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Clinical Atlas Prestige · Evidence-first

Psych VivasChild and adolescent psychiatry — depression

Psych Vivas · Child and adolescent psychiatry — depression

Child and adolescent depression — structured clinical viva

Fellowship viva on stepping from CBT to fluoxetine in adolescent MDD, black-box communication, family work, and TORDIA-informed next steps.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the CAMHS registrar. A 16-year-old with first-episode major depression has partial response to 8 weeks of CBT alone. PHQ-A remains 16. There is intermittent suicidal ideation without plan, weekly NSSI, and parental conflict about 'putting her on drugs'. Discuss indication for fluoxetine, how you consent for the black-box warning, monitoring schedule, school interface, and what you would do if she fails fluoxetine.

Interpretation

Reveal interpretation

This is moderate adolescent MDD with incomplete response to CBT alone, ongoing ideation/NSSI, and family ambivalence about medication. Re-confirm diagnosis, bipolar screen, substances, adherence to CBT homework, and risk. Combination treatment is reasonable: continue structured psychological care and offer fluoxetine as best-evidenced first-line SSRI.[1][4][5]

Consent/black-box. Explain that paediatric meta-analysis found a small absolute increase in suicidal ideation/behaviour signals on antidepressants versus placebo, without establishing a large completed-suicide signal in those short trials. Frame as need for early monitoring and safety planning, balanced against risks of undertreated depression (including suicide and functional loss). Invite questions; avoid coercive or dismissive tone with parents.[2]

Practical plan. Start fluoxetine around 10–20 mg orally daily, early reviews, carer means restriction for medication stock, private youth check-ins, school liaison for attendance and supports. If adequate fluoxetine fails, TORDIA supports switch + CBT rather than endless same-drug inertia.[1][3][4]

Key points

Fluoxetine is first among SSRIs in youth

Trial and network evidence favour fluoxetine when medication is indicated for youth MDD.

Black-box means monitor

Communicate small absolute suicidality signals and schedule early reviews — do not abandon indicated treatment out of fear alone.

TORDIA after first SSRI failure

Switch antidepressant and ensure CBT rather than switch alone.
[1] [2] [3] [4]

References

  1. [1]March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial JAMA, 2004.PMID 15315995
  2. [2]Hammad TA, Laughren T, Racoosin J Suicidality in pediatric patients treated with antidepressant drugs Arch Gen Psychiatry, 2006.PMID 16520440
  3. [3]Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial JAMA, 2008.PMID 18314433
  4. [4]Emslie GJ, Heiligenstein JH, Wagner KD, et al. Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial J Am Acad Child Adolesc Psychiatry, 2002.PMID 12364842
  5. [5]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391