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NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/depressionNICE Pathway last updated: 24 April 2018

This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.

DepressionDepression© NICE 2018. All rights reserved. Subject to Notice of rights.

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1 Child or young person at risk of depression

No additional information

2 Recognition, detection, risk profiling and referral in tier 1

No additional information

3 Child or young person has acute sadness and distress ('situationaldysphoria')

Consider ongoing social and environmental factors if dysphoria becomes more persistent.

4 Child or young person exposed to a single recent undesirable lifeevent

Examples of a single recent undesirable life event include bereavement, parental divorce or

separation, or a severely disappointing experience.

5 Assessment of risk of depression

Assess the risks of depression associated with the event.

Make contact with parent(s)/carer(s) to help integrate parental/carer and professional

responses.

Record the risk profile.

6 No other risk factors for depression

If there are no other risk factors for depression:

offer support and the opportunity to talk over the event

do not normally refer for further assessment or treatment following an undesirable event.


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7 High risk of depression and/or family history

If high risk of depression is identified (the presence of two or more other risk factors) and/or

where one or more family members (parents or children) have multiple-risk histories:

offer the opportunity to talk over recent negative experiences with a tier 1 professional

assess for depression

consider early referral if there is evidence of depression and/or self-harm.

Also see assessment and treatment considerations.

8 Tier 1 and referral to tiers 2, 3 or 4 CAMHS

Criteria for management to remain at tier 1

Management can remain at tier 1 if one or more of the following factors exist:

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 factorswith no evidence of depression and/or self-harm

exposure to a recent undesirable life event where one or more family members (parents orchildren) have multiple-risk histories for depression, providing that there is no evidence ofdepression and/or self-harm in the child/young person

mild depression without comorbidity.

Referral to tier 2 or tier 3

Refer to tier 2 or tier 3 CAMHS if one or more of the following factors exist:

depression with two or more other risk factors for depression

depression where one or more family members (parents or children) have multiple-riskhistories for depression

mild depression in those who have not responded to interventions in tier 1 after 2–3 months

moderate or severe depression (including psychotic depression)

signs of a recurrence of depression in those who have recovered from previous moderateor severe depression

unexplained self-neglect of at least 1 month's duration that could be harmful to the child/young person's physical health


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active suicidal ideas or plans

young person or parent(s)/carer(s) request referral.

Referral to tier 4

Refer to tier 4 CAMHS if one or more of the following factors exist:

high recurrent risk of acts of self-harm or suicide

significant ongoing self-neglect (such as poor personal hygiene or significant reduction ineating that could be harmful to physical health)

requirement for intensity of assessment/treatment and/or level of supervision that is notavailable in tier 2 or 3.

Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

Depression in children and young people

3. Suspected severe depression and at high risk of suicide

4. Suspected severe depression without high risk of suicide

9 Management of mild depression – tiers 1 and 2

See Depression / Management of mild depression in children and young people – tiers 1 and 2

10 Management of moderate to severe (including psychotic) depression– tiers 2–4

See Depression / Management of moderate to severe (including psychotic) depression inchildren and young people – tiers 2–4

11 Recognition in tiers 2–4

If a child or young person aged 11 years or older is referred to CAMHS without a diagnosis of

depression, routinely screen with a self-report questionnaire for depression as part of general

assessment.


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http://pathways.nice.org.uk/pathways/depression/management-of-moderate-to-severe-including-psychotic-depression-in-children-and-young-people-tiers-24


Glossary

CAMHS

child and adolescent mental health services

CAPA

child and adolescent psychiatric assessment

CBT

cognitive behavioural therapy

CCBT

computerised cognitive behavioural therapy

DSM-IV

diagnostic and Statistical Manual of Mental Disorders

ECT

electroconvulsive therapy

HoNOSCA

Health of the Nation Outcome Scales for Children and Adolescents

ICD-10

International Statistical Classification of Diseases and Related Health Problems (tenth edition)

IPT

interpersonal therapy

K-SADS

schedule for affective disorders and schizophrenia for school-age children


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MAOI

monoamine oxidase inhibitor

MFQ

mood and feelings questionnaire

Mild depression

few, if any, symptoms of depression in excess of the 5 required to make the diagnosis, and

symptoms result in only minor functional impairment, according to DSM-IV

Moderate depression

symptoms of depression or functional impairment are between mild and severe

NSAID

non-steroidal anti-inflammatory drug

SDQ

strengths and difficulties questionnaire

Severe depression

most symptoms of depression according to DSM-IV, and the symptoms markedly interfere with

functioning. Can occur with or without psychotic symptoms

SSRI

selective serotonin reuptake inhibitor

Subthreshold depressive symptoms

fewer than 5 symptoms according to DSM-IV

TCA

tricyclic antidepressant


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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

child and adolescent mental health services 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

Tier 3

specialised child and adolescent mental health 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 child and adolescent mental health services such as day units, highly specialised

outpatient teams and inpatient units

Sources

Depression in children and young people: identification and management (2005 updated 2017)

NICE guideline CG28

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful

consideration of the evidence available. When exercising their judgement, professionals and

practitioners are expected to take this guideline fully into account, alongside the individual


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http://www.nice.org.uk/guidance/CG28


needs, preferences and values of their patients or the people using their service. It is not

mandatory to apply the recommendations, and the guideline does not override the responsibility

to make decisions appropriate to the circumstances of the individual, in consultation with them

and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline

to be applied when individual professionals and people using services wish to use it. They

should do so in the context of local and national priorities for funding and developing services,

and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to

advance equality of opportunity and to reduce health inequalities. Nothing in this guideline

should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of

implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, health

professionals are expected to take these recommendations fully into account, alongside the

individual needs, preferences and values of their patients. The application of the

recommendations in this interactive flowchart is at the discretion of health professionals and

their individual patients and do not override the responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable

the recommendations to be applied when individual health professionals and their patients wish

to use it, in accordance with the NHS Constitution. They should do so in light of their duties to

have due regard to the need to eliminate unlawful discrimination, to advance equality of

opportunity and to reduce health inequalities.





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https://www.nice.org.uk/about/who-we-are/sustainability





Medical technologies guidance, diagnostics guidance and interventional proceduresguidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, healthcare

professionals are expected to take these recommendations fully into account. However, the

interactive flowchart does not override the individual responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful

discrimination, advance equality of opportunity, and foster good relations. Nothing in this

interactive flowchart should be interpreted in a way that would be inconsistent with compliance

with those duties.





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