Adult depression — structured viva

Structured oral on adult depression: defending PHQ-9-based severity triage with operating characteristics, the bipolar-screen-before-prescribing reflex, suicide risk assessment beyond prediction models, STAR*D expectations, lithium augmentation in treatment resistance, and perinatal SSRI choice.

Prompt

The examiner opens: 'Your practice partner says every sad patient gets a script for sertraline and a six-month review. Defend your different approach.' The viva branches through diagnosis and instruments, the pre-prescribing differential, risk assessment, stepped care evidence, treatment resistance, duration of therapy, and perinatal prescribing.

Stem

You are the GP registrar supervisor. Your trainee reports that the practice's default for low mood is 'sertraline, review in three months'. ^[1]

References19Show

[1]Kroenke K, Spitzer RL, Williams JB The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 2001.PMID 11556941
[2]Levis B, Benedetti A, Thombs BD, DEPRESsion Screening Data (DEPRESSD) Collaboration Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ, 2019.PMID 30967483
[3]US Preventive Services Task Force, Barry MJ, Nicholson WK, Silverstein M, Chelmow D, et al. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA, 2023.PMID 37338872
[4]Hirschfeld RM, Williams JB, Spitzer RL, Calabrese JR, Flynn L, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry, 2000.PMID 11058490
[5]Zimmerman M Using Screening Scales for Bipolar Disorder in Epidemiologic Studies: Lessons Not Yet Learned. J Affect Disord, 2021.PMID 34161888
[6]Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry, 2011.PMID 22193671
[7]Belsher BE, Smolenski DJ, Pruitt LD, Bush NE, Beech EH, et al. Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiatry, 2019.PMID 30865249
[8]Brown GK, Batdorf WH, Dedert EA, Kumpula MJ, Day KT, et al. National implementation of advanced training in the safety planning intervention in the Department of Veterans Affairs health care system. Psychol Serv, 2025.PMID 38900568
[10]Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry, 2006.PMID 17074942
[11]Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet, 2018.PMID 29477251
[12]Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 2010.PMID 20051569
[13]Ross EL, Vijan S, Miller EM, Valenstein M, Zivin K The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model. Ann Intern Med, 2019.PMID 31658472
[17]Nelson JC, Baumann P, Delucchi K, Joffe R, Katona C A systematic review and meta-analysis of lithium augmentation of tricyclic and second generation antidepressants in major depression. J Affect Disord, 2014.PMID 25069082
[19]Lenze EJ, Mulsant BH, Roose SP, Lavretsky H, Reynolds CF 3rd, et al. Antidepressant Augmentation versus Switch in Treatment-Resistant Geriatric Depression. N Engl J Med, 2023.PMID 36867173
[20]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet, 2003.PMID 12642045
[21]Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet, 2003.PMID 12606176
[23]Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, et al. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev, 2021.PMID 33886130
[24]Warner CH, Bobo W, Warner C, Reid S, Rachal J Antidepressant discontinuation syndrome. Am Fam Physician, 2006.PMID 16913164
[36]Eisma MC Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Aust N Z J Psychiatry, 2023.PMID 36748103

Adult depression — structured viva

Stem

You are the GP registrar supervisor. Your trainee reports that the practice's default for low mood is 'sertraline, review in three months'. ^[1]

References19Show

[1]Kroenke K, Spitzer RL, Williams JB The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 2001.PMID 11556941
[2]Levis B, Benedetti A, Thombs BD, DEPRESsion Screening Data (DEPRESSD) Collaboration Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ, 2019.PMID 30967483
[3]US Preventive Services Task Force, Barry MJ, Nicholson WK, Silverstein M, Chelmow D, et al. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA, 2023.PMID 37338872
[4]Hirschfeld RM, Williams JB, Spitzer RL, Calabrese JR, Flynn L, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry, 2000.PMID 11058490
[5]Zimmerman M Using Screening Scales for Bipolar Disorder in Epidemiologic Studies: Lessons Not Yet Learned. J Affect Disord, 2021.PMID 34161888
[6]Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry, 2011.PMID 22193671
[7]Belsher BE, Smolenski DJ, Pruitt LD, Bush NE, Beech EH, et al. Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiatry, 2019.PMID 30865249
[8]Brown GK, Batdorf WH, Dedert EA, Kumpula MJ, Day KT, et al. National implementation of advanced training in the safety planning intervention in the Department of Veterans Affairs health care system. Psychol Serv, 2025.PMID 38900568
[10]Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry, 2006.PMID 17074942
[11]Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet, 2018.PMID 29477251
[12]Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 2010.PMID 20051569
[13]Ross EL, Vijan S, Miller EM, Valenstein M, Zivin K The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model. Ann Intern Med, 2019.PMID 31658472
[17]Nelson JC, Baumann P, Delucchi K, Joffe R, Katona C A systematic review and meta-analysis of lithium augmentation of tricyclic and second generation antidepressants in major depression. J Affect Disord, 2014.PMID 25069082
[19]Lenze EJ, Mulsant BH, Roose SP, Lavretsky H, Reynolds CF 3rd, et al. Antidepressant Augmentation versus Switch in Treatment-Resistant Geriatric Depression. N Engl J Med, 2023.PMID 36867173
[20]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet, 2003.PMID 12642045
[21]Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet, 2003.PMID 12606176
[23]Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, et al. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev, 2021.PMID 33886130
[24]Warner CH, Bobo W, Warner C, Reid S, Rachal J Antidepressant discontinuation syndrome. Am Fam Physician, 2006.PMID 16913164
[36]Eisma MC Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Aust N Z J Psychiatry, 2023.PMID 36748103