Psychological therapy must accompany antidepressants in young people
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7519.714-b (Published 29 September 2005) Cite this as: BMJ 2005;331:714Data supplement
Antidepressants must be used with psychological therapy in young people
London
Susan Mayor
Antidepressants should be considered for treating children or young people with moderate to severe depression only in combination with concurrent psychological therapy and with careful monitoring for side effects, and they should not be used at all in children with mild depression. These are among the recommendations of a clinical guideline published this week for the NHS in England and Wales.
"The guideline makes it clear that medication is not the first line treatment for children and young people with depression. Antidepressants should only be considered when psychological treatments are not working, and should only be used in combination with a psychological treatment," explained David Cottrell, professor of child and adolescent psychiatry at the University of Leeds.
Professor Cottrell was a member of the group that developed the guideline for the National Institute for Health and Clinical Excellence (NICE), the body that advises on the use of treatments in the NHS, and the National Collaborating Centre for Mental Health, a partnership between the Royal College of Psychiatrists and the British Psychological Society.
"The recommendations were based on a risk-benefit analysis," Professor Cottrell said. "There is evidence that certain antidepressants are effective in young people, but their use is associated with risk, so psychological treatments should be used first line." He warned that depression in children is more common than many people realise and often goes unrecognised.
"Around 1% of children and 3% of adolescents will suffer from depression in any one year. It can have a serious impact on school performance and self esteem and cause major effects into the future, making it a significant problem that is important to detect and treat effectively," he said.
The guideline recommends training for people in contact with children (defined for the guideline as aged 5-11 years) and young people (12-18 years) to improve the early detection of depression. Healthcare professionals in primary care, schools, and other relevant community settings should be trained to detect symptoms of depression and to assess children and young people who may be at risk of depression.
Once depression has been diagnosed and assessed, the guideline recommends that children and young people with moderate to severe depression should be offered a specific psychological therapy, such as cognitive behaviour therapy, interpersonal therapy, or family therapy, for at least three months’ duration as first line treatment. If the depression remains unresponsive, alternative or additional psychological therapies should be considered after a multidisciplinary review.
In young people treatment with fluoxetine should then be considered in addition to psychological therapy. Addition of the drug should be "cautiously" considered for children aged 5-11 years, as the guideline notes that evidence for its effectiveness in this age group is not established. Arrangements must be made for careful monitoring of adverse drug reactions, as well as for reviewing mental state and general progress.
Fluoxetine was recommended as the only antidepressant for which trials show that its benefits outweigh the risks, with sertraline or citalopram recommended as second line treatments. The guideline cautioned that paroxetine and venlafaxine, tricyclic antidepressants, and St John’s wort should not be used in children or young people.
Depression in Children and Young People: Identification and Management in Primary, Community and Secondary Care is accessible at www.nice.org.uk
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