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Are we just too polite to tell salaried GPs where to go?

By Emma Wilkinson

GPs should not initiate prescribing of antidepressants in under-18s under any circumstances, NICE has ruled.

New NICE guidelines on depression in children and young people have banned use of antidepressants altogether in mild depression (see box, right).

Fluoxetine can now only be prescribed in moderate to severe depression following assessment by a psychiatrist.

The guidance, released this week, also insists antidepressants should only be used in combination with psychological therapies.

GP experts said they would normally refer under-18s before prescribing, but there were special circumstances the guidelines didn't take into account.

Dr Graham Archard, RCGP vice-chair, said: ‘The majority of GPs would refer any child with depression. But if there are children with significant depressive illness and rapid consultations are not available I can understand why GPs would want to start treatment.'

Dr Dick Churchill, member of the guideline development group and a GP in Chilwell in Nottingham, agreed there were rare occasions when it might be appropriate for GPs to start treatment. ‘If routine waiting times were long I would certainly want to contact a specialist for advice,' he said.

‘There will be patients who won't want to be referred to children and adolescent mental health teams and it would be reasonable to have a consultation with them and initiate careful prescribing. I think the guidance undervalues that individual role in that small group.'

Under the new guidance, GPs will be offered more training to help them identify depression in young patients and manage mild cases themselves. ‘The emphasis on psychological therapies is good and obviously there's an imperative on PCTs to provide that,' said Dr Churchill, who is also senior lecturer

in the department of primary care at the University of


Dr Tim Kendall, joint director of the National Collaborating Centre for Mental Health which developed the guidance on behalf of NICE, said: ‘There is a problem with access and it's something the Department of Health is addressing.'

key points

Mild depression

• Do not use antidepressants

• Watch and wait, and assess after two weeks

• If patients still depressed after four weeks, offer supportive therapy, group CBT or self-help

• Refer after two to three months

Moderate to severe depression

• Refer for review by child and adolescent mental health team

• First-line offer individual CBT, interpersonal therapy or short-term family therapy

• Antidepressants can be offered second-line in conjunction with psychological therapies, after assessment by psychiatrist

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