Clinical Practice Guideline on Major Depression in Childhood and Adolescence CLINICAL PRACTICE GUIDELINES IN THE SNS MINISTRY OF HEALTH AND SOCIAL POLICY Clinical Practice Guideline on Major Depression in Childhood and Adolescence CLINICAL PRACTICE GUIDELINES IN THE SNS MINISTRY OF HEALTH AND SOCIAL POLICY “This CPG 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”. Version: 07/2009 Published by: Ministry of Science and Innovation NIPO: 477-09-048-9 ISBN: 978-84-95463-66-1 Copyright deposit: C 3987-2009 Printed by: Tórculo Artes Gráficas, S.A. “This 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”. This guideline must be cited as follows: Working group of the Clinical Practice Guideline on the Management of Major Depression in Childhood and Adolescence. Clinical Practice Guideline on Major Depression in Childhood and Adolescence. Quality Plan for the National Health System of the Ministry of Health and Social Policy. Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia (avalia-t); 2009. Clinical Practice Guidelines in the SNS: avalia-t Nº 2007/09. Table of contents Presentation 9 Authors and collaborations 11 Questions to be answered 16 Key to evidence statements and grades of recommendations from SIGN 18 Summary of recommendations 19 1 Introduction 23 1.1. Prevalence 23 1.2. Repercussions of depression 24 2 Scope and objectives 26 3 Methodology 28 4 Definition, clinical diagnosis and diagnostic criteria 32 4.1. Definition 32 4.2. Clinical diagnosis of major depression 32 4.3. Diagnostic criteria 33 4.4. Differential diagnosis 36 4.4.1. Comorbidity 36 5 Risk factors and the assessment of major depression 38 5.1. Risk factors 38 5.1.1. Family and environmental factors 38 5.1.2. Individual factors 39 5.2. Assessment 40 5.2.1. Assessment methods 41 5.2.2. Depression screening 44 6 Treatment of major depression 47 6.1. Psychotherapy 47 6.1.1. Cognitive behavioural therapy 48 6.1.2. Interpersonal therapy 51 6.1.3. Individual psychodynamic therapy 52 6.1.4. Family therapy 52 6.1.5. Relapse prevention 54 6.2. Pharmacological treatment 55 6.2.1. Prescription of antidepressants in childhood and adolescence 55 6.2.2. Efficacy of different drugs 56 6.2.3. Relapse prevention 59 7 Combined treatment and strategies for resistant depression 63 7.1. Combined treatment of major depression 63 7.1.1. The TADS study 63 CLINICAL PRACTICE GUIDELINE ON MAJOR DEPRESSION IN CHILDHOOD AND ADOLESCENCE 5 7.1.2. The ADAPT study 64 7.1.3. Other studies 65 7.2. Strategies for resistant depression 66 7.3. Electroconvulsive therapy 68 8 Other therapeutic interventions 72 8.1. Self-help techniques 72 8.1.1. Bibliotherapy and the use of self-help materials 72 8.1.2. Other techniques or interventions 73 8.2. Physical exercise 74 8.3. Family, social, and environmental interventions 75 9 Suicide in childhood and adolescence 76 9.1. Suicide: conceptualisation 76 9.2. Epidemiology of suicide 77 9.3. Risk factors 78 9.3.1. Individual factors 79 9.3.2. Family and contextual factors 80 9.3.3. Other factors 81 9.4. Precipitating factors 82 9.5. Protective factors 82 9.6. Treatment aspects 83 9.6.1. Assessment 83 9.6.2. Assessment of suicide risk 83 9.6.3. Hospitalisation criteria 85 9.6.4. Outpatient follow-up 85 9.6.5. Psychotherapy 85 9.6.6. Pharmacological treatment 86 9.6.7. Other treatments 87 9.7 Suicide prevention 87 9.7.1. Interventions at school 88 9.7.2. Early diagnosis 89 9.7.3. Prevention in patients with mental disorders 90 9.7.4. Other prevention strategies: the media 90 10 Legal aspects in Spain 94 10.1. Informed consent and Law 41/02 94 10.2. Psychiatric hospitalisation of minors 96 11 Quality indicators 98 12 Diagnostic and therapeutic strategies 105 13 Dissemination and implementation 109 14 Recommendations for future research 110 6 CLINICAL PRACTICE GUIDELINES IN THE SNS 15 Appendices 113 Appendix 1. Severity criteria according to ICD-10 and DSM-IV-TR 113 Appendix 2. Information for patients and relatives 116 Appendix 3. Glossary 133 Appendix 4. List of abbreviations 138 Appendix 5. Declaration of interests 140 Appendix 6. Models of informed consent 142 Appendix 7. Psychotherapeutic techniques 144 16 Bibliography 153 CLINICAL PRACTICE GUIDELINE ON MAJOR DEPRESSION IN CHILDHOOD AND ADOLESCENCE 7 Presentation One of the priorities of the Ministry of Health and Social Policy is to decrease unjustified clinical variability, thereby helping to make the most appropriate decisions based on the best ex- isting knowledge. The healthcare practice is increasingly more complex due to a multitude of factors, one of the most relevant of which is undoubtedly the exponential increase in scientific information. For clinical decisions to be appropriate, effective, efficient, and safe, professionals need to constantly update their knowledge, which requires that they dedicate considerable effort. In 2003, the Interterritorial Council of the National Health System (SNS) created the GuíaSalud project. Its ultimate aim is to improve clinical decision-making based on scientific evidence through training activities and by setting up a record of Clinical Practice Guidelines (CPG) in the SNS. Since then, the GuíaSalud project has evaluated dozens of CPGs according to explicit criteria determined by its scientific committee, it has registered those guidelines, and it has published them through the Internet. At the beginning of 2006, the Directorate General of the Quality Agency of the National Health System prepared the Quality Plan for the National Health System, which is deployed according to twelve strategies. The purpose of this Plan is to increase the cohesion of the SNS and to help guar- antee the highest quality healthcare for everyone, regardless of their place of residence. As a part of the Plan, the preparation of several CPGs was commissioned to various expert agencies and groups on prevalent pathologies related to healthcare strategies. This guide on major depression in childhood and adolescence is the result of that commissioning. Moreover, the definition of a common methodology for drafting CPGs for the SNS was com- missioned, and it has been drafted as the result of a collective effort of consensus and coordination among expert groups on CPGs in our country. In 2007, the GuíaSalud project was renovated, and the Library of Clinical Practice Guidelines was created. This project delves deeper into drafting CPGs, and it includes other services and products of Evidence-based Medicine. It likewise endeavours to favour the implementation and evaluation of the use of CPGs in the National Health System. Even though major depression is relatively frequent and represents a health problem due to the disability and the alteration of the quality of life that it causes, it is frequently underdiagnosed in childhood and adolescence. Moreover, the variability in managing it is well known, with dif- ferent attitudes regarding therapy, referral, and follow-up. This clinical practice guideline is the result of the work of a group of professionals belonging to the various disciplines that are comprised in caring for patients with depression. The members of the editing group have dedicated many hours to drafting the recommendations, which will undoubtedly help to improve the healthcare that is provided in both primary care and specialised care. The review process of the guideline has included the cooperation of scientific societies and patient associations that are directly involved with this health problem. This CPG attempts to provide healthcare professionals with a useful instrument that pro- vides answers to the most basic questions in the form of recommendations, which have been CLINICAL PRACTICE GUIDELINE ON MAJOR DEPRESSION IN CHILDHOOD AND ADOLESCENCE 9 prepared systematically and according to the best available evidence. We hope that all of this will result in greater quality healthcare for these patients and their families, which is the objective that motivates us. Pablo Rivero Corte Director General of the Quality Agency of the SNS 10 CLINICAL PRACTICE GUIDELINES IN THE SNS Authors and collaborations Guideline Development Group for the CPG on the Management of Major Depression in Childhood and Adolescence. 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 Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia.