DEPRESI PADA ANAK

Clinical Guideline sarka ade

PETUNJUK KLINIK
Direkomendasi untuk praktek yang baik yang didasarkan pada bukti (evidence based). Pedoman untuk standar yan kesehatan yang lebih baik dalam mengimplementasikan pedoman klinis Lembaga- Komisi Kesehatan akan memonitor kepatuhan dengan panduan.

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Alasan Pedoman:
Profesional yang terlibat dengan pengasuhan anakanak dan orang muda harus lebih mampu mengidentifikasi tanda-tanda depresi. Sekitar 75% dari kasus mungkin tidak terdeteksi Kenapa?

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DEPRESI TIDAK TERDETEKSI?

Pasien:
Gejala tidak dikenali Salah mengerti keparahan n konsekuensinya Terbatasnya akses yan kes Stigma gangguan jiwa Kepatuhan yg kurang

Tenaga Kesehatan
Edukasi yg kurang ttg gg jiwa Waktu konsults yg tidak cukup Ide/teori yg sdh terbentuk sebelumnya
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What this guideline covers

Best practice advice on the care of children and young people aged 5 18 years with depression

Recommendations for healthcare and other professionals who have a role to play in ensuring children and young people and their families and carers get appropriate care and support, in both primary and secondary care
A clinical description of depression based on ICD-10
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 Praktik terbaik nasihat tentang perawatan anak-anak dan orang muda berusia 5 -18 tahun dengan depresi

Rekomendasi untuk kesehatan dan profesional lain yang memiliki peran dalam memastikan anak-anak dan orang muda dan keluarga mereka dan wali mendapatkan perawatan yang tepat dan dukungan, baik dalam perawatan primer dan sekunder
Penjelasan depresi klinis berdasarkan ICD-10
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Prevalence
Pada setiap, waktu satu perkiraan jumlah anak dan remaja yang menderita depresi: 1 dari 100 anak-anak 1 dari 33 anak muda Angka Prevalensi melebihi angka pengobatan: sekitar 25% dari anak-anak dan orang muda dengan depresi terdeteksi dan diobati Bunuh diri adalah: 3 penyebab utama kematian di 15-24-year-olds 6 penyebab utama kematian di 5-14-year-olds

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Symptoms
Key symptoms
persistent sadness, or low or irritable mood loss of interests and/or pleasure fatigue or low energy

Associated symptoms
poor or increased sleep low self-confidence poor concentration or indecisiveness poor or increased appetite suicidal thoughts or acts guilt or self-blame agitation or slowing of movement

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Recommendations identified as key priorities

Assessment and coordination of care

Treatment considerations in all settings

Step 1: Detection and risk profiling

Step 2: Recognition
Step 3: Mild depression Steps 4 and 5: Moderate to severe depression

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 Pengkajian dan koordinasi perawatan Pengobatan pertimbangan dalam semua pengaturan Langkah 1: Deteksi dan profil risiko Langkah 2: Pengakuan Langkah 3: depresi ringan

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Diagnosing depression
KEY SYMPTOMS
persistent sadness, or low or irritable mood: AND/OR loss of interests and/or pleasure fatigue or low energy

ASSOCIATED SYMPTOMS
poor or increased sleep poor concentration or indecisiveness low self-confidence poor or increased appetite/nafsu makan suicidal thoughts or acts agitation or slowing of movements guilt or self-blame
Mild Up to 4 symptoms

Moderate 5-6 symptoms

Severe 7-10 symptoms

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The tiers (1-2)

TIER 1 Primary care services TIER 2 CAMHS Professionals relating to primary care workers GPs and paediatricians Health visitors and school nurses Social workers, teachers, juvenile justice workers Voluntary agencies and social services Clinical child psychologists and educational psychologists Paediatricians with training in mental health Child and adolescent psychiatrists and psychotherapists Counsellors and community and specialist nurses Family therapists

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The tiers (2-3)

TIER 3 CAMHS Services for more severe, complex or persistent disorders Child and adolescent psychiatrists and psychotherapists Clinical child psychologists Community and inpatient nurses Occupational therapists and speech and language therapists Art, music and drama therapists and family therapists

TIER 4 CAMHS Tertiary-level services

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Day units Specialised outpatient teams Specialised inpatient units

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The stepped care model

Focus
Detection Recognition Mild depression including dysthymia

Action
Risk profiling Detection in presenting children Waspada menunggu Non-direktif terapi suportif / kelompok terapi kognitif perilaku, dipandu self-help Brief psychological intervention +/ fluoxetine Intensive psychological intervention +/ fluoxetine

Responsibility
Tier 1 All tiers Tier 1 Tier 1 or 2

Moderate to severe depression Depression unresponsive to treatment/recurrent depression/psychotic depression

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Tier 2 or 3 Tier 3 or 4

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Step 1: detecting depression

Profesional di perawatan primer, sekolah dan masyarakat perlu: sadar akan faktor risiko terlibat 'mendengar aktif' dan 'teknik percakapan' mendeteksi gejala memberikan dukungan yang sesuai tahu kapan untuk merujuk

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Assessing and coordinating care

Perawatan harus bersifat komprehensif dan holistik dan mempertimbangkan: penyalahgunaan narkoba dan alkohol pengalaman bullying atau penyalahgunaan orangtua depresi risiko merugikan diri sendiri dan bunuh diri penggunaan bahan self-help dan metode masalah kerahasiaan

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Step 2: recognising depression

Untuk meningkatkan kemampuan mereka untuk mengenali CAMHS depresi profesional harus dilatih terutama dalam: penggunaan kuesioner laporan diri dan instrumen pewawancara berbasis skrining untuk gangguan mood dan ketrampilan dalam penilaian non-verbal suasana hati pada anakanak muda Sejarah keluarga dan dinamika keluarga

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Indications that management can remain at tier 1

Exposure to a single undesirable event in the absence of other risk factors for depression Exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm Exposure to a recent undesirable life event in the context of multiple-risk histories for depression in one or more family members (parents or children) providing that there is no evidence of depression and/or self-harm in the child/young person Mild depression without comorbidity
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 Paparan peristiwa tunggal yang tidak diinginkan tanpa adanya faktor risiko lain untuk depresi Paparan peristiwa kehidupan baru-baru ini tidak diinginkan di hadapan dua atau lebih faktor risiko lain tanpa bukti depresi dan / atau membahayakan diri Paparan peristiwa kehidupan baru-baru ini yang tidak diinginkan dalam konteks sejarah multi-risiko depresi pada satu atau lebih anggota keluarga (orang tua atau anak-anak) menyediakan bahwa tidak ada bukti depresi dan / atau membahayakan diri pada anak / orang muda Depresi ringan tanpa komorbiditas (gg lain yg menyertai)

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Step 3: mild depression

Treatment includes: up to 4 weeks watchful waiting non-directive supportive therapy group CBT guided self-help no use of antidepressants at this stage

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Criteria for referral to tier 2 or 3 CAMHS

Depression with two or more other risk factors for depression Depression with multiple-risk histories in another family member Mild depression and no response to interventions in tier 1 after 23 months Moderate or severe depression (including psychotic depression) Recurrence after recovery from previous moderate or severe depression Unexplained self-neglect of at least 1 months duration that could be harmful to physical health Active suicidal ideas or plans Young person or parent/carer requests referral
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 Depresi dengan dua atau lebih faktor risiko lain untuk depresi Depresi dengan sejarah beberapa-risiko anggota keluarga yang lain Depresi ringan dan tidak ada respon terhadap intervensi dalam 1 tier setelah 2-3 bulan Sedang atau berat depresi (termasuk depresi psikotik) Kambuh setelah sembuh dari depresi sedang atau berat sebelumnya Dijelaskan pengabaian diri durasi minimal 1 bulan yang 1 2 3 bisa 4 5 6 berbahaya 7 8 9 10 11 12 13 bagi 14 15 16 kesehatan 17 18 19 20 21 22 23fisik 24 25 26 27 28 29 30 31 32 33 34 Intro Context Key priorities and recommendations Implementation Info Aktif ide atau rencana bunuh diri

Steps 4 and 5: moderate or severe depression

General recommendations
Approach tailored to needs of family Familys preferences to be taken into account
E.g. when too depressed Does not want family involved

May require change of approach especially if symptoms deteriorate

Treatment starts with review by multidisciplinary team First line of treatment is specific psychological therapy for about 3 months
Individual cognitive behavioural therapy Interpersonal therapy Shorter-term family therapy
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 Rekomendasi Umum Pendekatan yang disesuaikan dengan kebutuhan keluarga Keluarga preferensi untuk diperhitungkan Misalnya bila terlalu tertekan Tidak mau terlibat keluarga Mungkin memerlukan perubahan pendekatan terutama jika gejala memburuk Pengobatan dimulai dengan review oleh tim multidisipliner Baris pertama pengobatan adalah terapi psikologis khusus untuk 1 2 3 4 5 6 7 8 sekitar 9 10 11 12 133 14 bulan 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Intro Context Key priorities and recommendations Implementation Info Masing-masing terapi perilaku kognitif

Steps 4 and 5: moderate or severe depression if unresponsive

If there is no response after 4-6 sessions
Multidisciplinary review Alternative psychological therapy that has not been tried Offer fluoxetine in combination with psychological treatment to young people (1218) and cautiously consider it in younger children (511)

If still no response after further 6 sessions

A further multidisciplinary review Systemic family therapy of at least 15 fortnightly sessions Individual child psychotherapy (30 weekly sessions)

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 Jika tidak ada respon setelah 4-6 sesi Multidisiplin tinjauan Alternatif terapi psikologis yang belum pernah dicoba Penawaran fluoxetine dalam kombinasi dengan pengobatan psikologis kepada orang-orang muda (12-18) dan hati-hati mempertimbangkan itu pada anak-anak muda (5-11) Jika masih tidak ada respon setelah lebih 6 sesi Suatu tinjauan multidisiplin lebih lanjut Keluarga terapi sistemik minimal 15 sesi dua minggu Individu anak psikoterapi (30 sesi mingguan)
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Referral criteria for tier 4 services

High recurrent risk of acts of self-harm or suicide

Significant ongoing self-neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to physical health)
Intensity of assessment/treatment and/or level of supervision that is not available in tiers 2 or 3

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 Tinggi berulang risiko tindakan merugikan diri atau bunuh diri

Signifikan yang sedang berlangsung pengabaian diri (seperti kebersihan yang rendah atau penurunan yang signifikan dalam makan yang dapat berbahaya bagi kesehatan fisik)
Intensitas penilaian / pengobatan dan / atau tingkat pengawasan yang tidak tersedia di tingkatan 2 atau 3
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Unresponsive depression
Reassess if no response Offer more intensive psychological treatments
alternative psychological therapy which has not been tried systemic family therapy individual child psychotherapy

Consider combining with SSRIs

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 Menilai kembali jika tidak ada respon Psikologis menawarkan perawatan yang lebih intensif alternatif terapi psikologis yang belum pernah dicoba keluarga terapi sistemik psikoterapi individu anak Pertimbangkan menggabungkan dengan SSRI

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The limited place for antidepressants

Should only be prescribed following assessment by a psychiatrist Should only be offered in combination with psychological treatments First-line treatment is fluoxetine* Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, St Johns wort Monitor for agitation, hostility, suicidal ideation and selfharm and advise urgent contact with prescribing doctor if detected
* Fluoxetine does not have a UK Marketing Authorisation for use in children and adolescents under the age of 18 at the time of publication (Sept 2005)
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The limited place for antidepressants

Sertraline or citalopram* as second-line treatment Consider adding atypical antipsychotic if psychotic depression Continue for 6 months if remission, then phase out over 612 weeks Issues:
Discussion, consent and written advice important Pre- and post-prescribing monitoring Continuation of medication post recovery *
Sertraline and citalopram do not have a UK Marketing Authorisation for use in children and adolescents under the age of 18 at the time of publication (Sept 2005)
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Discharge to primary care

Inform primary care professional within 2 weeks of discharge and provide contact details if symptoms recur Review for 12 months after first remission (< 2 symptoms for 8 weeks) Consider follow-up psychological treatment if second episode to prevent relapse Review for 24 months if recurrent depression in remission Re-refer early if signs of relapse
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 Menginformasikan perawatan primer profesional dalam 2 minggu debit dan memberikan rincian kontak jika gejala kambuh Review selama 12 bulan setelah remisi pertama (<2 gejala selama 8 minggu) Pertimbangkan perawatan tindak lanjut psikologis jika episode kedua untuk mencegah kambuh Review selama 24 bulan jika berulang depresi dalam remisi Re-lihat awal jika tanda-tanda kambuh
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Transfer to adult services

Young person (17 years) recovering from first episode Young person (1718 years) who either: has ongoing symptoms from first episode or is recovering from further episodes

Continue care until discharge appropriate, even when person reaches 18 years

Arrange transfer to adult services, informed by Care Programme Approach

Young person (1718 years) with recurrent depression considered for discharge from CAMHS Young person (1718 years) recovered from first episode and discharged from CAMHS
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Give patient information on: adult treatment (include NICE guideline) local services and support groups

Do not refer to adult services unless high risk of relapse

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Other treatment options

Inpatient care when individual is at high risk of suicide, serious self-harm or self-neglect, or when required for intensive treatment or assessment Cautious use of electroconvulsive therapy for lifethreatening depression when other treatments have failed NOT recommended for children (511 years)

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Implementation issues for clinicians

Diagnosis Recognising and managing potential comorbidities and risk factors in the wider social and educational context Providing care that is ethnically and culturally sensitive Treatment Knowing what psychological and drug treatments to offer and when Applying the stepped care model in practice Treatment of parental depression Access to services Transition from CAMHS to adult mental health services Availability of services for parents Training Identifying and contributing to the training of other key workers
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Implementation issues for managers

Active dissemination of the guidance Carry out baseline assessment Development and implementation of an action plan what, when, how, who Ensuring CBT and specialist teams can be accessed appropriately Training of professionals in CBT Monitor and review
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Organisation and planning of services

CAMHS and PCTs should: consider introducing a primary mental health worker (or CAMHS link worker) into each secondary school and secondary pupil referral unit as part of tier 2 provision within the locality routinely monitor detection, referral and treatment rates of children/young people with mental health problems from all ethnic groups in local schools and primary care use information about these rates to plan services, and make it available for local, regional and national comparison Primary mental health workers (or CAMHS link workers) should: establish clear lines of communication between CAMHS and tiers 1 and 2, with named contact people in each tier/service develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2
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Organisation and planning of services

All healthcare professionals should: routinely use, and record in the notes, appropriate outcome measures (e.g. HoNOSCA or SDQ), for assessing and treating depression in children/young people use this information from outcome measures to plan services, and make it available for local, regional and national comparison Commissioners and strategic health authorities should ensure that: inpatient treatment is available within reasonable travelling distance to enable family involvement and maintain social links inpatient admission occurs within an appropriate time scale immediate inpatient admission can be offered if necessary inpatient services have a range of interventions available including medication, individual and group psychological therapies and family support inpatient facilities are age appropriate and culturally enriching and can provide suitable educational and recreational activities
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Four implementation tools support this guideline

Costing tools a local costing template a national costing report implementation advice audit criteria this slide set The tools are available on our website www.nice.org.uk/implementation
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Where is further information available?

Quick reference guide summary of recommendations for health professionals: www.nice.org.uk/cg028quickrefguide NICE guideline: www.nice.org.uk/cg028niceguideline Full guideline all of the evidence and rationale behind the recommendations: www.rcpsych.ac.uk/publications Information for the public plain English version for patients, carers and the public: www.nice.org.uk/cg028publicinfo

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www.nice.org.uk

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