Low mood and depression

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1 Section 1 Low mood and depression Flow chart for the management of low mood or depression from Primary Care to Specialist CAMHS Child/young person presents to Tier 1 professional with signs of low mood/depression If suicidal or self harming refer to Self Harm Care Pathway Consider using Mood Scale Screener (Appendix 1) Ask young person to complete, or use Mood Scale questions in your assessment In addition assess whether one or more of the following SYMPTOMS are present: Persistent sad, low or irritable mood Loss of interest and/or pleasure Fatigue or low energy Sleep changes Guilt or self blame Poor concentration Low self confidence Appetite Changes Agitation/slowing down Mood scale score <17 or four or fewer symptoms and all of the following: - No family history of depression - Good social support - Little impairment in daily functioning - No suicidal ideas General advice and watchful waiting. Review mental health over two week period Mood scale score <17 and any of the following: - Second episode of low mood within one year - Self neglect - Relatives request referral - Relatives are struggling to cope. - Mood deteriorates Discuss with CAMHS Primary Mental Health Specialist (PMHS) Mood scale score or five or more symptoms Gather information and discuss with PMHS regarding referral to Specialist CAMHS Mood scale score 27+ or seven or more symptoms or any of following: - Actively suicidal or plans - Low mood of six weeks or longer - Psychotic symptoms - Severe agitation - Severe self neglect Make referral to Specialist CAMHS

2 Recognition of depression in children and young people It is a normal part of life to have periods of unhappiness and sadness as a reaction to negative life experiences. It is where these low moods become persistent, frequent and interfere with normal daily functioning that consideration should be given that the child or young person may be depressed. Depression in children and young people may not simply be shown through mood level; behaviour, social functioning and learning may also be significantly affected. When considering the following it is necessary to be aware that the more factors a child or young person is exposed to either simultaneously or over a period of time, the more likely his/her mood is to be affected and the potential to become depressed increases. Family Discord Bullying Physical, sexual or emotional abuse Ongoing physical illness Family history of depression Significant life events without resolution Caring responsibilities Looked After Children Drugs and alcohol Increase or development of risky behaviours Homelessness Refugee status Living in an institution Social isolation Ongoing psychological difficulties Major mental health difficulties Eating disorders Educational difficulties 2

3 Signs and symptoms of depression in children and young people Not all of the symptoms below will be evident in all settings and different symptoms may be displayed depending on the circumstances and the individual developmental stage. It is more relevant to consider changes in the individuals mood and behaviour or significant deviations from the normal negative moods and behaviours which are normal at various stages of development. Suicidal attempts in children under the age of 12 are rare but they may engage in potentially dangerous behaviours when angry and frustrated. Girls are more likely to attempt suicide and self harm. Boys are more likely to kill themselves when they make an attempt. Children and young people with multiple risk factors are more likely to be depressed, and to self harm or to attempt suicide. Irritabilty or anger Continuous feelings of sadness & helplessness Social withdrawl Increased sensitivity to rejection Changes in appetite increase or decrease Changes in sleep sleeplessness or increased sleep Vocal outbursts or crying Difficulty in concentrating Fatigue and low energy Physical complaints that do not respond to treatment Reduced ability to function in activities or events Feelings of worthlessness and guilt Impaired thinking Self harm (also see Self Harm Care Pathway) Thoughts of death and dying Anxiety Agitation Suicidal thinking (also see Self Harm Care Pathway) Poor self care Drug, alcohol & tobacco use. 3

4 Episode pathway for managing the wellbeing of children and young people with low mood and depression Powys Teaching Health Board Integrated Care Pathway (ICP) and Combined Referral ICP Reference No:... This integrated care pathway is to be used with all children and young people who present in primary care with low mood or depression. The ICP starts once the child or young person presents and is seen by a Tier 1 professional and ends once the child or young person has been discharged or transferred. Low Mood/Depression Care Pathway Children and young people under the age of 18 years Initial Assessor:... Department:... Name:... Dob:.. This ICP was developed by: Kate Davies, Primary Mental Health Specialist Please use black ink throughout the completion of this form 4

5 Episode pathway for managing the wellbeing of children and young people with low mood and depression Name:... Dob:.. 1. How to use this integrated care pathway This integrated care pathway is to be used with all children and young people who present in Tier 1 with low mood or depression. The ICP starts once the child or young person presents and is seen by a Tier 1 professional and ends once the child or young person has been discharged or transferred. This Integrated Care Pathway (ICP) serves as a guide to treatment and progress. Professional judgement should always be used and will override, but any variations in care must be clearly documented. This ICP is intended to clarify the assessment process for all children and young people who present with low mood or depression and ensure appropriate referral into Specialist CAMHS. Integrated Care Pathways can ensure that care is: High quality Evidence based Efficient The multidisciplinary team has met together to discuss and agree the care that is best for a typical patient who meets the criteria for this ICP. The ICP is therefore a guideline for the best multidisciplinary care for a patient. Remember, however, that every patient is an individual and that this ICP is not a substitute for clinical judgement and expertise. You are advised to use this document as follows. 2. Instructions The Integrated Care Pathway is an inclusive element of the notes and as such forms a part of the service users care record. Everyone using the Pathway documents their name, signature and initials on the page provided. Any variations from the outlined Pathway should be documented by the relevant professional as a variance and where necessary, acted upon accordingly. Provision is made for the documentation of variances throughout the pathway. In the event of there being a lack of space for such recording, a separate sheet should be attached to the rear of the document. Where it has been necessary to remove the patient from the Pathway, documentation should continue in the clinical notes. Variations may or may not result in the discontinuing of the Pathway, professional judgement should always be applied. As far as possible, the Integrated Care Pathway should stay a complete document. Where this has not been possible the relevant professional must ensure that the documentation is returned to its complete state as soon as possible. The Service Users Name, and Date of Birth should be on every page. 5

6 Integrated care pathway: for managing the wellbeing of children and young people with low mood or depression This ICP is to be used with all children and young people who present with low mood or depression. The ICP starts once the child or young person presents and ends once the child or young person has been discharged or transferred. Any reasons for service being refused or withheld should be recorded as a variance and the variance record sheet should be completed. 2.1 Instructions for use: Before writing in this ICP please ensure you have signed the signature sheet. 2.2 Overall care objectives: To meet the requirements/minimum standards as described in the NICE Clinical Guideline 28 Depression in Children & Young People 2005 Episode Pathway for managing the wellbeing of Children and Young People with low mood or depression Name:... Dob:. 6

7 Low mood and Depression Signature Sheet All disciplines writing in this ICP must sign below prior to writing in the ICP Full Name (Print) Designation Signature Initials Date of Entry Episode pathway for managing the wellbeing of children and young people with low mood/depression Name:... Dob:.. PLEASE ENSURE THAT ALL ASSESSMENTS WHICH RESULT IN AN ONWARD REFERRAL ARE SENT WITH THE PATHWAY TO CAMHS CAMHS (Brecknockshire and Radnorshire) Hillview House, Bronllys Hospital, Bronllys, Brecon, Powys, LD3 0LU Tel: Fax: CAMHS (Montgomeryshire) Community Health Offices, Ynys-y-Plant, Plantation Lane, Newtown, Powys, SY16 1LH Tel: Fax:

8 Episode Pathway for depression in young people from Primary Care to CAMHS Name:... Dob:.. Activity Indicate x/ all that apply Notes/Variants Date/Initials Child/young person presents in Primary Care setting with concerns about low mood If concerned check with safeguarding team and consider safeguarding issues throughout Collect history and make referral to GP for physical examination if concerned about physical health Assess risk of self harm/suicidal ideation and if identified continue with Self Harm Care Pathway Routinely screen for depression using the Mood Scale Screener (Appendix 1) Low mood following negative life event Identify recent negative life events i.e. family breakdown, bereavement, disappointing event Assess level of risks of depression associated with the event Identify appropriate support systems and working together with the young person make contact with them Offer support and the opportunity to talk over the event Consider management of associated problems Monitor effects of the above within 2 weeks and contact patients who do not attend follow up Low mood high risk of developing depression Previous history of depressive illness 8

9 Episode Pathway for depression in young people from Primary Care to CAMHS Name:... Dob:.. Activity Indicate x/ all that apply Notes/Variants Date/Initials Previous history of depressive illness in other family members 5 or more symptoms Offer opportunity to talk things through with a Tier 1 professional Discuss with CAMHs Primary Mental Health Specialist (PMHS) If self harm identified continue with self harm care pathway If mood deteriorates or no improvement is shown refer to NHS CAMHS Consider multi-agency involvement where social and environmental factors are contributing to low mood Depressive symptoms Recurrent episode of low mood within 1 year with 5 or more symptoms of depression Appropriate treatment offered by Tier 1 worker with support from PMHS No improvement after 2 interventions Evidence of self-neglect Relatives struggling to cope refer to specialist CAMHS Severe symptoms of depression Actively suicidal ideas or plans. Previous history of suicidal behaviours with serious intent 9

10 Low Mood & Depression Episode Pathway for depression in young people from Primary Care to CAMHS Interventions Indicate x/ all that apply Notes/Variants Action By/ Initials Evidence of psychotic symptoms (e.g hearing voices) or disordered thinking 7 or more severe symptoms of depression Severe agitation Severe self- neglect Make NHS CAMHS referral. Make accompanying telephone call. Mark referral - URGENT If more advice is needed contact the Primary Mental Health Specialist. Contact details below. CAMHS (Brecknockshire and Radnorshire) Hillview House, Bronllys Hospital, Bronllys, Brecon, Powys, LD3 0LU Tel: Fax: CAMHS (Montgomeryshire) Community Health Offices, Ynys-y-Plant, Plantation Lane, Newtown, Powys, SY16 1LH Tel: Fax:

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