The UK’s “National Institute of Health and Clinical Excellence” – abreviated to NICE – issued guidelines on treating under-18s with depression. NICE is intended to give doctors best practice in treatment. In part this is driven by a cost saving for the National Health Service by not giving outdated or inappropriate treatments that have been shown not to be as effective.
Although the advice is intended for UK doctors and can include references to medical structures not present in the USA – it can be really useful background reading for parents whose children have illnesses. In this case there is also some useful advice for teachers and other similar professionals in identifying children with depression. The most important recommendation certainly has relevance to the US scene. It is that drugs alone should not be used. To quote the press release:
o Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy (such as cognitive behavioural therapy, interpersonal therapy or family therapy of at least 3 months’ duration).
o Antidepressant medication should not be offered to children or young people with moderate to severe depression except in combination with a concurrent psychological therapy and should not be offered at all to children with mild depression.
o Healthcare professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression, and to assess children
and young people who may be at risk of depression.o Attention should be paid to the possible need for parents’ own psychiatric problems (particularly depression) to be treated in parallel, if the child or young person’s mental health is to improve.
Now I am not intending to offer you advice if you have already consulted a doctor. What you might want to do is look at the recommendations and the advice that is available in the various booklets. This page lists those and the formats they are available in. The formal guidelines have some interesting flow-charts about treatment decision but I will re-iterate the caution that some references are specific to the organisation of health treatments within the UK. Also remember these are also based on assessments of benefits against risks. There are considerable benefits and no health risks from talking therapies whereas the medications do carry risks of physical harming. Also note that even the recommended drugs are not licenced for use with children in the UK. If you investigate, you are likely to find the same applies in the USA.
The papers do point out a problem in the UK of a lack of trained therapists and I suspect a similar position for those specialised in treating the young will be similar in the USA. I also get the impression that anti-depressants are far more widely prescribed for children in the USA than here.
The guidelines do point out that medication alone is far less effective than in combination with a talking therapy. If anything, it will provide ammunition to argue with insurance companies etc about the best forms of treatment for your children. Simply pointing out the long term savings may well be enough to sway them to provide best practice.
Very important subject, Londonbear. Having been a teacher for 25 years, 9 of those years were in 2 gradeschools, the issue of diagnosis is always a big one. Many if not most depressed children that I have known were like that because of their family situation. If things have gotten that bad at home, usually one if not both parents were in denial of their own problems, never mind the children.
My job was being able to initially pinpoint any issues that were effecting a child’s academic performance. Then we would try to help in the classroom setting. Failing that, we would recommend the next level, whether that meant testing for learning disabilities, or behavioral problems, etc. Treatment for a depressed child that doesn’t include family counseling, in many if not most cases, is useless in my opinion. The UK has it right… I wish we had such specific recommendations that could be presented to parents in the USA.
became very depressed. She took Prozac for six months and kind of drifted around the house like a ghost. Since my husband has come home she has been able to work through a lot of her anger and despair about him being in Iraq and says that the Prozac was horrible and that she felt like she couldn’t feel anything, totally numb…..she said never again and if she becomes depressed again as a teen we will be heading right to a very good counselor’s office!
Prozac is one of the very few anti-depressants they suggest could be used in combination with talking therapy. Actually they suggest it is used as the first drug but only after therapy has made no progress (look at the detailed guidance) I also have severe reservations about anyone taking Prozac because of the very symptoms you describe (and a couple of others they do not acknowledge). Alternatives are suggested in the guidelines and these are given by their technical rather than brand name so there should not be problems about a doctor identifying it.
If your daughter still has to have drugs after getting therapy for a while, make sure she is only prescribed the ones on the NICE list. Some others should never be prescribed to young people, even up to 30 or older, as they can induce self-harming or violent behaviour. Also make sure she comes off the drugs in a controlled and supervised way, not “cold turkey”. Again, that is set out in the detailed guidance for doctors but in technical language.
Tracy, you obviously have the common sense to listen to your daughter. Sounds like you are very much aware of her issues and have been able to work through many of them… good for you and great for your daughter. I just wish individual and family counseling was the first line of defense here in America for juvenile depression. Time after time I was the sounding board for our school nurse who never ceased to be appalled at some of the meds our kids were on. (Many much worse than Prozac) She was so aware and knowledgeable, and used to get herself in hot water all the time by opening her mouth to administration and parents. God love her, she really cared. I learned a lot from her. I think that parents aren’t offered enough information or options for depression.
Why does it not surprise me that you’ve figured this out on your own? You have what we call in these parts ‘horse sense’… either you have it or you don’t, and you, my friend, definetly have it. 😉
I teach high school in a district that is too poor to have a psychologist. We have 3 or 4 social workers for 7 buildings. More funding to support mental health would be very well spent.
Thank you for posting this excellent diary, LondonBear. I like the NICE guidelines a great deal though I can’t judge how physicians might evaluate them
Admission here: Childhood depression is one of my particular specialties in my work in psychology.
Depression in children and teens a serious problem, and far more of it exists than most people are aware. As you noted, most teachers and parents don’t know about it. School staff in particular overlook depression as a possibility unless the child is disruptive, because a quiet, sad child usually isn’t causing trouble. It’s the squeaky wheel, etc.
And your daughter’s experience with Prozac, MTracy, is not unusual – except the medication shouldn’t be zombifying any child if the dose is correct. Trouble is, as I’ve told many people , the meds work mostly on the biology of depression, they don’t do anything for circumstances that brought on the depression. In other words, kids who become depressed when everything is ok in their lives, as some do, will possibly show the greatest improvement from getting one of the approved meds for depression in kids. But if things outside of the child’s biology are a big problem, the pills don’t take that away. Yes, the child might, might sleep better, concentrate better, have a more even appetite and energy level, but the difficulties in their environment continue. Would you expect a child to be “happy and well-functioning” with a parent in a war zone, for example? Of course not!
[I have to note again as so many have, MilitaryTracy, you are one fearsomely sensible person!]
I’m not anti-med, although I would never be in a position to prescribe medications, and that’s fine with me. However, I have seen them help children for a variety of emotional problems, including depression, when they are done right.
What I haven’t seen is general excellence in working with parents while a child is trying out meds:
working closely with a family to get medication adjusted to avoid side effects while trying to see if it will work for their child. Helping families understand that medication requires close attention to their child and trying to make the child’s life better beyond the meds and therapy, too. Getting counseling to go along with the medication. Helping the child and the family understand that medication for emotional problems is not like aspirin – you don’t just take it on days when you feel down, and skip it on days when you feel good. Helping parents and teachers understand that you don’t attribute kids successes to the meds and their failures to their not taking their meds. Helping children understand that the meds and/or the therapy is not some sort of magic wand. Helping the parents and teachers understand that when depression lifts, the child will still need help with whatever she has missed or learned badly or not at all while she was in deepest distress. The list could go on.
And last of all, you are absolutely correct, LBear, that therapy for kids is in short supply here in the states – as is any kind of help with children’s emotional problems. Therapists for children are very hard to find. Regular physicians don’t usually get much if any training in children’s mental health problems, not even pediatricians or family physicians. And our health insurance is so bad for these kinds of difficulties. . . I’ll stop with that.
the medication shouldn’t be zombifying any child if the dose is correct
In my experience with Prozac — which, along with my therapist, helped me tremendously when I had severe depression a few years ago — it does have a numbing effect even in very small doses. It was as if I couldn’t really feel anything at all emotionally (or sexually either, which is a well-known side effect for some people.) I didn’t like feeling numb, tried tapering my dosage down, and finally quit altogether after a year or so.
I don’t think I suffered from childhood/teenage depression myself, but I know a lot of people who did. One of the problems that I’ve seen a lot is the perception that taking medication or getting counselling for depression is somehow “shameful” or indicates “weakness”, and thus should be put off for as long as possible, so you can “fight” it yourself. Inevitably, this just seems to screw people up.
(But I’m by no means trained in psychology, and this is merely anecdotal evidence.)
Thank you for this post, Londonbear. Several years ago, when doing graduate courses in psychology, I read a book called “Infant and Childhood Depression” by Paul Trad. This book influenced me and my parenting strategy profoundly. So did John Bowlby’s trilogy.
I worry about this a lot in my son. Mood disorders run in my family at a much higher rate than in the general population. So far my son is doing very well, but he’s a little more than a year away from that vulnerable age (17-ish).
You’ve been doing the right thing by watching out for difficulties for your son. Children in families where depression appears to come up by a familial/genetic strain are more likely to become depressed in childhood compared to other children without that family history. The fact that he did not is very good. He is at a vulnerable age, perhaps moreso when he leaves home to go to college. I hope he finds a school with a good support system for students.
Best wishes for him!
Thank you for you helpful words. One thing about him is that he was an adorable but high-maintenance infant and young child. He insisted on high-quality attention! I have a feeling this is a great survival strategy and a sign of resilience. He makes sure he gets what he needs, but in a very nice way.
That’s consistent with what I know. The kids that do best are those that manage to get what they need from adults – and in good ways, rather than by feeling bad or being bad. It sounds like your son has a good personality for dealing with whatever he faces, and you’ve done a good job as his parent. Nothing better for giving a kid a good send-off in life than having a great parent – he is very lucky!
Great diary Londonbear and great comments as well. Over the last few years particularly, because my oldest daughter is now 15, and because our family is blessed (so far, crosses fingers) with open and free wheeling communication, I’ve heard some disturbing things from her about many of the kids she knows who are in her age group. A large number of the girls have taken up the practice of cutting. Certainly some or even most are doing this in an effort to banish emotional pain by replacing it with self inflicted pain. This is bad enough in itself, but from listening to her, it appears that many of them are doing it in a copycat fashion, like it’s the new cool thing to do. I believe that some of what passes for legitimate piercing that seems to be so popular is just another way of cutting or seeking self inflicted pain too. This freaks me out because in the town I live in, it seems like there is a giant blind eye turned toward it. Sort of a this doesn’t happen here attitude. To make matters worse, I know that a lot of the kids are being medicated for depression as a first course of action when i believe that counseling/therapy should probably be considered first, including family members, because there must be some deeply rooted issues going on inside a lot of these families to cause a child to harm themselves in this way. I just find it very frustrating that more and more emotional and mental illness issues are being painted with the broad medicate, medicate, medicate brush. How does this get at the root of the problem? To me it’s just a less violent way of covering up or numbing down the issue that is causing the behavior in the first place.
An excellent diary on a critical topic. Highly recommended.
Poor nutrition may be a factor in some depression/violent behavior according to Vitamin Cure:
Can common nutrients curb violent tendencies and dispel clinical depression? by Susan Freinkel in Discover Magazine.
Most of the evidence is anecdotal so far, but scientific studies are underway and preliminary results seem to back up the anecdotal evidence.
Since the article requires a subscription, I’ll excerpt a bit:
I found this on the newswire. Hope for Americans, possibly.