Antidepressants in under 18s

Policy: Primary Care Management of Antidepressants for Patients Under 18

Purpose: This policy outlines why primary care does not initiate antidepressant treatment for patients under 18 years of age, ensuring evidence-based, safe, and effective care in compliance with national guidelines.

Policy Statement

In primary care, antidepressants are not initiated for individuals under 18 years old. Management of depression or other mental health conditions in this age group requires specialized input due to the complexities of diagnosis, treatment, and monitoring. Initiation of antidepressants should occur under the guidance of a specialist in child and adolescent mental health.

Rationale

Specialist Expertise: Depression and other mental health conditions in children and adolescents are multifaceted and may present with overlapping symptoms with other conditions, including developmental disorders. Specialist assessment ensures accurate diagnosis and treatment tailored to the developmental and psychosocial context of the patient.

National Guidelines: The National Institute for Health and Care Excellence (NICE) recommends that antidepressants should only be prescribed for under-18s following assessment by a Child and Adolescent Mental Health Services (CAMHS) clinician and as part of a broader treatment plan, including psychological interventions. NICE also specifies fluoxetine as the first-line antidepressant for under-18s, initiated only after psychological therapy has been attempted unless symptoms are severe.

Safety Considerations: The under-18 population has an increased risk of adverse effects from antidepressants, including heightened suicidal ideation, agitation, and behavioural changes. Specialist care ensures close monitoring for these risks, particularly during the initiation and adjustment phases of treatment.

Psychological Therapies as First-Line Treatment: Evidence supports psychological therapies, such as cognitive-behavioural therapy (CBT), as the most effective and safest initial treatment for mild to moderate depression in young people. Antidepressants are generally reserved for moderate to severe cases or when psychological therapies alone have not been effective.

Continuity and Coordination of Care: Initiating antidepressants in primary care without specialist involvement may disrupt the coordinated care provided by CAMHS, which includes ongoing monitoring and access to multidisciplinary expertise. Collaboration with CAMHS ensures the patient and family receive holistic support.

Procedure

Referral to Specialist Services: Any young person presenting with symptoms of depression or other mental health concerns should be referred to Healthy Minds or the Primary Care Network Child and Adolescent Mental Health Worker for comprehensive assessment and management. Urgent referral should be considered for severe cases, including those with suicidal ideation or significant functional impairment.

Primary Care Role: Provide initial support, including psychoeducation, signposting to self-help resources, and liaison with schools or other agencies as appropriate. Monitor symptoms while awaiting specialist input and escalate concerns if necessary. This will normally be provided by the PCN mental health worker.

Shared Care: If antidepressant treatment is initiated by a specialist, primary care may take on a shared care role, including prescribing and monitoring under specialist guidance. This is decided on a case by case basis.

Exemptions: In exceptional cases, where immediate specialist input is unavailable and the patient’s condition is severe or life-threatening, primary care clinicians may consider initiating treatment but only in consultation with CAMHS or a consultant psychiatrist.