Dr Jane Roberts, RCGP Clinical Champion for Youth Mental Health and Chair of the RCGP Adolescent Health Group, looks at the implications of new NICE quality standards for management of depression in children and young people
Mental health problems among children and young people are a major concern. Globally they represent the single largest category of health concerns for 10-24 year olds. 1 Nationally we have conservative estimates that between 1 in 10 young people experience significant psychological distress which interferes with living a healthy, happy, productive life. Depression is particularly important to recognise in young people because of its high association with self-harm and suicide.
The new Quality Standards recently published by NICE (see p.7) refer to the 2005 NICE Guideline on Managing Depression in Children and Young People, 2 which described a stepped care model and called for frontline staff in primary care to be trained to detect depression. Psychosocial interventions were promoted as a better solution than medication. So what has changed in the intervening eight years since the Guidelines were published?
Firstly, low mood and rates of self-harm have increased. Collishaw et al report a two-fold increase in the last 20 years to 18% for girls reporting feeling frequently anxious or depressed (rates for boys, though lower, have also increased). 3 Regrettably there is no large national data base for youth mental health, but charities such as Young Minds report increases in rates of self-harming.4
Secondly, there has been no wide-scale introduction of educational support for GPs in training or practice in responding to youth mental health needs – even though we know that GPs consistently feel underprepared to deal with teenagers presenting with low mood or behavioural problems, the two most commonly seen presentations in surgery. The RCGP is calling for extended GP training, with mandatory time spent in paediatrics and mental health. Postgraduate medical training is currently under review, with the final report due out later this year.5
Thirdly, the financial crisis of 2008 has had a major impact on provision and delivery of services. A survey conducted by Young Minds (2012) found that 77% of Child and Adolescent Mental Health Services (CAMHS) staff reported a cut in the 2012/2013 budget, 74% reported a drop in staffing numbers, and 68% said the threshold for accessing services had increased (www.youngminds.org.uk).
At the same time the demand in general practices has increased steadily, with consultation rates now at 5.5 per patient with a mean duration of 11.7 minutes. This translates into pressured consultations, which we know disadvantage young people, who need time to build up trust and confidence in opening up to their GP and who worry about confidentiality.
On a positive note, the launch of Children and Young People’s Improving Access to Psychological Therapies (IAPT) Service (2011) has strengthened the delivery of evidence- based care through CAMHS. But there has been no increase in the numbers of professionals offering therapy, and 75% of GPs report waiting 5-13 weeks to access the service.6
The RCGP nomination of Youth Mental Health as a clinical priority recognises the importance of supporting GPs to identify early signs of psychological distress, including depression, resulting in earlier detection and better outcomes for young people, given the high recurrence rates of depression in later life.
1 WHO. Prevention of Mental Disorders: Effective Interventions and Policy Options Geneva: World Health Organization, 2004.
2 NICE. Depression in children and young people: identification and management in primary, community and secondary care. National Clinical Practice Guidelines. London: NICE, 2005.
3 Collishaw S, Maughan B, Natarajan L, Pickles A. J Child Psychol Psychiatry 2010;51(8):885-94.
4 Young Minds. Young people and self-harm London, 2013. 5 The Shape of Training, led by Profresor David Greenaway. http://www.shapeoftraining.co.uk 6 RCGP Youth Mental Health Clinical priority. Survey conducted by RCGP CIRC May 2013.
Jane Roberts will be writing on the management of depression in younger people in the next issue of BJFM