Depressive disorders in children and adolescents — branching viva

Opening

Examiner: A 15-year-old is in your clinic with six weeks of low mood, has stopped attending sport, her marks have slipped, she is sleeping badly, and her mother found superficial cuts on her forearm. How do you frame this assessment? [4]

Candidate: I would treat this as a possible depressive disorder and a safety concern first. I would take a structured, multi-informant history — the young person alone for part of it — map symptoms against DSM-5-TR criteria, and do a direct suicide and self-harm risk assessment before discussing treatment. [4]

Branch 1 — diagnosis

Examiner: What criteria make it a major depressive episode rather than ordinary low mood? [4]

Candidate: At least five of the nine symptom groups, including depressed or irritable mood or loss of interest, present for most of the day nearly every day for at least two weeks, with clinically significant impairment, and not better explained by a substance, a medical condition, or bipolar disorder. In this age group irritability can substitute for depressed mood. [4]

Examiner (probe): Why multi-informant? [4]

Candidate: Adolescents often under-report internalising symptoms, parents often under-detect mood, and teachers see function and peer behaviour the family does not. School collateral and parent report sharpen the picture. [4]

Branch 2 — the bipolar screen

Examiner: Before you reach for a drug, what must you exclude? [4]

Candidate: A past or current manic or hypomanic episode. I would ask explicitly about any period of elevated or irritable mood with decreased need for sleep, racing thoughts, grandiosity, and goal-directed overactivity. Giving an SSRI to a young person with undiagnosed bipolar depression risks a mixed state or a manic switch. I would also exclude organic mimics (thyroid, anaemia, substances). [4]

Branch 3 — risk and safety

Examiner: She has superficial cuts. Talk me through your risk assessment. [3]

Candidate: I ask directly about suicidal thoughts, plan, intent, means, and protective factors, and I document it. I form a collaborative written safety plan — warning signs, coping strategies, trusted people, professional contacts — and I restrict means (secure medications and sharp objects). If there is a plan or intent, that is a psychiatric emergency: same-day specialist review, do not leave alone, consider admission. [3]

Examiner (probe): Does asking about suicide increase the risk? [3]

Candidate: No. Asking directly does not increase risk, and means restriction saves lives. [3]

Branch 4 — treatment

Examiner: She has moderate depression. What is your stepped plan? [4]

Candidate: Psychoeducation, sleep and activity, and an evidence-based psychotherapy — CBT or IPT-A. Given moderate severity with self-harm, I would involve specialist child and adolescent mental-health services and add fluoxetine, the first-line SSRI in under-18s, starting low and reviewing weekly early. [1] [2]

Examiner (probe): Why fluoxetine and not another SSRI? [1]

Candidate: The Cipriani network meta-analysis found fluoxetine is the one antidepressant in under-18s with a favourable efficacy-tolerability balance; paroxetine, venlafaxine and duloxetine are not first-line. TADS and Emslie underpin its use. [1]

Branch 5 — the warning and the corners

Examiner: Her parents have read the black-box warning and want to avoid medication. How do you respond? [3]

Candidate: I explain the evidence honestly: a small absolute increase in suicidal thoughts in pooled trials, no completed suicides, the signal largest early. I operationalise it by starting low, reviewing at one week, and counselling the family to watch for activation. I also explain that untreated depression is itself a major suicide risk, so careful treatment — not avoidance — is the safer course. I use shared decision-making and document the plan. [3]

Examiner (final corner): And if she does not respond to an adequate fluoxetine trial? [6]

Candidate: Check adherence and re-examine the diagnosis — bipolar, comorbidity, substances, ongoing stressors. Optimise the dose, then switch (e.g. to escitalopram) or combine with structured psychotherapy and escalate to specialist care. TORDIA supports switching medication plus CBT in resistant depression. I build a relapse-prevention plan and a clear follow-up clinician, and plan transition to adult services in advance. [5] [6]