Explain adolescent depression and the fluoxetine decision to parents — OSCE

Candidate instructions

You are the paediatric registrar. The parents of a 15-year-old girl with a moderate depressive episode and recent superficial self-harm have ten minutes with you. They have read online that antidepressants cause suicide and are frightened. Explain, in plain language: (1) what depression in a teenager is and that it is treatable; (2) how you assessed suicide risk and the safety plan you will make together; (3) the role of talking therapy and when a medicine such as fluoxetine is added; and (4) an honest, balanced account of the suicide warning and how you will monitor. Invite their questions and agree a shared plan. Do not lecture; check understanding throughout. [1]

Encounter

Parent: "The GP said she's depressed and wants to start tablets, but everything online says they make teenagers suicidal. I don't know what to believe." [3]

Registrar: "Thank you for coming in, and I can see this is frightening. Let me explain what we found, what it means, and the choices we have — and please stop me whenever you need to. First, depression in teenagers is a real, treatable medical condition, not a weakness. It is a pattern of low or irritable mood and loss of interest that has lasted weeks and is getting in the way of school, sleep and friendships. The good news is we have treatments that work." [4]

Parent: "But she's been cutting herself. Is she going to try to kill herself?" [3]

Registrar: "That is exactly the right thing to ask, and I asked her directly too. I asked about her thoughts, whether she has a plan, and whether she has access to anything she could use. Right now she has distress and self-harm but no firm plan, which is important. I would like us to build a safety plan together — a short list she keeps of her warning signs, who she can call, what helps, and the crisis number — and I would ask you to lock away medications and sharp objects at home. Asking about suicide does not put the idea in her head; it helps keep her safe." [3]

Parent: "Do the tablets cause suicide though?" [3]

Registrar: "Let me give you the honest picture. When researchers pooled the trials of antidepressants in young people, there was a small increase in reports of suicidal thoughts, but no completed suicides, and it was most common in the first couple of weeks. So we take it seriously — we start on a low dose, see her back within a week, and ask you to watch for new restlessness, agitation or new thoughts of self-harm. The other side of the balance is just as important: untreated depression is itself one of the biggest risks. So the aim is careful treatment, not avoiding treatment." [3]

Parent: "So what would she actually take?" [1]

Registrar: "If we decide a medicine is needed, the first choice is fluoxetine. It is the one with the best evidence of helping young people with the fewest problems, and we start very low — a small dose once a day — and build up slowly. It takes about four to six weeks to see the full benefit. Alongside it, or sometimes instead, we arrange talking therapy — cognitive behavioural therapy — which helps her recognise the patterns and build skills. For a moderate episode like hers, we often use both together." [1] [2]

Parent: "Will she be on it forever?" [4]

Registrar: "No. Usually we continue for at least six months after she has fully recovered, then bring it down slowly. Stopping suddenly can cause dizziness and flu-like feelings, so we taper. Before we finish today, I want to agree the plan with you and with her — the therapy, the medicine if we go ahead, the safety plan, and a date I will see her again within the week. What questions do you still have?" [4]

Marking domains

• Communication (25%): plain language, empathy, checks understanding, invites questions, avoids jargon and does not lecture.
• Clinical content (30%): explains depression as a treatable condition; describes the suicide-risk assessment and a collaborative safety plan with means restriction; explains the role of CBT and fluoxetine with correct timing and monitoring; gives a balanced account of the black-box warning. [4]
• Shared decision-making (20%): presents options rather than dictating; acknowledges the family's fear; agrees a written plan and a clear follow-up.
• Safety (15%): names the warning signs that need urgent help and the crisis pathway; confirms means restriction.
• Professionalism and global (10%): maintains a calm, non-judgemental, collaborative stance; appropriate confidentiality with carer involvement.