Starting an SSRI with black-box counselling (CASC)

Station instructions (candidate)

You have 7 minutes. Engage the patient and parent. Validate fears about suicide risk and addiction language online. Explain accurately that SSRIs are not addictive in the substance-use sense but can cause discontinuation symptoms if stopped abruptly, and that a black-box warning means closer early monitoring because a minority of young people experience increased suicidal thoughts after starting — while untreated depression also carries suicide risk.[1][2][5] Offer a collaborative plan: optional sertraline start low, early review, safety plan, sexual side-effect discussion, and psychological therapy pathway. Do not coerce. Do not claim zero risk. Do not dismiss the parent.

Marking domains

Rapport and agenda; accurate black-box explanation without terror or denial; addiction vs discontinuation distinction; sexual side-effect consent; safety planning and early review; shared decision including right to decline; parent involvement with young adult autonomy respected; link to guideline-supported role of SSRIs in moderate–severe depression.[1][3][4][6]

Model communication map

1. Open: thank them; name goals (feel better, stay safe, keep uni functioning).[3]
2. Validate media fears: the warning exists because some young people get more suicidal thoughts early — that is why we check soon, not because the tablet is a death sentence.[1][2]
3. Balance untreated illness: depression itself raises suicide risk; therapy and/or medicine can help moderate–severe illness.[3][6]
4. Not addiction: you do not get a high or compulsive drug-seeking like opioids; if stopped suddenly you can feel dizzy or 'electric shocks' — we taper later.[5]
5. Sexual SE: many people get reduced libido or delayed orgasm — we ask and can adjust if it happens.[4]
6. Plan if starting: sertraline example 25–50 mg oral daily; review within 1–2 weeks; crisis contacts; parent role agreed; CBT/psychology referral.[3]
7. If declining medicine: honour choice; safety net; therapy-first still valid with close follow-up; door open to revisit.[3]
8. Close: written plan; next appointment; what to do if worse tonight.[1]

Common fails

• Saying “black box means you must never take SSRIs under 25.”[1][7]
• Calling SSRIs addictive like benzodiazepines/opioids.[5]
• Omitting sexual side-effects entirely.[4]
• Coercing start without safety plan or early review date.[2]
• Ignoring the parent’s fear or the patient’s autonomy.[3]

Optional OSCE skill add-on (2 minutes)

Write a one-line prescription teaching dose for sertraline start and state three red-flag symptoms that should trigger same-day contact (worsening suicidal ideation, severe agitation/akathisia, allergic reaction/serotonin toxicity features).[1][3]