DEPRESI ANAK

7/30/2019 DEPRESI ANAK

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DEPRESI PADA ANAK

Clinical Guideline

sarka ade



Intro Context Key priorities and recommendations Implementation

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PETUNJUK KLINIK

• Direkomendasi untuk praktek yang baik yang

didasarkan pada bukti (evidence based).

• Pedoman untuk standar yan kesehatan yang lebihbaik dalam mengimplementasikan pedoman klinis

• Lembaga- Komisi Kesehatan akan memonitor

kepatuhan dengan panduan.




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Alasan Pedoman:

• Profesional yang terlibat dengan pengasuhan anak-

anak 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 andyoung people aged 5 –18 years with depression

• Recommendations for healthcare and other professionals who have a role to play in ensuringchildren and young people and their families andcarers 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


http://slidepdf.com/reader/full/depresi-anak 7/43Intro Context Key priorities and recommendations Implementation

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Prevalence

• Pada setiap, waktu satu perkiraan jumlah anak danremaja 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 dengandepresi terdeteksi dan diobatiBunuh diri adalah:3 penyebab utama kematian di 15-24-year-olds6 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 risikoLangkah 2: Pengakuan

Langkah 3: depresi ringan



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Diagnosing depression

KEY SYMPTOMS ASSOCIATEDSYMPTOMS

•persistent sadness, or

low or irritable mood:

AND/OR

•loss of interests and/or

pleasure

•fatigue or low energy

•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

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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

•GPs and paediatricians

•Health visitors and school nurses

•Social workers, teachers, juvenile justice workers

•Voluntary agencies and social services

TIER 2

CAMHS

Professionals

relating to

primary care

workers

•Clinical child psychologists and educationalpsychologists

•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 persistentdisorders

•Child and adolescent psychiatrists and

psychotherapists

•Clinical child psychologists

•Community and inpatient nurses

•Occupational therapists and speech andlanguage therapists

• Art, music and drama therapists and family

therapists

TIER 4CAMHS

Tertiary-level

services

•Day units•Specialised outpatient teams

•Specialised inpatient units

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The stepped care modelFocus Action Responsibility

Detection Risk profiling Tier 1Recognition Detection in presenting children All tiers

Mild depression

including dysthymia

Waspada menunggu

Non-direktif terapi suportif /kelompok terapi kognitif perilaku,

dipandu self-help

Tier 1Tier

1 or 2

Moderate to severe

depression

Brief psychological intervention

+/ – fluoxetine

Tier 2 or 3

Depressionunresponsive

to treatment/recurrent

depression/psychotic

depression

Intensive psychologicalintervention

+/ – fluoxetine

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 gejalamemberikan dukungan yang sesuaitahu 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 dilatihterutama dalam:

• penggunaan kuesioner laporan diri dan instrumen

• pewawancara berbasisskrining untuk gangguan mood dan ketrampilandalam penilaian non-verbal suasana hati pada anak-

anak 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 thecontext of multiple-risk histories for depression in oneor more family members (parents or children)providing that there is no evidence of depressionand/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 diripada 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

2 –3 months• Moderate or severe depression (including psychotic depression)

• Recurrence after recovery from previous moderate or severe

depression

• Unexplained self-neglect of at least 1 month’s 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 bisa ber bahaya bagi kesehatan f isik Aktif ide atau rencana bunuh diri




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Steps 4 and 5: moderate or severe

depression• General recommendations

– Approach tailored to needs of family

– Family’s 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 memburukPengobatan dimulai dengan review oleh tim

multidisipliner

Baris pertama pengobatan adalah terapi psikologis

khusus untuk sekitar 3 bulan Masin -masin tera i erilaku ko nitif




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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 (12 –18) and cautiously consider it in younger children

(5 –11)

• 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 sesiSuatu 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 apsychiatrist

• Should only be offered in combination with psychologicaltreatments

• First-line treatment is fluoxetine*

• Do NOT use: tricyclic antidepressants, paroxetine,venlafaxine, St John’s wort

• Monitor for agitation, hostility, suicidal ideation and self-

harm 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 ageof 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 6 –12 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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Intro Context Key priorities and recommendations Implementation1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

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Discharge to primary care• Inform primary care professional within 2 weeks of

discharge and provide contact details if symptomsrecur

• Review for 12 months after first remission (< 2symptoms for 8 weeks)

• Consider follow-up psychological treatment if secondepisode to prevent relapse

• Review for 24 months if recurrent depression inremission

• 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 dalamremisi

Re-lihat awal jika tanda-tanda kambuh




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Transfer to adult services

Young person (17 years)

recovering fromfirst episode

Young person (17 –18 years)

who either:

• has ongoing symptoms from first episode

or •is recovering from further episodes

Young person (17 –18 years) with

recurrent depression considered for

discharge from CAMHS

Young person (17 –18 years)

recovered from first episode

and discharged from CAMHS

Continue care until discharge

appropriate, even whenperson reaches 18 years

Arrange transfer to adult

services, informed byCare Programme Approach

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 life-

threatening depression when other treatments have

failed – NOT recommended for children (5 –11 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 actionplan – 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 ethnicgroups 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 includingmedication, 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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http://www.nice.org.uk/implementation

http://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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http://www.nice.org.uk/cg028quickrefguide

http://www.nice.org.uk/cg028niceguideline

http://www.rcpsych.ac.uk/publications

http://www.nice.org.uk/cg028publicinfo

http://www.nice.org.uk/cg028publicinfo

http://www.rcpsych.ac.uk/publications

http://www.nice.org.uk/cg028niceguideline

http://www.nice.org.uk/cg028quickrefguide



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www.nice.org.uk

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