Contents
1 Aim
This procedure is designed to ensure that medics and clinicians within the children, adolescent mental health service (CAMHS) section of the children’s care group have a full understanding of the management and administration of antidepressant medication for the treatment of a defined mental health condition. Specifically, in line with NICE guideline (NG134) depression in children and young people, identification and management (opens in new window).
2 Scope
The standard operating procedure (SOP) is for use by children, adolescent mental health service (CAMHS) clinicians and medics within the children’s care group.
3 Link to overarching policy
This SOP overarched by and should be read in conjunction with the safe and secure handling of medicines manual.
4 Glossary of terms
| Term | Definition |
|---|---|
| Prescribing doctor or nurse prescriber | This could be any doctor or nurse who prescribes medication |
| Care coordinator | This is the lead CAMHS clinician that has been identified to undertake the assessment, and maintains overall responsibility for managing the care plan, crisis plan, contingency plan, and risk assessment |
| Identified clinician | This is the clinician who has been identified and specified as doing the regular medication monitoring. It could be a nurse, therapist, junior doctor or consultant. They may or may not also be the care coordinator |
5 Procedure
5.1 Consent to treatment
If the child or young person is under 16 years Gillick competence will be assessed in relation to them being able to consent to their own treatment. If appropriate the parent or carer will be involved in these discussions also. If the child or young person is unable to consent the parental or carer will be involved in the discussions around treatment and decisions for consent to treatment. Young people who are over 16 years who have mental capacity can consent to treatment.
5.2 Psychological interventions
Psychological interventions should be considered as first-line treatment for child and adolescent depression. The national institute for health and clinical excellence (NICE) recommends the introduction of medication in conjunction with psychological treatment if there is a failure to respond to psychological treatment. (NICE 2015)
Antidepressant medication should not be used for the initial treatment of children and young people with mild depression (NICE 2005).
Discuss the choice of psychological therapies with children and young people with mild depression and their family members or carers (as appropriate). Explain:
- what the different therapies involve
- the evidence for each age group (including the limited evidence for 5-to 11-year-olds)
- how the therapies could meet individual needs, preferences, and values (2019)
The choice of psychological therapies should include the patient and carer preferences and values (as appropriate) (2019).
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 at least 3 months’ duration) (NICE 2015 update).
Antidepressant medication should not be offered to a child or young person with moderate to severe depression without considering psychological therapy at the same time. (NICE 2015 update).
Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS team (2019).
For 12 to 18 year olds with moderate to severe depression, offer individual CBT for at least 3 months (2019).
If individual CBT would not meet the clinical needs of a 12-to 18-year-old with moderate to severe depression or is unsuitable for their circumstances, consider the following options:
- IPT-A (IPT for adolescents)
- family therapy (attachment-based or systemic)
- brief psychosocial intervention
- psychodynamic psychotherapy (2019)
5.3 The first 4 weeks of prescribing
At the onset of prescribing an antidepressant the identified clinician must ensure that the child or young person has an appointment every week for the first 4 weeks of prescribing to monitor their progress particularly focusing on emergent adverse drug reactions.
There needs to be clear monitoring arrangements.
It needs to be clearly recorded in the records and care plan as to who will be undertaking this task. If a CAMHS clinician is to undertake this task they need to have the necessary knowledge and understanding to be aware of the potential side effects. It would be expected that any staff member working with children with moderate to severe depression should have the necessary skills and knowledge. The clinical leads or service manager should ensure this is the case. However, if the clinician does not have such knowledge, then they need to make the service manager and clinical lead aware so they can access appropriate training. They also need to make the prescribing doctor aware, who will inform them of the potential side effects they are to check for.
When the child or young person is started on antidepressant medication, they and their parent(s) or carer(s) as appropriate should be informed about the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed. Discussion of these issues should be supplemented by written information appropriate to the age of the child or young person’s and parents’ or carers’ needs. Healthcare professionals should make contact with children and young people with depression who do not attend follow-up appointments (NICE 2005).
The child or young person that has been prescribed an antidepressant should be closely monitored for the appearance of suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment, by the clinician identified to do the follow up as above. If any of these side effects occur the monitoring clinician should have a face to face discussion with the prescribing doctor or another doctor to raise their concerns (not by email). The patient and their parent(s) or carer(s) should be informed that if there is any sign of new symptoms of these kinds, urgent contact should be made with the identified clinician or the CAMHS duty worker.
Unless it is felt that medication needs to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored by the care coordinator for 7 days before the initial appointment with the doctor. Once medication is started the patient and their parent(s) or carer(s) should be informed that if there is any sign of new symptoms of these kinds, urgent contact should be made with the identified clinician.
5.4 Alternative prescribers or CAMHS clinicians
If the care coordinator or identified clinician are to be on leave or leaving the service, then it is the responsibility of the team leader or service manager to ensure that adequate cover is provided to manage and review the child or young person(s) care. Handover of any specific instructions where required would be the responsibility of those clinicians handing over the case. All relevant information needs to be available in the electronic clinical records.
The prescribing doctor should review the patient after initiation of antidepressant medication within six weeks of initiation or should arrange for another doctor or prescribing nurse to carry out this review.
It is the responsibility of the identified clinician to ensure that they book in a medication review appointment with a doctor or a prescribing nurse every three to four months or sooner if problems arise. The care coordinator identified clinician has a responsibility to report directly to the prescribing doctor or another doctor or prescribing nurse should any difficulties arise whilst the patient is on antidepressant medication.
5.4 Duration of treatment and discontinuation of selective serotonin reuptake inhibitors
There is little evidence regarding optimum duration of treatment (Kennard et al 2006). To consolidate the response to the acute treatment and avoid relapse, treatment with fluoxetine should continue for at least 6 and up to 12 months (Emslie et al 2008, Emslie et al 2004). Evidence shows that there is a significant reduction of the risk of relapse with a continuation of treatment for 6 months (Emslie et al 2008)
At the end of treatment, the antidepressant dose should be tapered slowly to minimise discontinuation symptoms. Ideally this should be done over 6 to 12 weeks. (NICE 2005)
6 Dissemination and implementation
The updated SOP will be shared at team meetings and staff will be made aware of it.
7 References
- Emslie GJ et al. Fluoxetine treatment for the prevention of relapse of depression in children and adolescents: a double-blind, placebo controlled study. J Am academy child adolescent psychiatry 2004, 43, 1397 to 1405.
- Emslie GJ et al. Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. Am J psychiatry 2008, 165, 459 to 467.
- Kennard BD et al. Relapse and recurrence in paediatric depression. child adolescent psychiatry clinical North America 2006, 15, 1057 to 1079, xi.
- NG134 depression in children and young people, identification and management. (2019).
Document control
- Version: 4.
- Unique reference number: 136.
- Date approved: 6 February 2024.
- Approved by: Clinical lead CAMHS.
- Name of originator or author: Clinical lead CAMHS.
- Name of responsible individual: Children’s care group director or medical director.
- Date issued: 16 February 2024.
- Review date: 28 February 2027.
- Target audience: All clinical staff in children and young people’s mental health service (CAMHS) across the trust.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025