Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Depression and anxiety in children and young people
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute suicide or severe functional danger
Current suicidal intent or preparation, inability to maintain basic safety, psychotic depression, severe self-neglect, refusal of essential food or fluid, marked agitation, suspected abuse or rapidly worsening symptoms require same-day specialist assessment and may require emergency care.
Action: Ask directly about thoughts, intent, plans, access to means, recent acts and protective support; address immediate physical needs, remove accessible lethal means with the family where safe, obtain urgent CAMHS or emergency mental-health input, and activate safeguarding procedures when harm or exploitation is possible. Do not leave a high-risk young person without an agreed responsible adult and transfer plan.
Overview
Recognise developmentally expressed depression and anxiety, assess suicide, safeguarding and functional risk, distinguish normal distress from disorder, and deliver age-appropriate psychological and specialist treatment with safe antidepressant monitoring.
Development changes how distress appears. A younger child may lose interest in play, become irritable or clingy, complain of pain, regress or struggle to learn; an adolescent may withdraw, sleep irregularly, use substances, self-harm or appear angry rather than sad. Depression requires a persistent syndrome with meaningful impairment, not one difficult day. Anxiety is common and adaptive, but a disorder becomes more likely when fear and avoidance are excessive for developmental stage, persist and constrict ordinary life. Always ask what has changed from the child's own baseline.
Assessment needs several perspectives without allowing one to silence another. Speak directly with the child or young person using concrete language and offer some private time, explaining confidentiality and its safety limits first. Obtain a developmental history and accounts from parents or carers and school with appropriate permission. Differences between settings are informative: social anxiety may be hidden at home, ADHD may look like restless anxiety, and a child may conceal bullying or abuse in front of an accompanying adult.
Practice
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PsychiatryOriginal SBA
Fluoxetine starting regimen
A child and adolescent psychiatrist diagnoses moderate-to-severe depression in a 15-year-old and recommends fluoxetine alongside psychological therapy. What starting regimen matches NICE guidance?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Map mood, pleasure, energy, sleep, appetite, concentration, guilt, hopelessness, bodily symptoms, panic, worries, separation fears, social evaluation, compulsions and avoidance. Establish duration, triggers, daily pattern, impairment and strengths. Ask directly and calmly about self-harm and suicide, including intent, plans, preparation, previous acts and access to medication, firearms or other means. Also assess mania or hypomania, psychosis, trauma, autism, ADHD, eating disorder, substance use, physical disease, family mental health and safeguarding.
Treatment matches diagnosis, severity, age and preference. Mild depression is usually managed initially with active support and an evidence-based psychological approach rather than an antidepressant. For five- to eleven-year-olds with moderate-to-severe depression, NICE says to consider family-based interpersonal psychotherapy, family therapy, psychodynamic psychotherapy or individual CBT, adapted to developmental level. For twelve- to eighteen-year-olds, offer individual CBT for at least three months; when it is unsuitable or does not meet clinical need, consider adolescent interpersonal psychotherapy, family therapy, a brief psychosocial intervention or psychodynamic psychotherapy. For social anxiety, offer individual or group CBT focused on social fear and avoidance, involving parents particularly for younger children and collaborating with school around agreed exposure goals.
Medication has a narrower role than in adult practice. For ages twelve to eighteen, NICE allows initial combined fluoxetine and psychological therapy; when psychological therapy alone has not produced a response after four to six sessions, complete multidisciplinary review before offering fluoxetine. For ages five to eleven, cautiously consider fluoxetine only after four to six unresponsive sessions and multidisciplinary review, explaining that effectiveness in this age group is not established. Prescribing follows assessment and diagnosis by a child and adolescent psychiatrist, and medication should normally accompany psychological therapy; if therapy is declined, monitor especially closely. Start fluoxetine at 10 mg once daily, increasing to 20 mg after one week if necessary; consider a lower dose at lower body weight and recognise limited evidence above 20 mg. Explain delayed benefit, common effects, adherence and discontinuation, and monitor early activation, hostility, self-harm and suicidality.
Recovery is broader than a symptom score. Track attendance, learning, relationships, sleep regularity, activity, pleasure, family stress, safety and the young person's own goals. A rating scale can support communication but cannot replace interview, formulation or safeguarding judgement. Agree what worsening looks like, who will respond after hours and how the young person can seek help privately. Review diagnosis and treatment delivery when progress stalls rather than simply escalating medication.
Key points
Depression in younger children may present through irritability, loss of play, somatic complaints, withdrawal, decline at school or developmental regression rather than a verbal report of sadness.
Anxiety becomes clinically important when fear and avoidance are persistent, disproportionate for development and impair family, school, peer or daily functioning.
Interview the child or young person for part of the assessment without accompanying adults when safe, while also obtaining developmental, family and school information.
Ask every young person with depression about self-harm, suicide, abuse, bullying, substance use, manic symptoms, psychosis and access to medication or other lethal means.
Psychological treatment is central; NICE social-anxiety guidance offers individual or group disorder-focused CBT and does not routinely recommend medication for children or young people.
Do not use antidepressants as initial treatment for mild depression; moderate-to-severe depression requires CAMHS review and developmentally appropriate psychological care.
When fluoxetine is indicated for depression after specialist assessment, start 10 mg daily and increase to 20 mg after one week if clinically necessary, with lower doses considered at lower body weight.
Monitor closely for suicidal behaviour, self-harm and hostility particularly at treatment initiation, and give the young person and carers an explicit urgent-contact route.
Aetiology
01
Biological vulnerability
Heritable liability, temperament, puberty, sleep disruption and physical illness interact with development rather than determining a fixed outcome.
02
Learning and cognition
Threat learning, avoidance, negative self-appraisal, rumination and hopeless predictions can persist after the original stress has passed.
03
Relational and structural stress
Bullying, discrimination, poverty, family conflict, caring burden, loss, abuse and academic pressure can precipitate or maintain distress.
04
Neurodevelopmental context
Autism, ADHD, learning and communication differences alter exposure to stress, symptom expression and access to ordinary coping support.
Pathophysiology
1
Threat-system sensitisation
Repeated danger prediction amplifies autonomic arousal and attention to threat, while avoidance prevents new learning that situations can be tolerated.
2
Reward withdrawal
Reduced rewarding activity and social contact deepen low mood, fatigue and hopelessness, creating a self-reinforcing depressive cycle.
3
Developmental regulation
Maturing executive, emotional and social systems shape impulse control, future thinking and the language available to describe internal states.
4
Sleep and stress feedback
Irregular sleep and sustained stress impair concentration and emotion regulation, worsening school performance and further increasing anxiety or shame.
Clinical features and red flags
Developmental depressive change
Irritability, loss of play or interest, withdrawal, somatic complaints, falling attainment and altered sleep or appetite mark change from baseline.
Generalised anxiety pattern
Excessive difficult-to-control worry spans several domains and brings reassurance seeking, tension, poor sleep, concentration difficulty or avoidance.
Social anxiety pattern
Fear of scrutiny, embarrassment or rejection produces distress and avoidance of class, eating, speaking, peers or performance situations.
Separation and panic
Developmentally excessive distress about separation or recurrent unexpected panic can restrict school, sleep, travel and ordinary independence.
Severe depressive state
Pervasive hopelessness, suicidality, psychomotor change, psychosis, self-neglect or near-total functional loss indicates urgent specialist need.
Masked environmental threat
Bullying, abuse, discrimination, poverty, caring burden or unsafe home conditions may sustain symptoms and require action beyond individual therapy.
Red flags requiring action
A specific suicide plan, preparatory behaviour, recent high-lethality self-harm, command hallucinations or stated inability to remain safe needs immediate senior assessment.
Psychotic symptoms, manic features, severe agitation, catatonic change or profound functional collapse requires urgent specialist diagnostic review before routine depression treatment.
Investigations
01Developmental mental-health interviewFirst step
Why
Characterise mood, anxiety, behaviour, cognition, physical symptoms, duration and impairment in age-appropriate language.
Interpretation and limitations
Diagnosis rests on syndrome, development and function; irritability or pain may carry the same significance as verbally reported sadness.
A formulation of current drivers, intent, capability and support guides immediate action; a numerical risk category cannot establish safety.
03Collateral developmental and school history
Why
Clarify onset, cross-setting change, learning, attendance, peer relationships, family response and protective factors.
Interpretation and limitations
Disagreement prompts further enquiry and private discussion rather than automatic preference for an adult or child account.
04Physical and medication assessment
Why
Look for endocrine, neurological, sleep, pain, nutritional, substance and medicine contributors to emotional symptoms.
Interpretation and limitations
Target examination and tests to the history; routine broad panels do not
Differential diagnosis
01
Bipolar or psychotic disorder
Episodic elation, decreased need for sleep, grandiosity or sustained psychosis changes urgency and makes routine antidepressant escalation unsafe.
02
Neurodevelopmental difference
Autism, ADHD, language or learning needs can produce overload, withdrawal, restlessness and academic decline that coexist with anxiety or depression.
03
Trauma or maltreatment
Hypervigilance, avoidance, dissociation, irritability and somatic distress may reflect current danger or trauma requiring safeguarding and trauma-focused formulation.
04
Physical or substance cause
Endocrine, neurological, sleep, nutritional, pain and medication or drug effects can mimic or compound emotional and cognitive symptoms.
05
Expected transient distress
Short-lived proportionate reactions can resolve with support, but persistence, severity, developmental mismatch and impairment suggest a clinical disorder.
Management
01Initial assessmentSee the child and the contextFirst stepPersistent low mood, irritability, fear, avoidance or functional change raises concern for depression or anxiety.+
1Explain confidentiality and its limits, speak with the child or young person directly and privately for part of the encounter when safe.
3EscalationShare a formulation and agree care intensity, family involvement, school liaison and explicit escalation routes based on needs rather than a score alone.
02Psychological careMatch intervention to disorder and developmentDepression or anxiety is identified without an immediate need for emergency admission.+
1For mild depression, provide active support and an evidence-based psychological option rather than beginning with an antidepressant.
Complications
01
Self-harm and suicide
Hopelessness, impulsivity, isolation and access to lethal means can converge into rapidly changing danger requiring direct repeated assessment.
02
Educational and social loss
Avoidance and poor concentration produce absence, falling attainment, reduced friendships and shrinking confidence that may persist after symptoms improve.
03
Substance and eating problems
Alcohol, drugs, restriction, bingeing or purging may be used to regulate distress and create additional physical and psychiatric risk.
04
Family-system strain
Fear, conflict, accommodation and caring burden can exhaust relationships unless treatment includes practical communication and support for carers.
05
Iatrogenic harm
Dismissal, unnecessary disclosure, poorly monitored medication or punitive responses to avoidance can reduce trust and intensify risk.
Monitoring and follow-up
Review suicidal thoughts, self-harm, hostility, activation and safeguarding at every early contact and whenever treatment, stress or functioning changes; when an antidepressant starts, NICE gives weekly contact for the first four weeks as an example, with the individual frequency recorded.
Track mood, anxiety, avoidance, sleep, appetite, school participation, family and peer function and personally meaningful goals rather than a symptom score alone.
For fluoxetine, record dose, adherence, adverse effects, emergent mania or psychosis and the urgent-contact plan shared with the young person and carers.
Confirm that psychological sessions and agreed school or family adjustments are actually accessible and delivered, including interpreter or neurodevelopmental adaptations.
After fluoxetine response, continue for at least six months after remission, defined as no symptoms and full functioning for at least eight weeks, then use specialist-guided gradual stopping; maintain relapse signatures and a rapid route back to care.
At transition between services, name who owns prescribing, physical monitoring, therapy, safeguarding information and crisis response.
Special situations
Irritability can be depressive
A child who appears angry may be expressing pervasive low mood, shame, exhaustion or lost pleasure rather than deliberate defiance.
Avoidance briefly rewards itself
Escaping a feared situation reduces anxiety immediately and thereby strengthens future avoidance, making graded exposure an active treatment ingredient.
Private time changes disclosure
A young person may reveal suicide, sexuality, bullying, substance use or abuse only after confidentiality and its limits are explained.
Scores do not make safety
Questionnaires structure symptoms and change but cannot predict an individual suicide or substitute for formulation and safeguarding action.
Family involvement is tailored
Carers often enable treatment and safety, while coercion or abuse may make particular involvement unsafe and require an alternative supporter.
Common pitfalls
01
Requiring a child to use adult sadness language before recognising a depressive syndrome.
02
Interviewing only the accompanying adult and failing to offer private, developmentally appropriate conversation.
03
Using an anxiety or depression questionnaire as a diagnostic, suicide-prediction or discharge tool.
04
Starting an antidepressant for mild depression without an appropriate psychological and specialist pathway.
05
Prescribing fluoxetine without an early monitoring plan for suicidal behaviour, self-harm, hostility and activation.
06
Treating school absence or family conflict as mere non-compliance without exploring fear, bullying, abuse, learning and neurodevelopmental needs.
Coordinate with school only with appropriate consent or a safeguarding basis, specifying useful adjustments rather than disclosing an unrestricted clinical history.
Marked weight loss, dehydration, prolonged school absence, inability to get out of bed or loss of basic self-care indicates severity even when symptom words are limited.
Bruising, sexualised behaviour, coercion, online exploitation, domestic abuse, fear of going home or a controlling accompanying adult must trigger private safeguarding enquiry.
New suicidal behaviour, self-harm or hostility after starting or changing an antidepressant requires urgent prescriber contact and reassessment rather than automatic discontinuation or reassurance.
validate or exclude a psychiatric diagnosis.
05Validated symptom measure
Why
Provide an age-appropriate baseline and track change alongside goals and functioning.
Interpretation and limitations
Scores are adjuncts affected by literacy, development and context and must never replace clinical or safeguarding assessment.
2For moderate-to-severe depression, use the five-to-eleven developmentally adapted options or offer twelve-to-eighteen individual CBT for at least three months with NICE alternatives when unsuitable; for social anxiety offer focused individual or group CBT.
3Review attendance, behavioural change, function and safety, adapt communication and family or school roles, and reformulate if the agreed response is absent.
03Specialist medicationUse fluoxetine with therapy and surveillanceA child and adolescent psychiatrist diagnoses moderate-to-severe depression and judges medication indicated with psychological treatment.+
1Discuss expected delay, adverse effects, adherence, off-label status where applicable and an urgent route for activation, hostility, self-harm or suicidal change.
2Start fluoxetine 10 mg daily and consider 20 mg daily after one week when clinically necessary, adapting for body weight and specialist judgement.
3Agree close early contact; NICE gives weekly contact for the first four weeks as an example, with individual frequency recorded. After response, continue for at least six months after remission before specialist-guided gradual stopping.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
NICE identifies fluoxetine as the antidepressant whose trial evidence shows benefits outweigh risks for depression in children and young people, used with psychological therapy after specialist diagnosis and the age-specific sequencing described above.
Fluoxetine for depressive illness
Children and young people: start 10 mg orally once daily; increase to 20 mg once daily after 1 week if clinically necessary. Consider a lower dose in children of lower body weight; evidence above 20 mg daily is limited and any higher dose requires specialist justification. After response, continue for at least 6 months after remission, defined by NICE as no symptoms and full functioning for at least 8 weeks, then stop gradually under specialist guidance.
Monitor suicidal behaviour, self-harm, hostility, activation, sleep and adherence particularly early; NICE gives weekly contact for the first 4 weeks as an example, with frequency individualised and recorded. Review bipolar or psychotic features, interactions and overdose access; evidence in ages 5 to 11 is not established, use under age 8 may be off label, and abrupt cessation should be avoided.