Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.

Treatments for mild depression

Recommendations 1.5.4 to 1.5.11

Why the committee made the recommendations

Making choices about treatments

To ensure that children and young people with depression and their families or carers (as appropriate) receive the best possible care and can take part in shared decision making, the committee recommended that healthcare professionals explain the treatment options, what these are like in practice and how different psychological therapies might best suit individual clinical needs, preferences and values. The discussion should also cover the evidence for the different treatments and make it clear that there is limited evidence for effective treatments for 5- to 11‑year‑olds.

The committee recognised that some children and young people have difficulties accessing treatment because of lack of transport (particularly in rural areas), chaotic family lives, being in a young offender's institute or being in care. They agreed that the healthcare professional should not only think about clinical needs, but also take into account the child or young person's personal/social history, the current environment, the setting where the treatment will be provided and individual preferences and values. In addition, certain therapies may not be suitable or may need to be adapted for use with children generally or those with comorbidities, neurodevelopmental disorders, learning disabilities or different communication needs (due to language or sensory impairment). To ensure that these factors are part of the decision-making process, the committee included them in the full assessment of needs.

Psychological therapies for 5- to 11‑year‑olds with mild depression

The evidence for psychological therapies for 5- to 11‑year‑olds was confined to group cognitive–behavioural therapy (CBT), and although depression symptoms were reduced at the end of treatment compared with waiting list/no treatment, this was not maintained in the longer term. There were no data for other outcomes such as functional status or remission. As a result, the committee decided to recommend the same interventions that were effective in 12- to 18‑year‑olds for this age group, but adapted for their age and developmental level.

Because of the limited evidence for effective treatments for 5- to 11‑year‑olds with mild depression, the committee made a research recommendation to try to stimulate research in this area.

Psychological therapies for 12- to 18‑year‑olds with mild depression

Analysis of the evidence for 12- to 18‑year‑olds with mild depression showed that digital CBT (also known as online CBT or computer CBT), group therapies (group CBT, group interpersonal psychotherapy [IPT] and group non-directive supportive therapy [NDST]), individual CBT and family therapy reduced depression symptoms or improved functional status by the end of treatment and up to 6 months later compared with a waiting list control or no treatment. In some cases, such as digital CBT, these positive effects persisted for longer than 6 months, but information on long-term effects was not always available. Digital CBT was also better than other psychological therapies at reducing depression symptoms longer term.

The committee agreed to base recommendations for psychological therapies on clinical effectiveness and cost. The average costs estimated for digital CBT and group therapy (CBT, IPT and NDST) were lower than those for individual CBT and family therapy. Taking the magnitude of effect, the estimated cost and the size of the evidence base into account, the committee agreed that a choice of digital CBT, group IPT, group NDST or group CBT should be offered first.

However, the committee recognised that digital CBT is not well defined and the evidence for effectiveness came from studies using a variety of different programmes. In addition, digital CBT can be delivered with support (from a healthcare professional) or as an unsupported intervention. It is unclear whether unsupported or supported digital CBT is more effective and which programmes would be most effective for use in the UK. As a result, the committee made a research recommendation to inform future guidance.

Individual CBT and family therapy were among the more expensive options. Individual CBT had a smaller effect on depression symptoms than digital CBT or group therapy (CBT, IPT or NDST). Individual CBT had a meaningful effect on functional status; this outcome was only reported in a study that recruited young people with depression and a comorbidity. Family therapy showed meaningful effects on depression symptoms, but these results were based on a single study.

The committee acknowledged that digital CBT, group CBT, group IPT and group NDST may not be suitable for everyone and that individual CBT or family therapy could be considered in these situations. They specified attachment-based family therapy in the recommendation because that was the type of family therapy used in the study.

The committee agreed not to make a recommendation for individual NDST or guided self-help because:

  • Individual NDST was not more effective at reducing depression symptoms at the end of treatment or at 6 months' follow‑up than control and there was no evidence for functional status or remission.

  • Although guided self-help reduced depression symptoms at the end of treatment compared with a waiting list control/no treatment, this was not sustained at later time points. In addition, guided self-help was no more effective at reducing depression symptoms at the end of treatment, and was either less effective or no more effective at later time points, than the recommended group therapies (group CBT, group IPT, group NDST), digital CBT, individual CBT or family therapy.

The committee made a research recommendation aimed at investigating the effectiveness of behavioural activation compared with other psychological therapies. They agreed that behavioural activation may meet the needs of some children and young people with depression that are not already covered by the other recommended psychological therapies. In particular, it might suit children and young people who struggle with the concepts of CBT, and children and young people with learning disabilities or neurodevelopmental disorders. The only evidence for behavioural activation came from a single small study (60 participants) that found no difference between behavioural activation and usual care, but this may have been because of the small study size.

The committee also made a research recommendation for group mindfulness, because, although it was more effective at reducing depression symptoms post treatment and at 6 months' follow‑up than a waiting list control/no treatment, there was no evidence for other key outcomes such as functional status or later time points, and the evidence came from a single small study.

How the recommendations might affect practice

The recommendation for digital CBT or group therapy (CBT, IPT or NDST) for children and young people with mild depression is not likely to result in increased resource use. It may even result in lower resource use if these interventions reduce the need for intensive individual therapies. Individual NDST and guided self-help are no longer recommended and the net resource impact of this change is therefore unclear.

Full details of the evidence and the committee's discussion are in evidence review A: Psychological interventions for the treatment of depression.

Return to recommendations

Treatments for moderate to severe depression

Recommendations 1.6.1 to 1.6.6

Why the committee made the recommendations

Making choices about treatments

As for mild depression, the committee agreed that children and young people and their families or carers should be empowered to take part in shared decision making. Healthcare professional should also think about a number of key factors, including history, individual circumstances, comorbidities and developmental level and maturity.

Psychological therapies for 5- to 11‑year‑olds with moderate to severe depression

There was some evidence for psychological therapies for children aged 5 to 11 years with moderate to severe depression, but this included very few interventions. The committee agreed that the child or young person and their family or carers should be made aware of this when making decisions about treatments.

In the analysis of evidence for 5- to 11‑year‑olds with moderate to severe depression, family-based IPT and family therapy were more effective at reducing depression symptoms at the end of treatment than psychodynamic psychotherapy; but psychodynamic psychotherapy was better than family therapy at maintaining remission 6 months later. However, the evidence base was small (3 studies) and none included a control intervention. In other studies that included a control, no interventions were better than the control at reducing depression symptoms after treatment or at later time points.

Despite the limited evidence for 5- to 11‑year‑olds, the committee agreed that treatment was important for these young children. They agreed to recommend the treatments (family therapy, family-based IPT and psychodynamic psychotherapy) for which there was some evidence. They specified the types of family therapy used in the studies (family-focused treatment for childhood depression and systems integrative family therapy). They also included individual CBT in the recommendation because it was the most effective treatment for 12- to 18‑year‑olds with moderate to severe depression and they agreed that more mature children might benefit from this intervention.

Because of the limited evidence for effective treatments for 5- to 11‑year‑olds with depression, the committee made a research recommendation to inform future guidance.

Psychological therapies for 12- to 18‑year‑olds with moderate to severe depression

In an analysis of a large body of evidence for 12- to 18‑year‑olds with moderate to severe depression, individual CBT was better at reducing depression symptoms and improving functional status, quality of life and suicidal ideas compared with waiting list/no treatment, or usual care. It also increased remission at the end of treatment compared with attention control and other therapies (such as family therapy). Based on the size of these effects, the number of outcomes showing improvement and the size of the evidence base, the committee agreed to recommend individual CBT as the first-line treatment for young people with moderate to severe depression.

However, the committee recognised that individual CBT might not be suitable or meet the needs of all young people with moderate to severe depression and so they agreed that other therapies (IPT‑A [IPT for adolescents], family therapy, brief psychosocial intervention [BPI] and psychodynamic psychotherapy) could be considered as second-line options because there was some evidence supporting them, but this was less certain.

IPT-A and family therapy both increased functional status and depression symptoms at the end of treatment compared with waiting list/no treatment, or usual care (4 studies each). Family therapy was also better at inducing remission at the end of treatment than attention control.

The IMPACT trial could not detect a difference between BPI, psychodynamic psychotherapy and individual CBT over a range of outcomes and follow‑up times for 12- to 18‑year‑olds with moderate to severe depression. The committee agreed that BPI could be considered as an option when individual CBT is unsuitable. But they acknowledged that further research would be helpful to determine the effectiveness of BPI when delivered by a wider range of less senior practitioners and in other settings such as primary care.

Psychodynamic psychotherapy increased remission at the end of treatment compared with attention control or family therapy and relaxation. However, there was no evidence for functional status and psychodynamic psychotherapy was not more effective than control at relieving depression symptoms or improving quality of life post treatment. The data for this analysis came from the IMPACT trial[8], which found no detectable differences between the effectiveness of psychodynamic psychotherapy and individual CBT across a range of outcomes and follow‑up times. However, a second trial of this intervention was identified with participants that spanned both age groups. It was included in the analysis for 5- to 11‑year‑olds. The committee decided not to recommend psychodynamic psychotherapy as a first-line option because it was no better than control at reducing depression symptoms at the end of treatment and there were only 2 studies including this intervention.

The committee recognised that there were fewer studies of family therapy, IPT‑A and psychodynamic psychotherapy than for individual CBT, and the existing studies either lacked data for later follow‑up times or did not cover the full range of outcomes of interest. The committee wanted more evidence to support their use in young people with moderate to severe depression and they therefore made a research recommendation to look at the relative effectiveness of these interventions compared with each other and individual CBT.

The committee agreed that behavioural activation may meet the specific needs of some children and young people with depression. In particular, it might suit those who might struggle with the concepts of CBT and children and young people with learning disabilities or neurodevelopmental disorders. They made a research recommendation to inform future practice.

How the recommendations might affect practice

Individual CBT, family therapy, psychodynamic psychotherapy and IPT‑A are already in widespread use and, as a result, the recommendations are unlikely to change resource use. Brief psychosocial intervention is not commonly delivered in current practice. Although this represents a change in practice, it is a lower intensity intervention than other individual therapies and may therefore reduce overall resource use.

Full details of the evidence and the committee's discussion are in evidence review A: Psychological interventions for the treatment of depression.

Return to recommendations

  • National Institute for Health and Care Excellence (NICE)