Guidelines - Depression in children and adolescents

This tool provides information to facilitate the identification and management of depression in children and young people 5-18 years old.*

Disclaimer: Healthcare providers are required to practice within their respective scopes of practice. Patients should be recommended to an appropriate healthcare provider when necessary.

Focused examination

1. Patient History 

  • Address psychosocial risk factors that could be contributing to depressive symptoms.

  • Identify and assess other conditions or co-morbidities.

  • Conduct a family history of psychological conditions including parents and grandparents. If required, provide collaborative management with appropriate healthcare providers.

Psychosocial Risk Factors:

  • Age, gender, family discord, turbulent interpersonal relationships or social network, bullying, physical, sexual or emotional abuse, drug and alcohol use, history of parent depression, single loss events, ethnic and cultural factors, homelessness, refugee status, living in institutional settings, combination of multiple risk factors

Examples of other conditions/co-morbidities:

  • Physical conditions: back pain, headache

  • Psychological conditions: mood disorder, anxiety

  • Co-morbidities: diabetes, developmental, social and educational problems

2. Physical Examination

  • Screen for mood and bipolar disorders.

  • Identify any signs of self-harm, neglect and abuse. If identified, immediate emergency services are required.

Signs of self-harm: unexplained injuries, making sure areas of the body are hidden

 

Signs of neglect: dirty skin, offensive body odor, unwashed, uncombed hair, undersized, oversized or unclean clothing, clothing inappropriate for the weather, frequent lack of supervision

Signs of abuse: unexplained changes in behaviour or personality, becoming withdrawn, seeming anxious, becoming uncharacteristically anxious, lacking social skills with peers, poor bond of relationship with parent or carer, knowledge of adult issues inappropriate for their age

3. Management 

  • Offer age-appropriate information on nature, management, and the course of depression.

  • Discuss the range of effective interventions with the patient and caregiver, if appropriate, and, together, select a therapeutic intervention.

General Management

Conduct a risk profile for the risks of depression when a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience

Provide age-appropriate structured patient education (nature, course of treatment and likely side effect of medication, if applicable) and any of the following therapeutic interventions*:

Offer support and the opportunity to talk over the event. Provide active listening and conversational tone for acute sadness and distress (situational dysphoria)
Offer advice on the benefits of regular exercise and encouraged to participate in a structured supervised exercise programme of 3 sessions per week of moderate duration (45 min to 1 hour) for 10-12 weeks
Offer sleep hygiene education
Offer anxiety management
Offer nutrition advice and the benefits of a balanced diet
Consider ongoing social and environmental factors if dysphoria becomes more persistent to provide support where necessary

Always make contact with children and young people with depression who do not attend follow-up appointments

Recurrent Depression and Relapse Prevention

  • Specific follow-up psychological therapy sessions to reduce the likelihood of, or at least detect, a recurrence of depression should be considered for children and young people who are at a high risk of relapse

  • Recognize illness features, early warning signs, and subthreshold disorders

  • Self-management techniques may help individuals to avoid and/or cope with trigger factors

Psychological Intervention for Mild Depression—5-18 years old

 

Provide watchful waiting followed by further assessment within 2 weeks. If depression continues after 2 weeks, and without signs of significant comorbid problems or active suicidal ideas or plans, select one of the following psychological interventions (adapted to developmental level as needed)*:

Consider digital cognitive behavioural therapy (CBT)
Consider group CBT
Consider group non-directive supportive therapy (NDST)
Consider group interpersonal psychotherapy (IPT)
 

If these options do not meet the child's clinical needs or are unsuitable for their circumstances, consider one of the following options:
Consider attachment-based family therapy
Consider individual CBT

Do not offer antidepressant medication as initial treatment


If patient has not responded to psychological therapy after 2-3 months, refer for review by a CAMHS team. Follow recommendations for moderate to severe depression if depressive symptoms continue after 2-3 months of psychological therapy

*Discuss the choice of psychological therapies (including the limited evidence for 5– to 11-year olds).

Psychological Intervention for Moderate to Severe Depression—5-11 years old

 

Provide a referral for patients to be reviewed by a CAMHS team and select one of the following psychological interventions (adapted to developmental level as needed)*:


Offer family-based IPT
Offer family therapy (family-focused treatment for childhood depression and systems integrative family therapy)
Offer psychodynamic psychotherapy
Offer individual CBT


Do not offer electroconvulsive Therapy (ECT)

*Discuss the choice of psychological therapies (including the limited evidence for 5– to 11-year olds).

Psychological Intervention for Moderate to Severe Depression—12-18 years old

Provide a referral for patients to be reviewed by a CAMHS team and select one of the following psychological interventions (adapted to developmental level as needed):


Consider individual CBT for at least 3months
If this option does not meet the child's clinical needs or is unsuitable for their circumstances, consider one of the following options:

Consider interpersonal psychotherapy for adolescents (IPT-A)
Consider family therapy (attachment-based or systemic)
Consider brief psychosocial intervention
Consider psychodynamic psychotherapy
Consider multimodal care if patient is unresponsive to a specific psychological therapy after 4-6 sessions:

  • Combined pharmacological (fluoxetine) and psychological therapyᶿ†

    • If patient responds well to medication, it should be continued for at least 6 months following remission (no symptoms and full functioning for at least 8 weeks)

Consider inpatient care for patients who present with a high risk of suicide, high risk of serious self-harm or high risk of self-neglect, and/or when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated
Consider electroconclusive therapy (ECT) for young people with very severe depression and either life-threatening symptoms (such as suicid-al behaviour) or intractable and severe symptoms that have not responded to other treatments

 

Do not offer antidepressants except in combination with a concurrent psychological therapy

ᶿClosely monitor any child or young person prescribed an antidepressant for the appearance of suicidal behaviour, self-harm or hostility.
†If fluoxetine is unsuccessful or is not tolerated because of side effects, consider sertraline or citalopram as second-line treatments. Paroxetine, venlafaxine, and tricyclic antidepressants should not be used.

Treating Psychotic Depression

 

Provide a referral for patients to be reviewed by a CAMHS team and the following psychological intervention:

 

Consider augmenting the current treatment plan with a second-generation antipsychotic medication‡

‡Closely monitor any child or young person prescribed a second-generation antipsychotic medication for side effects

Treating Depression Unresponsive to Combined Treatment

 

Conduct a review of diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family
 

Discuss alternative psychological therapies not been tried previously:
Consider individual CBT
Consider interpersonal therapy
Consider shorter-term family therapy (3 months' duration)
Consider systemic family therapy (15 fortnightly sessions)
Consider psychodynamic psychotherapy (30 weekly sessions)

Care Pathway for the management depression in children (5-11 years old)

Care Pathway for the management of mild depression in young people (12-18 years old)

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to child and adolescent mental health services (CAMHS) for further evaluation at any time during their care if depression is identified, suspected or if they develop new or worsening physical or psychological symptoms.

Referral Considerations

 

Indications that management can remain at primary level:

  • 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 2 or more other risk factors with no evidence of depression and/or self-harm

  • Exposure to a recent undesirable life event, where 1 or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child or young person

  • Mild depression without comorbidity

Indications to refer to mental healthcare professional:

  • Depression with two or more other risk factors for depression

  • Depression where one or more family members (parents or children) have multiple-risk histories for depression

  • Mild depression in those who have not responded to interventions in tier primary care after 2–3 months

  • Moderate or severe depression (including psychotic depression)

  • Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression

  • Unexplained self-neglect of at least 1 month's duration that could be harmful to their physical health

  • Active suicidal ideas or plans

  • Referral requested by a young person or their parents or carers

  • High recurrent risk of acts of self-harm or suicide

  • Significant ongoing self-neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health)

  • Requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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