We certainly agree with authors Hodes & Garralda (Psychiatric Bulletin October 2007, 31, 361–362) who observe that there are flaws in the National Institute for Health and Clinical Excellence (NICE) guidelines and a lack of available evidence for the treatment of depression in children and young people. During basic training in psychiatry, a trainee is encouraged to follow the NICE guidelines, Maudsley guidelines and others when initiating any intervention.
The same principle applies to the speciality of child and adolescent psychiatry. However, as a trainee in this speciality we have noticed that there are different factors that contribute to the use of pharmacological interventions.
As the authors mention, these trials demonstrated the benefit of fluoxetine over and above that of cognitive–behavioural therapy (CBT). This is supported by the TADS study (Reference March, Silva and PetryckiMarch et al, 2004) and by the ADAPT trial (www.iop.kcl.ac.uk/projects/?id=10095).
Another concern is the low availability of CBT as a first line treatment for adolescents with moderate to severe depression (Reference Perera, Gupta and SamuelPerera et al, 2007).
Consider the teenager presenting in crisis after an intentional overdose, or serious deliberate self-harm, following traumatic life events and family disruption. Thought must be given to the family's ability, resources and motivation to support the young person through CBT.
It is clear that the authors are not advocating indiscriminate prescribing of antidepressant medications, but it also seems that the NICE guidelines for depression do not fully appraise the ‘real world’ situation with respect to resources and patient choice.
We trust that NICE recognises this and plans a timely review of its recommendations. We continue to exercise our clinical acumen and review the available evidence when treating the young people that we see.
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