1. Depression in children and young people referred to Specialist CAMHS: An audit of screening procedures. Dr. Michelle Rydon-Grange Clinical Psychologist, Denbighshire CAMHS

2. Background NICE guidelines & Welsh Government… 62,000 children and young people (11-16 years) experience clinically significant depression 1 Associated with longer-term adverse consequences 2 Under-diagnosed and poorly recognised 3 [1] Office for National Statistics (2004). [2] Fombonne, E., Wostear, G., Cooper, V., Harrington, R., & Rutter, M. (2001). [3] Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012).

3. Background National Institute for Clinical Excellence (NICE) — Depression in Children and Young People (2005) 4 — Recommend routine screening for depression in children aged 11 – 16 referred to CAMHS — Self-report measure completed by child or young person in combination with a parent report measure, in order “…to achieve a best estimate of detection” [4] National Institute for Health and Clinical Excellence. (2005). The treatment of depression in children and young people: identification and management in primary, community and secondary care.

4. Background Depression in children and young people is associated with suicidal ideation – A particularly high-risk group of young people Welsh Government Target for Urgent Referrals – Young people experiencing sustained low mood of 6 weeks or > and suicidal ideation are assessed (and any intervention plans initiated) within 4 weeks of referral.

5. Clinical Questions 1.How well do CAMHS multi-disciplinary team adhere to NICE good practice guidelines regarding routine screening of depression in children aged 11+? 2.How well do CAMHS adhere to the 4-week (i.e. 28 days) target stipulated by the Welsh Government?

6. Method BCUHB Audit department approval received Participants – 100 Children aged 11+ (age range 11.0 – 17.11 years (M=14.6; SD=1.9) – 17-month time-frame Design – Retrospective – Clinical files of eligible children examined – Descriptive statistics used to answer clinical questions

7. Method Question 1: CAMHS adherence to NICE guidelines – % files with completed MFQ – Of the files with a completed MFQ, % which included both Child and Parent MFQ, as recommended by NICE

8. Results Adherence to NICE Good Practice Guidelines for Depression Screening: 73 files had a completed MFQ – 100% had both a completed MFQ-Child and MFQ-Parent Depression screening was not undertaken in 27% of cases.

9. Method Question 2: CAMHS adherence to Welsh Government Target Step 1: Identify number of children reporting clinically significant depression for 6 weeks or > – Defined as scoring ≥ clinical cut-off on MFQ Step 2: From this sub-sample, identify number of children reporting suicidal ideation – Taken from clinical file

10. Results Adherence to Welsh Assembly 4-week Target: 21% of the entire sample were identified as experiencing depression plus suicidal ideation 100% were seen by CAMHS within the 28-day target. The number of days wait between referral received at CAMHS and date of initial appointment ranged from 0 – 28 days (M = 11.85 days; SD = 8.5; mdn = 13 days).

11. Results Figure 3. Box plot showing distribution of waiting times (in days) for children with depression and suicidal ideation, against Welsh Government 4-week cutoff (range = 0 – 71 days). Figure. Distribution of waiting times (in days) for children reporting clinically significant depression and suicidal ideation, against Welsh Government 28-day cutoff (range = 0 - 28 days). Welsh Government 28-day Cutoff

12. Conclusions and Implications Just over a quarter (27%) of children referred to Specialist CAMHS were not screened for depression during initial assessment, as recommended by NICE. Further audit is needed to examine factors related to decision-making in those cases where depression screening is not occurring – Clinical judgment & appropriate use of screening measures? – Language barrier?

13. Conclusions and Implications Accurate detection has implications for: – treatment of depression in this population – if we can’t detect it, we can’t treat it! – service delivery

14. Conclusions and Implications Findings indicate CAMHS were meeting the 28-day Welsh Government Target, regarding the assessment of high-risk children referred to the service. Very small sample (only 21 cases) Future audit could utilise a larger sample size Data is collected routinely – possible to evaluate adherence to national guidelines over time

15. Audit Recommendations Implementing Change: Staff training regarding the importance of screening for depression could potentially improve adherence to NICE guidelines. – Training opportunities could be made available to improve the accuracy of CAMHS multi-disciplinary clinicians in detecting depressive conditions – A re-audit of adherence following staff training should be undertaken – Pragmatics of screening

16. Thank you for listening Questions

17. Mood and Feelings Questionnaire Mood and Feelings Questionnaire (MFQ) 5 – “currently the best” self-report measure – 8-18 year-olds – Child (33 items) and Parent (34 items) versions – 3-point scale: “I felt miserable or unhappy” 0 = not true 1 = sometimes 2 = true – 32 clinical cut-off [5] Angold, A., & Costello, E. J. (1987). Mood and feelings questionnaire (MFQ).

18. Supplementary Information Sample Characteristics: 22% of the sample had a diagnosed co-morbidity at time of referral. The most common co-morbidities were Pervasive Developmental Disorder (n=6), and ADHD (n=6). Over half the sample (57%) were referred by their G.P. The most common presenting problem identified by CAMHS staff at the child’s initial appointment was Depressive Episode (n=45%).

19. Supplementary Information For cases with co-morbidity, a lower cutoff score of 22 is utilised. For cases where a child or parent/carer only MFQ was completed, cutoff scores were based upon this version alone. Of the 49% of children scoring above the clinical cutoff on the MFQ, 16% (n=12) had a diagnosed co- morbidity, and thus the lower cutoff score was adopted (mean MFQ = 35.3; SD = 6.5).

20. Prevalence of Depression Of the 73 files with a completed MFQ, 49% children (n=36) scored ≥ MFQ cut-off (95% CI 38.18, 60.53; mean MFQ = 41.7; SD = 8.4)