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Guideline Summary
Guideline Title
Clinical practice guideline on major depression in childhood and adolescence.
Bibliographic Source(s)
Working Group of the CPG on the Management of Major Depression in Childhood and Adolescence. Clinical practice guideline on major depression in childhood and adolescence. Madrid: Ministry of Health and Social Policy, Galician Health Technology Assessment Agency; 2009 Jul. 169 p. [269 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Major depression

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Neurology
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
  • To improve the healthcare given to children and adolescents with depression, within the scope of primary and specialised care
  • To offer recommendations to healthcare professionals about caring for these patients
  • To develop indicators that can be used to evaluate the practice of professionals
  • To help patients and their family members to make informed decisions, for whom specific information has been prepared
Target Population

Children and adolescents from 5 to 18 years of age who show criteria for mild, moderate, or severe major depression

Note: The guideline does not cover other mood alterations. The guideline covers the care that children and adolescents with depression can expect to receive from healthcare professionals, both in primary care and in specialised care (child and adolescent mental healthcare). Other services are not covered, such as social, educational, or free time.

Interventions and Practices Considered

Diagnosis and Risk Assessment

  1. Clinical interview for diagnosis of depression
  2. Active search for depressive symptomatology in children and adolescents who present risk factors
  3. Questionnaires on depressive symptoms in children over 8 years of age and in adolescents

Treatment/Management

  1. General interventions for treatment of depression
    • Comprehensive treatment of depression in childhood and in adolescence
    • Standard clinical care for management of depression
    • Establishment of a solid therapeutic alliance, use of specific techniques for children and adolescents, and inclusion of parents in the therapeutic process
  2. Treatment of mild major depression
    • Observation and follow up with active support
    • Referral to specialised care when indicated
    • Psychological therapy (e.g., cognitive behavioural therapy, family therapy, interpersonal therapy) with regular follow-up
  3. Treatment of moderate and severe depression
    • Referral to mental healthcare
    • Psychotherapy (e.g. cognitive behavioural therapy and interpersonal or family therapy)
    • Psychotherapy together with pharmacological treatment (selective serotonin reuptake inhibitors [SSRIs], especially fluoxetine)
    • Tricyclic antidepressants, paroxetine, venlafaxine, and mirtazapine (considered but specifically not recommended)
    • Pharmacological treatment alone in individual cases
    • Counselling about pharmacological treatment
    • Monitoring for suicidal ideation or suicidal behaviour
    • Consideration of hospitalisation, depending on the symptoms
  4. Combined treatment strategies for resistant depression (cognitive behavioural therapy and pharmacological treatment; electroconvulsive therapy in exceptional cases)
  5. Other therapeutic interventions
    • Self-help
    • Regular physical exercise
    • Counselling on balanced nutrition and sleep
    • Consideration of family and social context
    • Questioning patient and family about possible consumption of alcohol and other drugs and about history of school harassment, abuse, or self-injurious behaviour
  6. Management of suicidal behaviour and ideation
    • Assessment of risk factors by questionnaire and clinical history
    • Psychiatric or psychosocial assessment following any suicide attempt
    • Management of patient access to medication
    • Hospitalisation, as indicated, or re-assessment
    • Suicide prevention measures
Major Outcomes Considered
  • Risk of depression
  • Level of depressive symptoms
  • Validity, reliability, differentiating power, sensitivity, and specificity of diagnostic and screening tests for depression
  • Predictive value, validity, sensitivity, specificity, and consistency of tests for suicide risk
  • Efficacy of treatments
  • Rates of remission/recovery from depression
  • Functional state
  • Quality of life
  • Relapse after remission of depression
  • Rate of suicidal behaviour (including suicide ideation and suicidal attempts)

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

An initial bibliographical search of the last ten years was performed to locate all clinical practice guidelines (CPGs) existing in the main bibliographical databases.

A search of MEDLINE (PubMed); EMBASE (OVID) & PsycINFO (OVID); Cochrane Library plus; Centre for Review and Dissemination (CRD) databases; Trip database; ISI WoK- Social Science Citation Index (ISI Web of Knowledge); ClinicalTrials.gov was performed. There was no limit to the time frame of the literature search. Documents were excluded if they addressed depression in individuals over 18 years of age. Search terms included "Depressive Disorder"[MeSH] OR "Depression"[MeSH] OR "Dysthymic Disorder"[MeSH] OR "Seasonal Affective Disorder"[MeSH] OR "Adjustment Disorders"[MeSH] OR "major depression" OR "anaclitic depression" OR "dysthymic disorder" OR "endogenous depression" OR "reactive depression" OR "recurrent depression" OR "Treatment resistant depression") AND ("Child"[MeSH] OR "Adolescent"[MeSH] OR child*[TW] OR adolescent*[TW] OR "Pediatrics"[MeSH].

The guideline authors also conducted a manual search of the bibliography included in the selected articles in order to locate additional studies.

After having identified relevant articles for the review, they were selected and assessed to see if they met the established inclusion or exclusion criteria. Moreover, studies were critically assessed using quality checklists. This entire process was performed by the two independent reviewers.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1–: Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort or studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2–: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies, e.g., case reports, case series

4: Expert opinion

Note: Studies classified as 1- and 2- should not be used in the process of developing recommendations due to their high possibility of bias.

Source: Scottish Intercollegiate Guidelines Network. SIGN 50: A guideline developers' handbook (Section 6: Forming guideline recommendations), SIGN publication no. 50, 2001.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Data Extraction

A specific form was used, which helped to uniformly extract all relevant information and subsequently include it in the evidence tables. In general, the components of the form for efficacy and effectiveness studies were the following:

  • Data extraction date and identification of the reviewer
  • Title, authors, journal, and other details of the study
  • Characteristics of the study
    • Population characteristics
    • Design and methodological quality of the study
    • Intervention data
  • Outcome measures

Clinical Practice Guideline Selection

The methodological quality of the prior clinical practice guidelines (CPGs) was assessed according to the Appraisal of Guidelines Research and Evaluation (AGREE) document, and the one with the highest score was selected and considered to be the benchmark. The assessment of the previous CPGs is set forth in a document of methodological material. The situations faced were the following:

  • The guideline provided an incomplete response to the question, because it had not been updated. This occurred in all cases, wherefore the bibliography was updated to the current date.
  • The guideline provided an incomplete response to the question, because the guideline's response was only partial or did not adapt to the local context, wherefore it was necessary to re-draft the recommendation. In this case, it was developed partially, with an additional search and assessment.
  • The guideline did not respond to the question: De novo preparation.

Synthesis and Interpretation of the Outcomes

A descriptive synthesis was provided by preparing the evidence tables, in which the main characteristics and the outcomes of each study were summarised. The outcomes were interpreted by discussing the strength of the evidence (quality of the studies included, magnitude and significance of the observed effects, consistency of the effects of the various trials, etc.), the applicability of the outcomes, and other information such as costs, legal and ethical aspects, and the usual practice within the context.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Participants in the Clinical Practice Guidelines

The roles of the various participants in the development of the guideline are detailed in Table 2 of the original guideline document.

Formulation of the Clinical Questions

The members of the guideline's development group were responsible for formulating the necessary clinical questions for covering the scope of the guideline. The clinical questions were produced generically and in the so-called PICO format: P (patients), I (interventions), C (comparisons), and O (outcomes).

Conclusions and Recommendations

Recommendations were formulated based on the Scottish Intercollegiate Guidelines Network (SIGN) "formal assessment" or "considered judgement". They were drafted clearly, thereby avoiding deductions that could give rise to an incorrect interpretation, and they were based solely on the reviewed knowledge. The recommendations were graduated according to the strength of the evidence following the SIGN scale (see the "Rating Scheme for the Strength of the Recommendations" field).

Controversial recommendations or recommendations with an absence of evidence were resolved by informal consensus of the guideline development group. For preparing the quality indicators, the "RAND/UCLA appropriateness method" was used.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendations

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+.

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++.

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+.

Good Practice Points1: Recommended best practice based on the clinical experience of the guideline development group.

Source: Scottish Intercollegiate Guidelines Network. SIGN 50: A guideline developers' handbook (Section 6: Forming guideline recommendations), SIGN publication no. 50, 2001.

1Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available. Generally, these cases are related to some aspect of the treatment, considered to be a good clinical practice that nobody would normally question. These aspects are considered good clinical practice points. These messages are not an alternative to evidence-based recommendations, but must only be considered when there is no other way.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Expert professionals proposed by the various scientific societies and associations involved in the subject of the guideline participated in reviewing the guideline, in addition to other professionals who were considered relevant.

Recommendations

Major Recommendations

The levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, and 4) and grades of the recommendations (A-D and Good Practice Points) are defined at the end of the Major Recommendations field.

The recommendations adopted from a clinical practice guideline (CPG) are indicated by the "CPG" superscript.

Risk Factors and the Assessment of Major Depression

  • Family physicians and primary care paediatricians should have suitable training that allows them to assess those children and adolescents at risk of depression and to record the risk profile in their clinical history. (Strength of Recommendation DCPG).
  • When faced with a child who has suffered from a stressful life event, in the absence of other risk factors, primary care professionals should perform follow-up and foment the normalisation of daily life. (Strength of Recommendation DCPG)
  • Any mental health assessment of a child or adolescent should routinely include questions about depressive symptoms. (Strength of Recommendation DCPG)
  • Major depression should be diagnosed through a clinical interview. Questionnaires alone do not allow making an individual diagnosis. (Good Practice Point)
  • It is not advisable to screen for depression in children or adolescents among the general population due to the nonexistence of studies that assess the effectiveness of screening. (Good Practice Point)
  • There should be an active search for depressive symptomatology in those children and adolescents who present risk factors, and children and adolescents should be asked separately from their parents about current symptoms and problems. (Good Practice Point)
  • In children over 8 years of age and in adolescents, one of the most-used and validated questionnaires in Spanish is the Children's Depression Inventory (CDI). In adolescents, the use of self-applied questionnaires that are validated in Spain and that allow the early detection of depressive symptoms is recommended. Nevertheless, it must not be forgotten that a clinical interview must be performed for a complete diagnosis. (Good Practice Point)

Treatment of Major Depression

General Recommendations

  • The treatment of depression in childhood and in adolescence must be comprehensive, and it must cover those psychotherapeutic, pharmacological, and/or psychosocial interventions that could improve well-being and functional capacity. (Good Practice Point)
  • The management of depression should always include standard clinical care, which is understood as psychoeducation, individual and family support, problem-solving techniques, coordination with other professionals, attention to other comorbidities, and regular monitoring of the mental state. (Good Practice Point)
  • Regardless of the therapy used, a solid therapeutic alliance must always be established, and specific techniques must be used for childhood and adolescence, in addition to the fact that parents must be included as a fundamental part of the therapeutic process. (Good Practice Point)

Mild Major Depression

  • In children and adolescents with mild major depression and in the absence of risk factors, self-injurious ideas/behaviours, and comorbidities, the family physician or paediatrician could allow a two-week period to elapse for observation and follow-up on evolution. (Strength of Recommendation DCPG)
  • During this period, the primary care professional should provide active support for the child or adolescent and their family, thereby facilitating guidelines for healthy life habits, psychoeducational guidelines, or guidelines for handling situations. (Strength of Recommendation D)
  • If the depressive symptoms persist after this observation period, it is advisable to refer the patient to specialised care on child and adolescent mental health. (Good Practice Point)
  • Those patients with depression who present self-injurious ideation or behaviours, risk factors, or serious comorbidities such as substance abuse or another mental pathology should be initially referred to child and adolescent mental healthcare, even though the degree of the depression may be mild. (Good Practice Point)
  • In specialised care on child and adolescent mental health, the treatment of choice for mild major depression will be psychological therapy for a period of 8 to 12 weeks (weekly sessions). (Strength of Recommendation B)
  • The initially recommended modes of psychotherapy for mild major depression are cognitive behavioural therapy, family therapy, or interpersonal therapy. (Strength of Recommendation B)
  • During this period of psychological therapy, there must be regular follow-up on the clinical evolution of the child or adolescent. (Strength of Recommendation DCPG)
  • In general, the use of antidepressant drugs is not recommended for initially treating children and adolescents with mild depression. (Strength of Recommendation B)

Moderate and Severe Major Depression

  • All children and adolescents with moderate/severe major depression should be initially referred to child and adolescent mental healthcare. (Strength of Recommendation B)
  • Whenever possible, adolescents with moderate depression will be initially treated using psychotherapy for at least 8 to 12 weeks (minimum of 1 session per week). Cognitive behavioural therapy and interpersonal or family therapy are psychotherapeutic modes that have demonstrated the best outcomes. (Strength of Recommendation B)
  • For severe depression in adolescents, it is recommended that psychotherapy be used initially (cognitive behavioural therapy) together with pharmacological treatment (fluoxetine). In individualised cases, pharmacological treatment alone could be used, always associated with standard clinical care. (Strength of Recommendation B)
  • Combined treatment using fluoxetine and cognitive behavioural therapy is especially recommended in cases in which there is a personal or family history of suicidal ideation and/or behaviour. (Strength of Recommendation B)
  • In children under 12 years of age, cognitive behavioural therapy or family therapy is initially recommended. If it is impossible to apply or if the evolution is poor, adding pharmacological treatment (fluoxetine) is recommended. (Good Practice Point)
  • Before initiating pharmacological treatment using antidepressants, it is advisable to inform about the reasons for the prescription, the expected benefits, the possible delay of any therapeutic effect, the secondary effects, and the duration of the treatment. (Good Practice Point)
  • Even though an increase in suicides committed by children and adolescents has not been demonstrated, monitoring the possible appearance of adverse effects is recommended, especially suicidal ideation or behaviour, above all during the first four weeks of pharmacological treatment. (Strength of Recommendation A)
  • The only antidepressant drugs that are recommendable for treating moderate or severe depression in children or adolescents are selective serotonin reuptake inhibitors (SSRIs). Fluoxetine is the drug with the most trials that support its use in these age groups. (Strength of Recommendation A)
  • According to the patient's clinical profile (clinical characteristics of depression, family history, and history of prior response in family members), another SSRI could be selected (sertraline, citalopram, or escitalopram). (Good Practice Point)
  • After remission of the depressive symptoms, it is recommended that pharmacological treatment with an SSRI be continued for at least 6 months (recommendable between 6 and 12 months) as from remission of the depressive symptoms, with the same dose at which remission was achieved. (Strength of Recommendation D)
  • It is advisable that the use of an antidepressant drug be suspended gradually. If symptoms reappear, pharmacological treatment should be re-initiated. (Strength of Recommendation D)
  • Current evidence does not allow recommending the use of tricyclic antidepressants, paroxetine, venlafaxine, or mirtazapine for treating major depression in children and adolescents. (Strength of Recommendation B)
  • Hospitalisation of children or adolescents with major depression should be considered:
    • If there is a high risk of suicide
    • If the depression is severe and is accompanied by psychotic symptoms
    • When there is association with severe comorbidities
    • When there are reasons that make it difficult to ensure suitable outpatient monitoring and control. (Good Practice Point)

Combined Treatment and Strategies for Resistant Depression

  • With a patient who does not improve after initiating treatment, it is advisable to review the diagnosis and verify compliance with the therapy. Whenever treatment is pharmacological, it must be confirmed that the drug is being taken at the appropriate time and in the appropriate dose. (Good Practice Point)
  • When a patient does not improve after psychological treatment, it must be verified that the suitable time and number of sessions have been given. (Good Practice Point)
  • For patients with moderate major depression who do not respond to specific psychological therapy, it is advisable to combine cognitive behavioural therapy with pharmacological treatment from the SSRI group. (Strength of Recommendation B)
  • If there is a response to treatment, it should be continued for at least six months (recommendable between 6 and 12 months) after remission of the depressive symptoms. (Good Practice Point)
  • For adolescents with moderate-severe depression who do not respond to initial treatment with an SSRI, it is advisable to combine cognitive behavioural therapy with a change to another antidepressant of the SSRI group. (Strength of Recommendation B)
  • Electroconvulsive therapy will be indicated for adolescents who have severe and persistent major depression and who have severe symptoms that place their lives in danger or who do not respond to other treatments. (Strength of Recommendation C)
  • The use of electroconvulsive therapy in adolescents should be exceptional and be given by an experienced professional (child and adolescent psychiatrist) after a physical and psychiatric assessment and in a hospital environment. (Strength of Recommendation C)

Other Therapeutic Interventions

  • It is recommendable that all health professionals involved in managing depression in children and adolescents have suitable training that allows them to advise about all forms of self-help that are potentially useful for patients, parents, or carers. (Good Practice Point)
  • Recommending self-help interventions should form a part of a comprehensive treatment strategy. (Good Practice Point)
  • It is recommendable to offer information about the advantages of regular physical exercise for children or youths with depression, as long as the severity does not hinder this activity. (Strength of Recommendation DCPG)
  • It is recommendable to also provide information about the benefits of balanced nutrition and maintaining a pattern of adequate sleep. (Good Practice Point)
  • When assessing children or adolescents with major depression, the family and social context must be taken into account. The quality of the patient's interpersonal relationships must also be assessed, both the relationships with their family members and with their friends and peers. (Good Practice Point)
  • It is recommendable to always ask a patient and their family members about the consumption of alcohol and other drugs and about the existence of a history of school harassment, abuse, or self-injurious behaviour. (Good Practice Point)

Suicide in Childhood and Adolescence

  • Primary care professionals should have suitable information about the main risk factors of suicidal behaviour and ideation in children and adolescents and about the assessment of their risk profile. (Good Practice Point)
  • In patients with depression and/or a suicide risk profile, questions should always be asked about suicide ideas or plans, and the clinical history must include all aspects related to the method, planning, and intent. (Good Practice Point)
  • After a suicide attempt by a child or adolescent, there must always be an immediate psychiatric or psychosocial assessment, if possible by a professional specialising in these age groups. (Good Practice Point)
  • Guidelines will be given to parents or carers regarding accompaniment and control of direct access to medication by children and adolescents. (Good Practice Point)
  • The clinical history should include the medical severity of the suicide attempt, the method used, the degree of planning of the suicidal behaviour, the motivation or intent of the behaviour, and the presence of the feeling of hopelessness. (Strength of Recommendation D)
  • The information will come from the patients themselves, and it is also recommendable to use multiple sources, if possible, such as parents or carers, teachers and friends. (Strength of Recommendation D)
  • While the various psychometric instruments that exist, such as the Risk of Suicide Questionnaire, the Beck Hopelessness Scale, or the Beck Depression Inventory, can help to assess the suicide risk, they cannot substitute the clinical interview, given that those instruments alone lack predictive value. (Strength of Recommendation D)
  • Hospitalisation is recommended for all children or adolescents who have attempted suicide and who show several risk factors and limited family and community support. (Strength of Recommendation D)
  • After a suicide attempt, and if hospitalisation has not been considered, there must be a re-assessment within 7 to 10 days. Subsequently, there must be periodic follow-up by primary care professionals and by child and adolescent mental healthcare professionals. (Strength of Recommendation D)
  • Suicide prevention in children and adolescents should be considered a priority and should fundamentally establish measures that allow early diagnosis of the suicide risk. (Strength of Recommendation D)
  • Measures designed to reach a consensus about suicide coverage by the media and about the content of Internet web pages must be established. (Strength of Recommendation D)

Definitions:

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1–: Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort or studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2–: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies, e.g., case reports, case series

4: Expert opinion

Note: Studies classified as 1- and 2- should not be used in the process of developing recommendations due to their high possibility of bias.

Grades of Recommendations

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+.

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++.

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+.

Good Practice Points1: Recommended best practice based on the clinical experience of the guideline development group.

Source: Scottish Intercollegiate Guidelines Network. SIGN 50: A guideline developers' handbook (Section 6: Forming guideline recommendations), SIGN publication no. 50, 2001.

1 Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available. Generally, these cases are related to some aspect of the treatment, considered to be a good clinical practice that nobody would normally question. These aspects are considered good clinical practice points. These messages are not an alternative to evidence-based recommendations, but must only be considered when there is no other way.

Clinical Algorithm(s)

The original guideline document contains a therapeutic algorithm.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Effective management of major depression in children and adolescents

Potential Harms

Selective Serotonin Reuptake Inhibitors

Fluoxetine

The most frequently observed adverse effects of selective serotonin reuptake inhibitors (SSRIs) were headache, sedation, insomnia, vomiting, abdominal pain, and occasionally skin rash and hyperkinesia. The Treatment for Adolescents with Depression Study (TADS) also observed, in the group treated with fluoxetine, a greater frequency of other adverse effects such as euphoria, anxiety, agitation, and aggression towards self and others, although generally mild.

With respect to suicidal ideation, the National Institute for Clinical Excellence (NICE) guideline records greater suicidal ideation in the group treated with fluoxetine, although neither the percentages in both comparison groups nor the statistical significance between them are specified.

In one meta-analysis, no statistically significant differences of risk were observed, grouped between patients treated with placebo or with diverse antidepressants (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, venlafaxine, and mirtazapine), wherefore it was concluded that regarding suicidal ideation and behaviour, the benefits that are obtained from antidepressant treatment seem to be greater than the risks.

Sertraline

Regarding the appearance of adverse effects, the appearance of nausea is recorded, and to a lesser extent diarrhoea and vomiting, which could favour early abandonment from treatment, although significant differences compared with placebo have not been found.

Citalopram

The most frequently cited adverse effects were headache, rhinitis, nausea, diarrhoea, and insomnia.

Escitalopram

The most frequent adverse effects in one study were headache (23%) and abdominal pain (11%), although significant differences with the placebo group were not found.

Electroconvulsive Therapy

Studies on children and adolescents have rarely reported adverse effects from electroconvulsive therapy (ECT), and no study that contributed evidence regarding the impact by ECT on cerebral development was found. The effects could be the same as in adults, and it could cause retrograde and anteretrograde amnesia. In some cases, it is difficult to differentiate the effects of ECT from the symptoms of the illness itself. Prolonged epilepsy can also occur, and there are risks associated with general anaesthesia. Other, less serious adverse effects could be the following: headache, nausea, vomiting, muscle pain, confusion, and agitation, which do not usually persist beyond the day when treatment is given. In adults, the mortality rate associated with ECT is 2.2/10,000, and the mortality rate associated with anaesthesia is 1.1/10,000. It is thought that in adolescents there is no additional rate of risk for ECT or an increased risk in complications related to anaesthesia during the immediate recovery period.

Nevertheless, the NICE report on ECT published in 2003 reports that the risks could be greater in children and adolescents, and therefore doctors should be particularly cautious when considering this treatment in this age group.

Contraindications

Contraindications

Even though there is insufficient data, the available literature demonstrates contraindications to electroconvulsive therapy similar to those found in adults. They include the following: tumours of the central nervous system associated with intracranial hypertension, serious respiratory infection, and a recent myocardial infarction.

Qualifying Statements

Qualifying Statements

This clinical practice guideline is an aid for making decisions about healthcare. It is not mandatory, and it is not a substitute for the clinical judgement of healthcare professionals.

Implementation of the Guideline

Description of Implementation Strategy

Formats of the Guideline, Dissemination and Implementation

The Clinical Practice Guideline (CPG) consists of two versions, the complete and the summarised versions, in addition to information for patients and a document with methodological material. The complete version, the information for patients, and the methodological material can be accessed through the web pages of Axencia de Avaliacíon de Tecnoloxías Sanitarias (avalia-t) and GuíaSalud. The dissemination and implementation strategies would be the following:

  • Official presentation of the guideline by public health authorities and individual delivery to professionals who are potential users.
  • Distribution of the patient guideline.
  • Presentation of the guideline in Primary and Specialised Care through interactive chats.
  • Dissemination of the guideline electronically on the web pages of the public health services and of the companies involved in the project.
  • On-line and/or attended training activities on managing patients with depression.
  • Presentation of the guideline in scientific activities (workshops, conferences, meetings).
  • Publication of the guideline in medical and psychological journals.
  • Establishment of good care criteria for patients with depression in programme contracts and clinical management contracts.
  • Establishment of support systems for clinical decisions, which incorporate the guideline and the indicators selected in the computer programme used in primary care.
Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Foreign Language Translations
Mobile Device Resources
Patient Resources
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Working Group of the CPG on the Management of Major Depression in Childhood and Adolescence. Clinical practice guideline on major depression in childhood and adolescence. Madrid: Ministry of Health and Social Policy, Galician Health Technology Assessment Agency; 2009 Jul. 169 p. [269 references]
Adaptation

Some questions for this clinical practice guideline have been partially adapted from:

  • National Collaborating Centre for Mental Health. Depression in Children and Young People. Identification and management in primary, community and secondary care [Internet]. London: National Institute for Health and Clinical Excellence; 2005.
Date Released
2009 Jul
Guideline Developer(s)
Galician Health Technology Assessment Agency - State/Local Government Agency [Non-U.S.]
GuiaSalud - National Government Agency [Non-U.S.]
Ministry of Health (Spain) - National Government Agency [Non-U.S.]
Source(s) of Funding

This clinical practice guideline (CPG) has been financed through the agreement signed by the Instituto de Salud Carlos III, an independent body of the Ministry of Science and Innovation, and Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia, within the framework of cooperation provided for in the Quality Plan for the National Health System of the Ministry of Health and Social Policy.

Guideline Committee

Guideline Development Group for the Clinical Practice Guideline on the Management of Major Depression in Childhood and Adolescence

Composition of Group That Authored the Guideline

Group Members: María Álvarez Ariza, Doctor of Medicine, Specialist Physician in Psychiatry, Pontevedra Hospital Complex; Gerardo Atienza Merino, Doctor of Medicine, Technician of the Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia, Consellería de Sanidade; Elena de las Heras Liñero, Doctor of Medicine, Specialist Physician in Psychiatry, University Hospital Complex of Vigo (Pontevedra); Rafael Fernández Martínez, Doctor of Psychology, Clinical Psychologist, Pontevedra Hospital Complex; Ernesto Ferrer Gómez del Valle, Doctor of Medicine, Specialist Physician in Psychiatry, Ourense Hospital Complex; Ana Goicoechea Castaño, Physician, Specialist Physician in Paediatrics, San Roque Health Care Centre, Vilagarcía (Pontevedra); José Luis Iglesias Diz, Doctor of Medicine, Specialist Physician in Paediatrics, University Hospital Complex of Santiago (A Coruña); Arturo Louro González, Physician, Specialist Physician in Family and Community Medicine, Primary Health Care Service of Cambre (A Coruña); Belén Martínez Alonso, Physician, Specialist Physician in Psychiatry, Child-Adolescent USM, University Hospital Complex of Vigo (Pontevedra); José Mazaira Castro, Physician, Specialist Physician in Psychiatry, Child-Adolescent USM, University Hospital Complex of Santiago (A Coruña); Aurea Paz Baña, University Graduate of Nursing, Conxo Psychiatric Hospital, University Hospital Complex of Santiago (A Coruña); Lucinda Paz Valiñas, Biologist, Technician of the Axenciade Avaliación de Tecnoloxías Sanitarias de Galicia, Consellería de Sanidade; María Isabel Roca Valcárcel, Psychologist, Clinical Psychologist, USM, Child-Adolescent, Xeral-Calde Hospital Complex of Lugo; Yolanda Triñanes Pego, Psychologist, Technician of the Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia, Consellería de Sanidade

Financial Disclosures/Conflicts of Interest

Gerardo Atienza Merino, Elena de las Heras Liñero, Rafael Fernández Martínez, Ernesto Ferrer Gómez del Valle, Ana Goicoechea Castaño, Jose Luis Iglesias Diz, Arturo Louro González, Belén Martínez Alonso, José Mazaira Castro, Aurea Paz Baña, Lucinda Paz Valiñas, María Isabel Roca Valcárcel, and Yolanda Triñanes Pego declared no conflicts of interest.

María Álvarez Ariza declared having received financing for meetings or conferences (AstraZeneca and Pfizer) and for attending courses (Janssen).

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English External Web Site Policy and Spanish External Web Site Policy from the GuíaSalud Web site and from the Galician Health Technology Assessment Agency Web site External Web Site Policy.

Print copies: Available from the Consellería de Sanidade. San Lázaro S/N, 15 781. Santiago de Compostela. Spain.

Availability of Companion Documents

The following are available:

  • Quick reference guides and summary versions are available in Spanish from the GuíaSalud Web site External Web Site Policy.
  • The Spanish version of the guideline is also available via a mobile application from the GuíaSalud Web site External Web Site Policy.

Proposed quality indicators can be found in section 11 of the original guideline document External Web Site Policy.

In addition, severity criteria can be found in Appendix 1, two models of informed consent can be found in Appendix 6, and a number of psychotherapeutic techniques can be found in Appendix 7 of the original guideline document External Web Site Policy.

Patient Resources

The following are available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on May 7, 2011. The information was verified by the guideline developer on May 23, 2011. This summary was updated by ECRI Institute on September 12, 2011 following the U.S. Food and Drug Administration advisory on Celexa (citalopram hydrobromide). This summary was updated by ECRI Institute on April 16, 2012 following the updated U.S. Food and Drug Administration advisory on Celexa (citalopram hydrobromide).

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the Galician Health Technology Assessment Agency.

Disclaimer

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