Depressive disorders in children and adolescents — formative SAQs

SAQ 1 (10 marks)

A 14-year-old girl is brought by her mother after her grades fell from A to D over one term, she stopped seeing friends, sleeps poorly, feels worthless, and has begun cutting her forearms. She is irritable in the interview and says "everyone would be better off without me" but denies a specific plan. Her PHQ-9 is 17. There is no history of manic episodes, no substance use, and no medical symptoms. [4] [5]

1. Give the most likely diagnosis with the criteria that support it, and list three differentials with discriminators. (3) [4]
2. Outline your immediate suicide-risk assessment and safety plan. (4) [3]
3. Describe the stepped-care treatment plan, naming the first-line therapy and the first-line drug if one is indicated. (3) [1] [2]

Model answer — SAQ 1

(1) Diagnosis and differentials (3). The picture fits major depressive disorder, moderate to severe — at least five symptoms for at least two weeks with impairment (depressed/irritable mood, anhedonia, sleep disturbance, worthlessness, fatigue, and suicidal ideation), and a PHQ-9 above the adolescent cut-point that triggers a full interview. Differentials: adjustment disorder (here the syndrome exceeds a proportionate stress reaction); bipolar depression (excluded by the absence of manic or hypomanic episodes — but re-screen); substance-induced or organic mood disorder (no substance use and no medical symptoms, but exclude with focused tests); anaemia or hypothyroidism as mimics (fatigue and low mood). [4] [5]

(2) Risk assessment and safety plan (4). Ask directly about suicidal ideation, plan, intent, and access to means (medication, sharp objects), and weigh protective factors (family, friends, future orientation). Document the assessment. Form a collaborative written safety plan: warning signs, internal coping strategies, trusted people and places, professional contacts, and means restriction (secure medications and sharp objects). Agree a clearly named clinician for follow-up within days, involve carers within the bounds of confidentiality and safety, and arrange same-day specialist review if intent or plan escalates. Asking directly does not increase risk. [3]

(3) Stepped care (3). Severity is moderate to severe, so specialist child and adolescent mental-health involvement is appropriate. First-line is evidence-based psychotherapy (CBT or IPT-A). Because of the severity and suicidality, add fluoxetine — the first-line SSRI in under-18s (Cipriani NMA; TADS) — starting low (e.g. fluoxetine 10 mg oral daily), reviewing at one week then about two weekly. Combination of fluoxetine with CBT is supported by TADS for severe presentations. Do not let the suicidality warning delay treatment; monitor carefully instead. [1] [2] [3]

SAQ 2 (10 marks)

A 16-year-old with moderate depression has had 8 weeks of cognitive behavioural therapy with minimal improvement. He has no history of mania, no psychosis, normal thyroid function and full blood count, and no active suicidality. His parents ask whether an antidepressant is now needed and are frightened by the black-box warning. [5] [6]

1. State the indication for an SSRI here and which drug you would choose, with reasoning. (4) [1]
2. Explain the black-box warning to the parents, including how you will operationalise it. (3) [3]
3. Describe what you would do if there is only a partial response after an adequate trial. (3) [6] [7]

Model answer — SAQ 2

(1) SSRI choice (4). An SSRI is now indicated: moderate depression with poor response to an adequate psychotherapy trial, with bipolar and organic causes excluded. Fluoxetine is first-line because the network meta-analyses show it is the one antidepressant with a favourable efficacy-tolerability balance in under-18s, and it underpins the TADS and Emslie evidence. Start low (e.g. fluoxetine 10 mg oral daily) and titrate within the licensed range, continuing the psychotherapy. [1] [2]

(2) The warning (3). Explain that pooled paediatric trials show a small absolute increase in suicidal thoughts or behaviours with antidepressants, with no completed suicides and the signal largest early in treatment. Operationalise it by starting low, reviewing at one week for activation and suicidality, then about two weekly, and counselling the family to watch for new agitation, restlessness, increased energy with low mood, or new suicidal thoughts. Reassure that untreated depression is itself a major risk, so the goal is careful treatment, not avoidance. Use shared decision-making and document the plan. [3]

(3) Partial response (3). After an adequate trial (full dose for at least four to six weeks), check adherence and re-examine the diagnosis (bipolar, comorbidity, substance use, ongoing stressors). Optimise the dose if tolerated; if still inadequate, switch (e.g. to escitalopram) or combine with structured psychotherapy and refer for specialist care. TORDIA supports switching medication combined with CBT in resistant depression; IMPACT supports the value of delivering a competent structured therapy. Build a relapse-prevention plan from the outset. [6] [7]