / recurrent / psychotic depression
Intensive psychological therapy +/- pharmacological therapy and augmentation with antipsychotic
Tier 3 or 4
2.5 National Outcome Frameworks
The table below shows the indicators from the frameworks that the quality standard could contribute to:
NHS Outcomes
Framework
Domain 4: Ensuring people have a positive experience of care.
4.7 Improving children and young peoples experience of healthcare
Suggested area for improvement Stakeholder
Nutrition Stakeholder suggests children and young people with depression should be offered advice about nutrition.
RDS
Psychological therapies Two stakeholders call for changes to the range of psychological therapies recommended by the guideline. They quote evidence for the use of individual CBT, IPT and family therapy at all levels of depression irrespective of the ‘tier’ at which it is recognised. Stakeholders have submitted examples from IAPT services data suggesting the use of a wider range of therapies than recommended in CG28.
AFT BPS
Anti-depressants Stakeholder suggests there is variation in under- and over-use and on newer evidence showing anti-depressants to be safer and more effective than originally found in CG28. However no evidence has been presented. Stakeholder suggests nurse prescribers may be better placed than psychiatrists to decide on anti-depressant usage. Specialist Committee member suggests anti-depressants are being prescribed more readily than recommended by NICE CG28, without adequate monitoring or adjunct psychological therapy.
BPS RSM SCM SSS
Routine outcome measurement Stakeholder suggests that if services aim to offer effective treatment then routine outcome measurement should be used to monitor effectiveness of services.
BPS
Inappropriate admissions Stakeholder suggests that current measures of inappropriate admissions to adult wards could be extended to examine other locations that are inappropriate.
RCGP
Transition to adult services Specialist committee member reports the increased risks for young people transitioning to adult services. Eligibility criteria can differ, leading to young people falling into a ‘black hole’ upon turning 19 years old.
SCM
Table 2 Stakeholder details (abbreviations)
The details of stakeholder organisations who submitted suggestions are provided in the table below.
Abbreviation Full name AFT Association for family therapy and systemic practice ASCL Association of school and college leaders BACP British association for counselling and psychotherapy BMA British Medical Association BPS British Psychological Society Break Break ES Epilepsy Society
LGBTP National LBGT Partnership LGF The Lesbian and Gay Foundation RCGP Royal College of General Practitioners RCN Royal College of Nursing RDS Rotheram, Doncaster and S Humber NHS Trust RSM Royal Society of Medicine SCM Specialist Committee Member SSS South Staffordshire & Shropshire Healthcare NHS Foundation Trust YM Young Minds
associated with the event and make contact with their parent(s) or carer(s) to help integrate parental/carer and professional responses. The risk profile should be recorded in the child or young person's records.
4.3 Current UK practice
The Department of Health commissioned an independent review in 2006, of national CAMHS progress^3. The report concluded that professionals in universal services (including primary care and school nursing services) need a better understanding of their role in the promotion, prevention and early intervention in psychological well- being of children and young people.
A Royal College of Psychiatry peer review into the quality of community CAMHS^4 reported 84% of teams now provide training and advice to primary healthcare services.
A cross-sectional study of 258 UK school nurses in 2008^5 , aimed to measure the attitudes of nurses towards mental heath work and the need for greater training. Nearly half of the respondents had not received any post-registration training in mental health, yet 93% agreed it was important to their job. Being better equipped to recognise depression was considered a key topic for development programmes.
(^3) Department of Health (2006) Children and young people in mind: the final report of the National CAMHS Review 4 Royal College of Psychiatry (2011) Quality Network for Community CAMHS, cycle 6. Self-reported assessment of 67 CAMHS teams and peer-reviewed assessment of 32 teams. 5 Haddad (2010) School nurses’ involvement, attitudes and training needs for mental health work. Journal of Advanced Nursing.
5 Suggested improvement area: Assessment and
diagnosis
5.1 Summary of suggestions
Stakeholders suggest that as recommended in CG28, children and young people should have a comprehensive assessment of biological, psychological and social factors. Only through this full assessment can the causes and factors related to depression be fully understood.
Stakeholders also suggest that more training is needed in CAMHS on using scales and instruments to diagnose depressive conditions.
5.2 Selected recommendations from development source
Assessment
NICE CG28 Recommendation 1.1.3.1 (KPI)
When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient's notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers.
NICE CG28 Recommendation 1.1.3.
In the assessment of a child or young person with depression, healthcare professionals should always ask the patient and their parent(s) or carer(s) directly about the child or young person's alcohol and drug use, any experience of being bullied or abused, self-harm and ideas about suicide. A young person should be offered the opportunity to discuss these issues initially in private.
Diagnosis
NICE CG28 Recommendation 1.4.
Children and young people of 11 years or older referred to CAMHS without a diagnosis of depression should be routinely screened with a self-report questionnaire for depression (of which the Mood and Feelings Questionnaire [MFQ] is currently the best) as part of a general assessment procedure.
NICE CG28 Recommendation 1.4.2 (KPI)
Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer-based
6 Suggested improvement area: Decision making
6.1 Summary of suggestions
Stakeholders suggest that if treatment is to be effective, service users, their family and carers should be involved in decision making and treatment decisions. However this should account for age and capacity considerations.
6.2 Selected recommendations from development source
NICE CG28 Recommendation 1.1.1.
Healthcare professionals should make all efforts necessary to engage the child or young person and their parent(s) or carer(s) in treatment decisions, taking full account of patient and parental/carer expectations, so that the patient and their parent(s) or carer(s) can give meaningful and properly informed consent before treatment is initiated.
6.3 Current UK practice
No published reports relating to current practice were highlighted by stakeholders for this quality improvement area; this area is based on stakeholder’s knowledge and experience.
A Royal College of Psychiatry peer review into the quality of community CAMHS^7 reported 100% of services actively sought the views of parents and carers during assessments. However, only 63% of teams are ensuring that young people have written plans for intervention and 32% of services do not give young people and their parents copies of any written plans for intervention or allow ready access to them. Only in 54% of services are young people and their parents/carers provided with information about the evidence base, risks, benefits and side effects of intervention options and of non-intervention. Only 61% of services gain consent sought for each proposed treatment or intervention, and documented this in health records.
(^7) Royal College of Psychiatry (2011) Quality Network for Community CAMHS, cycle 6.
7 Suggested improvement area: Access to services
7.1 Summary of suggestions
Stakeholders suggest that timeliness of response from CAMHS and access to services providing NICE recommended psychological therapies should be improved.
Multiple stakeholders report that IAPT services for children and young people are not yet available nationally.
Specialist Committee member reports large discrepancy across the country in the provision of psychological therapies.
7.2 Selected recommendations from development source
Access to CAMHS
NICE CG28 Recommendation 1.1.4.
CAMHS and primary care trusts (PCTs) should consider introducing a primary mental health worker (or CAMHS link worker) (see glossary) into each secondary school and secondary pupil referral unit as part of tier 2 provision within the locality.
NICE CG28 Recommendation 1.1.4.
Primary mental health workers (or CAMHS link workers) should establish clear lines of communication between CAMHS and tier 1 or 2, with named contact people in each tier or service, and develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2.
NICE CG28 Recommendation 1.1.4.
CAMHS and PCTs should routinely monitor the rates of detection, referral and treatment of children and young people, from all ethnic groups, with mental health problems, including those with depression, in local schools and primary care. This information should be used for planning services and made available for local, regional and national comparison.
NICE CG28 Recommendation 1.3.2.
For children and young people, the following factors should be used by healthcare professionals as indications that management can remain at tier 1:
exposure to a single undesirable event in the absence of other risk factors for depression exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm
7.3 Current UK practice
Access to CAMHS
A Department of Health review of national CAMHS progress (2006)^8 reported some specific improvements in local CAMHS provision between 2005 and 2007. This included some decreases in waiting lists size, waiting times, an increase in 24/ support and an increase in alternatives to inpatient care in Tier 4. However it concluded that children and young people are still waiting too long to access services. The review found barriers remain preventing people from working together to deliver care. Schools, social care and primary healthcare reported insufficient access to CAMHS specialists.
Young Minds Children and Young People Manifesto for Change highlights the importance of accessing CAMHS easily. The manifesto uses an example of Joe, 18, waiting 12 weeks to access CAMHS, which was then located in a distant part of London.
A Royal College of Psychiatry peer review into the quality of community CAMHS^9 reported 33% of CAMHS services don’t have documented, up-to-date procedures and response times agreed with other agencies for specialist referrals. However for those offered an appointment, 85% of services are able to provide easy and prompt contact. Average waiting time for assessment was reported as 11 days (range 1 to 98 days), with average waiting time for treatment (from point of referral) reported as 13 days (range 1 to 52 days).
The Wales Audit Office however, reported in 2009^10 that waiting times for specialist CAMHS services varied between 19 weeks and 41 weeks.
Access to psychological therapies
Stakeholders have highlighted reports outlining historical under-provision of service and evidence based therapies for children and young people with mental health problems. Mind highlighted in 2005^11 , that staffing levels in CAMHS were approximately 33% of that recommended by the National Service Framework. One report by the Mental Health Policy Group of the London School of Economics^12 claims that in 2010, 78% of GPs in an ad hoc survey were rarely able to access specialist psychological therapy within two months.
(^8) Department of Health (2006) Children and young people in mind: the final report of the National CAMHS Review 9
10 Royal College of Psychiatry (2011) Quality Network for Community CAMHS, cycle 6. Wales Audit Office (2009) Services for children and young people with emotional and mental health needs 11
12 Mind (2005)^ We need to talk: getting the right therapy at the right time. London School of Economics (2012) How mental illness loses out in the NHS.
More recent data is highlighted by stakeholders available in the resources from the Children’s and Young People’s project in the Improving Access to Psychological Therapies programme (CYP IAPT) www.iapt.nhs.uk/cyp-iapt/.
In 2011, the existing adult IAPT programme added a new project working to support children and young people to access evidence based treatments and approaches. Different to the adult programme, CYP IAPT is not creating new standalone services. It works with existing CAMHS services to focus on extending training and embedding evidence based practice.
In 2012-13 there will be five Learning Collaboratives covering multiple CAMHS partnerships, which will be funded to provide the training programme:
Learning Collaborative CAMHS Partnerships
Oxford and Reading
Ox and Bucks Wilts, Bath and NE Somerset Gloucestershire Swindon
Bournemouth, Dorset and Poole Berkshire Kensington and Chelsea Bedfordshire Luton
London and South East
Lambeth & Southwark Hertfordshire Sussex Westminster Haringey Cambridge Wandsworth Greenwich
Waltham Forest Tower Hamlets Hackney Islington Camden Bromley Croydon Richmond
Salford
Derby Manchester and Salford Pennine North Pennine South
Barnsley Central Lancashire North Lancashire Bolton
North East, Yorkshire and Humber
Tees County Durham North Yorkshire
Darlington Rotherham Doncaster North Lincolnshire
South West Devon Plymouth
Torbay
By the end of 2013, services covering 34% of the population aged 0–19 years will have been through the CYP IAPT service transformation process^13.
(^13) Department of Health (2012) IAPT three year report: the first million patients.
9 Suggested improvement area: Psychological
therapies
9.1 Summary of suggestions
Stakeholders called for changes to the range of psychological therapies recommended by the guideline. They quote primary evidence sources, published since the review decision for CG28, on the use of individual cognitive behavioural therapy, interpersonal therapy and family therapy at all levels of depression irrespective of the ‘tier’ at which it is recognised.
9.2 Selected recommendations from development source
A review decision was made in 2011 that the guideline would not be updated. No new published evidence on effectiveness of psychological treatments was presented.
NICE CG28 Recommendation 1.5.2.
Following a period of up to 4 weeks of watchful waiting, all children and young people with continuing mild depression and without significant comorbid problems or signs of suicidal ideation should be offered individual non-directive supportive therapy, group CBT or guided self-help for a limited period (approximately 2 to 3 months). This could be provided by appropriately trained professionals in primary care, schools, social services and the voluntary sector or in tier 2 CAMHS.
NICE CG28 Recommendation 1.6.1.2 (KPI)
Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual cognitive behavioural therapy [CBT], interpersonal therapy or shorter-term family therapy); it is suggested that this should be of at least 3 months' duration.
9.3 Current UK practice
Stakeholders have highlighted the resources available from the Children’s and Young People’s project in the Improving Access to Psychological Therapies programme (CYP IAPT) www.iapt.nhs.uk/cyp-iapt/.
Year One of the programme (2011-12) delivered training in cognitive behavioural therapy and parenting for 3-10 year olds.
Year Two of the programme (2012-13) will also deliver training in Systemic Family Therapy and Interpersonal therapy.
10 Suggested improvement area: Anti-depressants
10.1 Summary of suggestions
Stakeholder suggests there is variation in under- and over-use of anti-depressants and newer primary evidence showing anti-depressants to be safer and more effective than originally found in CG28.
Stakeholder suggests nurse prescribers may be better placed than psychiatrists to decide on anti-depressant usage.
Specialist Committee member suggests anti-depressants are being prescribed more readily than recommended by NICE CG28, without adequate monitoring or adjunct psychological therapy.
10.2 Selected recommendations from development source
A review decision was made in 2011 that the guideline would not be updated. No new published evidence on effectiveness of pharmacological treatment was presented.
NICE CG28 Recommendation 1.5.2.3 (KPI)
Antidepressant medication should not be used for the initial treatment of children and young people with mild depression.
NICE CG28 Recommendation 1.6.2.
Following multidisciplinary review, if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after four to six sessions, fluoxetine should be offered.
NICE CG28 Recommendation 1.6.2.
Following multidisciplinary review, if moderate to severe depression in a child (5– 11 years) is unresponsive to a specific psychological therapy after four to six sessions, the addition of fluoxetine should be cautiously considered, although the evidence for its effectiveness in this age group is not established.
NICE CG28 Recommendation 1.6.4.1 (KPI)
Antidepressant medication should not be offered 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 parent(s) or
