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GPAC: Guidelines and Protocols Advisory Committee Anxiety and Depression in Children and Youth – Diagnosis and Treatment Effective Date: January 1, 2010 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline presents recommendations for early diagnosis, intervention, and maintenance treatment of depression and anxiety disorders in children and youth (18 years and under).
 Routine Screening and DiagnosisPeriodically screen children and youth for early signs of depression and/or anxiety. Record these results in the patient’s problem list. Ask questions of the child (or parent where applicable) when there are red flags including: unexplained somatic complaints; unexplained behavioural changes; teenage pregnancy; school absences and family members with depression, anxiety, alcohol or other substance abuse.
Family involvement is invaluable for assisting with and monitoring treatments as well as providing assurance and emotional support for the child or youth. Assure the family that the questions and fact-finding is not to assign blame but to better understand the situation. Choose an appropriate diagnostic questionnaire available for download on the internet. If the screen indicates a possible problem then either begin or schedule time to begin a detailed inquiry about anxiety or depressive symptoms, evaluate severity, and the potential for self-harm. Consider that there may be more than one psychiatric disorder when screening because anxiety and depressive disorders are highly comorbid in children and adolescents. Refer to Appendix A Diagnosis of Anxiety Disorders in Children and Youth for descriptions of these disorders. All youth with mood or anxiety disorders should be screened for alcohol or drug use. Note red flags for risk of bipolar depression: family history; psychotic depression; ma nia with Selective Serotonin Reuptake Inhibitors (SSRIs); hyper-sexuality; risk-taking behaviour and pre-pubertal depression. Consider referral if bipolar disorder is suspected. Manage the patient while waiting for referral (see management considerations) and provide follow-up. DiagnosisTake a medical history and do a physical examination with attention to conditions that may mimic anxiety or depressive disorders. Consider indications for diagnostic tests such as TSH. Consider the family situation and social stressors. Refer to Appendix A for descriptions of anxiety disorders, examples of anxiety disorders appearing as another disorder, prevalence, development, and treatment tips. If post-partum depression is possible, consider referring for treatment. Manage while waiting for referral and provide follow-up. Management ConsiderationsRemember the basics: regular sleep, eating and exercise routines, along with consistent effective parenting are essential.1 Enlist the family for help in supporting the child with the treatment plan. Reassure them that they are not being blamed for the problems but that they can provide valuable help with developing and enacting a treatment plan and can help provide reassurance to the child or youth throughout the process. Consider the strengths of the family (and possibly larger community and school), use these and build upon them in the treatment plan. Make a diagnosis if possible, and then begin to treat or refer as appropriate.
Set these treatment goals:
Monitor management regularly:
Avoid these common pitfalls:
Attempt non-pharmacological management strategies firstNon-pharmacological approaches are essential first-line treatments for both anxiety2-7 and depression.2-3 It is likely that your initial visits along with parent input and books that are read by parent and child will affect a significant response. If physician counseling, parental involvement and use of books does not effect a significant improvement it is appropriate to refer to a specialist or to the Child and Youth Mental Health team for treatment. Treatment Algorithm for Children and Youth with Anxiety or DepressionTreatment TypeI. Cognitive Behavioural TherapyAnxiety: The evidence-based psychological treatment for anxiety disorders is Cognitive Behavioural Therapy (CBT), a brief, directive therapy to promote realistic and adaptive thinking patterns and build behavioural competence through graduated exposure.2-7 Depression: CBT is also considered effective for child and adolescent depression.2,3
There is evidence of benefit using Interpersonal Psychotherapy (IPT) but it is not as strong as for CBT.8 IPT is similar to CBT but has more focus on interpersonal problem solving. There are fewer professionals trained in IPT treatment.
II. Pharmacological Management StrategiesIn general, pharmacotherapy alone is not recommended for children and adolescents. Its use should ideally be preceded and complemented by psychotherapy and/or behavioural therapy. Employ pharmacological management strategies if non-pharmacological interventions are not achieving therapeutic goals. If required, these are the issues to be considered. There is very little peer reviewed evidence as to the safety or efficacy of SSRI medications for the treatment of anxiety and/or depression in young children. Approximately two-thirds of randomized placebo controlled pharmacological trials for depressive disorders in children and adolescents consider an age range starting from ages 6-8 through to ages 17 or 18, while the other third of cases consider ages 12-13 through 17-18.9-18 Given the above, no SSRIs are approved for marketing in Canada as appropriate medications for patients under age 18. Refer to the Health Canada statement below.21 “It is important to note that Health Canada has not approved these drugs for use in patients under 18 years. The prescribing of drugs is a physician’s responsibility. Although these drugs are not authorized for use in children, doctors rely on their knowledge of patients and the drugs to determine whether to prescribe them at their discretion in a practice called off-label use. Off-label use of these drugs in children is acknowledged to be an important tool for doctors. Doctors are advised to carefully monitor patients of all ages for emotional or behavioural changes that may indicate potential for harm, including suicidal thoughts and the onset or worsening of agitation-type adverse events.” Adding pharmacotherapy to the non-pharmacological approaches needs to be done with careful monitoring, while informing patient and family about risks and benefit. An emergency safety plan should be made when there is moderate to severe symptoms, whether or not pharmacotherapy is used. Indications for pharmacotherapy include: persistent depression and/or a comorbid anxiety disorder which have not responded to psychosocial interventions. Anxiety: Drugs most often used are fluoxetine, fluvoxamine, or sertraline for Generalized Anxiety Disorder (GAD) and mixed anxiety, including social anxiety disorders and obsessive compulsive disorder (OCD). 9-14 SSRIs appear to be generally somewhat effective in randomised control trials in anxiety. Benzodiazepines are not recommended because of anger, disinhibition, habituation and irritability response. Depression: Psychotherapy can be effective for treating depression, particularly in adolescents. If unavailable, medications may be indicated. 15-18
The majority of randomised control trials in depression show no significant benefit of SSRI medications over placebo. Spontaneous remission in community diagnosed adolescent depression is 50% within two months. However, those not remitting in this time period have a high risk of chronicity. Refer to a specialist. Medication Dosing and Follow-Up for Anxiety and DepressionInitiation and Continuation: Pick target symptoms to self-monitor and document weekly (give form to parent or teenager - Appendix C or download from http://www.cpsbc.ca). Ask families and caregivers to help by daily monitoring the child or youth for worsening symptoms or any unusual changes or behaviours, particularly any emergence of suicidality. Discuss an emergency plan as well as planned follow-up. General Dosing Suggestions: Start with ¼ or ½ of the adult dose and wait at least one week to increase dosages. For adolescents, the maximum dose can be similar to adults, while the dose is less than the adult dose for children.19
Adverse Effects: In children, SSRIs and other new anti-depressants produce a higher rate of behavioural and emotional adverse effects (such as: agitation, disinhibition, irritability and occasionally thoughts of self-harm). The largest drug-placebo difference in the number of cases of suicidal ideation and behaviour is greatest for the under-24 age group. For all ages, the risk is highest during the first few months of drug therapy, therefore, monitor patients closely during this time. For more information, review the product monograph, Health Canada warnings for SSRIs at http://www.hc-sc.gc.ca, and the United States Food and Drug Administration (FDA) website at http://www.fda.gov. Monitoring: Request assistance of the family and/or teenager, to monitor both symptoms and functions. Use the SSRI Monitoring Form (Appendix C) and link below) as well as Measurement of Functional Change (Appendix D). Continuation: For both anxiety and depression the usual length of treatment is 6-12 months before a trial of tapering. Discontinuation: Anxious patients are very sensitive to physical sensations during discontinuation. So, taper off particularly slowly over 1-2 months by approximately 5 mg per reduction. For slow smooth tapering, capsules can be opened and/or pills divided. Refer to Pharmacare Plan G if financial assistance is needed for medication coverage. Information is available at http://www.health.gov.bc.ca/pharmacare and the form is available at http://www.health.gov.bc.ca. Referral to SpecialistIndications for referral to a specialist:
Referral options (also refer to other resources in the Resource List for Physicians)
RationalePsychiatric disorders in children and youth are under-detected in health care settings. Symptoms are likely to be missed unless they are severe or accompanied by physical illness.25 Under-detection represents a serious omission given the research evidence establishing effective treatments for both anxiety and depression in children.1-18 The prevalence of anxiety disorders in children aged 5 to 17 is 6.4%.22 The debilitating nature of these disorders is routinely underestimated and the need for help may not be realized until serious impairment in social and academic functioning has occurred.23 Untreated anxiety disorders in children and adolescents are associated with higher rates of comorbid depression and substance abuse.24 Depression affects 3.5% of children at any given time, impeding healthy psychosocial development.1 Diminished self-worth, academic struggles, and difficulties in social relations with family and peers exert a heavy toll on youth who are often unable to communicate the nature of their experience. Clinical depression during adolescence represents the strongest risk factor for teenager suicide and is linked to significant psychosocial impairment in adulthood.23 Periodic screening of children presenting -- for any reason -- to primary care physicians can improve clinical recognition of these disorders and result in improved rates of treatment.26 References
List of Abbreviations
AppendicesAppendix A – Diagnosis of Anxiety Disorders in Children and Youth (PDF 45K) Appendix B – Treatment of Anxiety Disorders and Depression in Children and Youth (PDF 69K) Appendix C – Selective Serotonin Reuptake Inhibitor (SSRI) Monitoring Form (PDF 48K) Appendix D – Measurement of Functional Change in depressed and/or Anxious Patients (PDF 31K) Associated DocumentsThe following documents accompany this guideline:
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Revised Date: March 5, 2010This guideline is based on scientific evidence current as of the effective date. The principles of the Guidelines and Protocols Advisory Committee are to:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Adobe Reader' icon.
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