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How Do You Balance Clinical Guidelines With What Young People Want From Their Treatment?

08/05/2017 10:28 BST | Updated 08/05/2017 10:28 BST

Talking with a doctor or psychiatrist about whether to take medication for a mental health condition can lead to one of the most difficult decisions that a young person can make. In this blog, I look at the National Institute for Clinical Excellence (NICE) guidelines for use of anti-depressants and what our research says about young people's views of using them.

The NICE guidelines

In the UK, the NICE guidelines aim to bring together the best current evidence to help make recommendations about what approach may be most helpful. The current guidelines are the culmination of revisions and changes in thought and attitudes over time.

When it comes to adolescent depression, earlier versions of the guidelines had recommended the use of evidence-based psychological therapies as first line treatment, with SSRI antidepressants only being offered if the young person was unresponsive to a psychological therapy.

However, a 2015 amendment to the guidelines recommends discussing the option of combined antidepressant prescription and psychological therapy as a first line of treatment, at least in the case of moderate to severe depression, but continues to warn against the use of SSRI antidepressants on their own. This change in guidance, which will potentially mean more young people being offered medication for depression, makes it even more essential that young people are helped to make the right decisions about whether such selective serotonin re-uptake inhibitor (SSRI) medications should be an element of the treatments they are offered.

The Anna Freud National Centre for Children and Families has developed a series of expert podcasts called Child in Mind which aims to explore these challenges and to empower parents and families to make informed decisions about child mental healthcare.

One episode focuses on medication and further highlights the importance of bringing young people's voices into the larger debate on the prescription of SSRI medication, especially in light of the increasing media coverage on their efficacy and safety, which may leave young people with more questions than answers.

What do young people think?

The podcast sees Anna Freud National Centre Young Champion, Maisy and Dr Peter Hindley, Chair of the Faculty of Child and Adolescent Psychiatry at the Royal College of Psychiatrists, speak about the different experiences that young people might have when being offered medication, taking medication, or stopping medication. You can listen to the episode and the rest of the Child in Mind series on the Anna Freud National Centre's iTunes and SoundCloud channels.

Listening to the experience of young people who have been offered medication for their depression is essential. One of my students at University College London, Rita Maroun, has recently examined interviews with 12 young people who had been referred to child mental health services with severe depression, six of whom had taken SSRI anti-depressant medication, and six of whom had been offered medication, but had chosen not to take it. All of them had been part of research we have been doing looking at the treatment of adolescent depression, in which we found that about 40% of teenagers referred to mental health services were prescribed SSRIs alongside a talking therapy (the IMPACT study, Goodyer et al., 2017).

In our interviews with these 12 young people, many of them described fears that they had when offered medication, including fears of losing control to, becoming dependent on, or not being able to come off the medication. Some young people described a desire to be able to manage their depression on their own terms and believed they could do this without medication, while others talked about being so low that they believed medication would be the next step in their treatment, even if it did not help resolve the underlying issues that they felt were important to address.

Young people from the IMPACT study who had taken medication talked about how it allowed them to engage in treatment, lifted their mood, or motivated them to resume pleasurable activities they had stopped when they first became depressed. However being on medication wasn't a straightforward experience. These same young people spoke about the trial-and-error process that occurred when they decided to take medication, which included finding the right type, dosage, frequency, length of treatment and managing side-effects. Some young people expressed a fear of withdrawal from the medication upon stopping.

What is the impact on treatment?

What these findings show, as does the podcast, is that young people attach various meanings to SSRI medication, and it is important to explore these meanings with them both before taking medication, and in an on-going way. The Anna Freud National Centre has recently been leading the way in promoting the idea of 'shared decision making' in child mental health; and this is especially important when thinking about medication.

Clinicians could support young people through this process by opening a dialogue where young people can ask questions and express any concerns or worries they may have throughout the decision-making process, both about whether or not to use medication, and if they do, whether it is working for them and how and when they may want to stop.