Depression in young people

Antidepressants should be considered for treating children or young people with moderate to severe depression only in combination with concurrent psychological therapy and with careful monitoring for side effects, and they should not be used at all in children with mild depression. These are among the recommendations of a clinical guideline published this week for the NHS in England and Wales.

The guideline makes it clear that medication is not the first line treatment for children and young people with depression. Antidepressants should only be considered when psychological treatments are not working, and should only be used in combination with a psychological treatment. The guideline was developed for the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health.

Once depression has been diagnosed and assessed, the guideline recommends that children and young people with moderate to severe depression should be offered a specific psychological therapy, such as cognitive behaviour therapy, interpersonal therapy, or family therapy. Fluoxetine was recommended as the only antidepressant for which trials show that its benefits outweigh the risks, with sertraline or citalopram recommended as second line treatments. The guideline cautioned that paroxetine and venlafaxine, tri-cyclic antidepressants, and St John's wort should not be used in children or young people.

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Self help books do not reduce GP consultations

Giving patients self care health books does not reduce the number or length of consultations with their GP. The research study was based on nearly 2000 patients in a large general practice in the south east of England. It showed that although many of the patients who were given such books said they would be less likely to consult a doctor, the actual likelihood that they saw their doctor was the same as for patients who were not allocated books.

The researchers concluded that handing out of self-care health books may provide qualitative benefits for patients but is unlikely to reduce attendance at the GP practice. In the study 1967 adult patients who volunteered to take part in the study were randomised to receive one of two self help books or to a control group. The two books were the UK edition of the Healthwise Handbook and the NHS Direct Healthcare Guide. Data on consultations over the next 12 months were collected from searches of computer systems. Questionnaires asked participants about their use of the books.

Among the patients who were allocated a book, after three months 69% of those reporting a health problem and 49% of those who reported no problem had consulted their book. The percentages after nine months were similar. Some 60% reported that the book made them more likely to deal with a problem themselves, but the mean numbers and duration of consultations over the 12 months, including routine GP consultations and emergency consultations with a GP or nurse practitioner, did not differ between the three groups. The mean lengths of consultations in minutes in the control, Healthwise, and NHS Direct book groups were, respectively, 9.9 (95% confidence interval 9.6 to 10.1), 9.7 (9.4 to 9.9), and 10 (9.8 to 10.3).

The authors, from the Department of Epidemiology and Public Health at University College London and the Parkbury House Surgery, St Albans, also said that differences between the groups in numbers of visits to hospital emergency departments, home visits, and visits to nurse clinics were small and not significant.

A total of 160 of the patients made an average of 1.2 calls to NHS Direct, and an analysis showed that the odds ratio for calling NHS Direct was nearly double for patients who were allocated the NHS Direct guide.

The authors wrote, "The study shows that approximately half of patients given either self-care book consulted it compared with only a quarter of those in the control group who consulted any healthcare book . . . The books did not, however, reduce the number of visits to the GP. This is surprising given that around 57% reported that the book made them more likely to try to deal with their health problem themselves and around 40% reported that the book make them less likely to contact the practice," the report says.

One possible explanation for this apparent contradiction is that patients who dealt with their health problem with the help of one of the books later visited the GP for reassurance and confirmation.

"Using the approach we adopted, it seems unlikely that either of these books can reduce consultation rates or workload. We can, however, speculate as to whether the books may benefit the appropriateness or quality of patients’ consultations," the authors wrote.

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Home visiting for child health

The health development agency has published evidence on this topic. They suggest that there is insufficient evidence to suggest that home visiting programmes can have a beneficial impact on low birth weight or other pregnancy outcomes.

The findings from review-level studies of home visiting on child abuse present an incomplete and complex picture. Where positive effects have been found, they tend to be in measures of parenting rather than in direct measures of abuse. There appear to be significant methodological problems with measuring child abuse in trials of home visiting, with a serious problem of outcome report and surveillance bias.

As a result, there is inconclusive evidence for any impact of home visiting on child abuse outcomes in review-level data, and outcome report and surveillance bias are likely to be a threat to the validity of findings in current or future trials. There is good evidence to suggest that home visiting can have an impact in reducing rates of childhood injury. There is some evidence to suggest a beneficial impact of home visiting on measures of intellectual development in children; these effects appear to be most apparent among children with identified problems associated with low birth weight or failure to thrive.

There is insufficient evidence to determine the influence or effect of home-visiting interventions on immunisation or hospital admission rates. Evidence suggests that home visiting has the potential to encourage and support breastfeeding but more evidence is needed.

There is some weak evidence to suggest a positive effect of home-visiting interventions on children’s diets, but further research is needed to assess this effect in the light of methodological issues.

HPA on the NICE public health web page

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