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NICE guidelines on depression in children and young people: not always following the evidence

  • Matthew Hodes (a1) and Elena Garralda (a2)
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Asarnow, J. R., Jaycox, L. H., Laborde, A. P., et al (2005) Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA, 293, 311319.
Brent, D., Holder, D., Kolko, D., et al (1997) A clinical psychotherapy trial for adolescent depression comparing cognitive, family and supportive therapy. Archives of General Psychiatry, 54, 877885.
Brent, D. A., Kolko, D. J., Birmaher, B., et al (2002) A clinical trial for adolescent depression: predictors of additional treatment in the acute and follow-up phases of the trial. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 263270.
Bridge, J. A., Iyengar, S., Salary, C. B., et al (2007) Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatments. A meta-analysis of randomized controlled trials. JAMA, 297, 16831696.
Dubicka, B., Hadley, S. & Roberts, C. (2006) Suicidal behaviour in youths with depression treated with new-generation antidepressants. Meta-analysis. British Journal of Psychiatry, 189, 393398.
Emslie, G., Heiligenstein, J. H., Wagner, K. D., et al (2002) Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 12051215.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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NICE guidelines on depression in children and young people: not always following the evidence

  • Matthew Hodes (a1) and Elena Garralda (a2)
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eLetters

Perplexed trainees - what do you follow: the NICE guidelines or Clinical wisdom?

vinuthna pemmaraju, SpR Child Adolescent Psychiatry
07 January 2008

We certainly agree with authors M Hodes and E Garralda ( Psych Bulletin 2007,31,361-362) who observe that there are flaws in the NICE guidelines and a lack of available evidence for the treatment of Depression in Children and Young people. During Basic training in psychiatry, a trainee is encouraged to follow the NICE guidelines, Maudsley guidelines and others when initiating any intervention.

The same principle applies to the speciality of Child and Adolescent Psychiatry. However, as a trainee in this speciality we have noticed that there are different factors that contribute to the use of pharmacological interventions.As the authors mention, these trials demonstrated the benefit of Fluoxetine over and above that of CBT. This is supported by the TADS studyand by the ADAPT trial. Another concern is the low availability of CBT for moderate to severely depressed adolescents as a first line treatment. Consider the teenager presenting in crisis, after an intentional overdose, or serious deliberateself harm, following traumatic life events and family disruption. Thought must be given to the family’s ability, resources and motivation to supportthe young person through CBT.It is clear that the authors are not advocating indiscriminate prescribingof antidepressant medications, but it also seems that the NICE guidelines for depression do not fully appraise the ‘real world ‘situation with respect to resources, and patient choice. We trust that NICE recognises this and plans a timely review of its recommendations. We continue to exercise our clinical acumen and review the available evidence when treating the young people that we see.

Vinuthna PemmarajuMBBS, MRCPsych, DRCOGOaklands Centre, Raddlebarn Road, Selly Oak, Birmingham, B17 0RNCorresponding author – Vinuthna@doctors.org.uk

Sasha HvidstenMBChB MRCPCH MRCPsychElms Centre, Slade Road, Halesowen, West Midlands, B63 2UR

1. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, BurnsB, Domino M, McNulty S, Vitiello B, Severe J:Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatmentfor Adolescents With Depression Study (TADS) Team. JAMA 2004; 292:807–820

2.Early Onset of Selective Serotonin Reuptake Inhibitor Antidepressant Action. Systematic Review and Meta-analysis Matthew J. Taylor, MRCPsych; Nick Freemantle, PhD; John R. Geddes, MD; Zubin Bhagwagar, DPhil Arch Gen Psychiatry. 2006;63:1217-1223.

3.Child and Adolescent Mental Health Volume 12, No2, 2007, pp 70-72 A survey of anti-depressant prescribing practice and the provision of psychological therapies in a south London CAMHS from 2003-2006. Alfred Perera, Priya Gupta, Rani Samuel, Birgit Berg

4.A Developmental Perspective on the Controversy Surrounding the Useof SSRIs to Treat Pediatric Depression James F. Leckman, M.D., and Robert A. King, M.D. Am J Psychiatry 164:1304-1306, September 2007
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Conflict of interest: None Declared

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Alternatives before ECT in adolescent depression

Kate S Robertson, staff grade psychiatrist
18 October 2007

Further to Garralda and Hodes’ useful review of the NICE guidelines on depression in children and young people, we would like to draw attention to two other areas of concern. Firstly, much of the evidence cited in the guidelines regarding the usefulness or otherwise of antidepressant medication does not differentiate between children and adolescents despite an increasing body of publications emphasising that incidence, presentation and responses to treatment differ in pre- and post- pubertal young people (ONS 1999, Dubicka and Goodyear 2005). Again, the vexed issue of transition between child and adolescent and general adult services raises its ugly head: at what point does a post pubertal young person become an ‘adult’ for the purposes of following guidelines to treatment?

Secondly, in the trial with the best response rates for combination therapy of major depressive disorder (SSRI and CBT in 12- 17 year olds, TADS 2004), the response rate was 71%; whilst this is an excellent result,it still implies that 29% of subjects did not respond. The NICE guideline recommends, in the case of young people with very severe depression, ‘intractable and severe symptoms that have not responded to other treatments… including at least two or more trials of appropriate psychopharmacology’ that ECT is to be considered a valid option. ECT was not mentioned in the editorial; is this due to the paucity of experience of most child and adolescent psychiatrists in the use of ECT in the younger age group (Rey and Walter 1997)? The only pharmacological treatments cited in the Clinical Practice Recommendations of the NICE guidelines are SSRIs, and the use of venlaflaxine is specifically not recommended; lithium and mirtazapine (recommended in the Adult guidelines in the treatment of refractory depression, and well reported augmentation strategies in adolescents (Hughes et al 1999) ) are not mentioned. This leaves open the possibility, we hope entirely theoretical, that the guidelines under discussion could be interpreted as recommending a jump toECT without trial of augmentation strategies that are well recognised in adults, and/or currently subject to trials in the adolescent age group (egvenlaflaxine, TORDIA). As CAMHS services have varying cut-offs, from 16 years of age up, this may result in young people being denied potentially useful treatment by general adult services less comfortable than their CAMHS counterparts with the concept of off label prescribing for the young.

Authors: Dr Kate Robertson (corresponding author)Dr Sunkanmi E Osunsanmi

Staff Grade PsychiatristsHuntercombe Hospital- StaffordIvetsey BankWheaton AstonStaffordshire ST19 9QTTel 01785 840000fax 01785 842192

No competing interests

References:Hodes M, Garralda E: NICE guidelines on depression in children and young people: not always following the evidence; Psychiatric Bulletin (2007) 31:361-362.

Treatment for Adolescents with Depression Study (TADS) Team, March J et al: Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination forAdolescents with Depression; JAMA, August 18, 2004- vol 292, No.7

Dubicka & Goodyer Should we prescribe antidepressants to children? Psychiatric Bulletin (2005), 29, 164-167

Hughes C W, Emslie G J, Crimson M L et al. The Texas Children’s Algorithm Project: report of the consensus conference panel on medication treatment of childhood major depressive disorder. Journal of American Academy of Child and Adolescent Psychiatry 1999; 38: 1442-54.

Rey JM, Walter G. Half a Century of ECT Use in Young People: AmericanJournal of Psychiatry; 154: 595-602
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Conflict of interest: None Declared

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