Psychopharmacology and psychotropic medicines in children and adolescents — formative SAQs

SAQ 1 — Starting an SSRI in adolescent depression (10 marks)

A 15-year-old girl presents with moderate major depressive disorder (PHQ-A in the moderate-severe range), four weeks of low mood, anhedonia, sleep and appetite disturbance, and declining school attendance. She has no current suicidal intent but has had fleeting passive thoughts. There is no history of mania or psychosis. Her mother asks whether she needs tablets, and what the risks are. ^{[1] [8]}

Questions

1. Justify your pharmacological choice and outline the starting dose, the role of cognitive-behavioural therapy, and the evidence you would cite. (5 marks) ^[1]
2. Explain the FDA black-box suicidality warning, how you would counsel the family, and the review schedule you would set in the first month. (5 marks) ^{[8] [9]}

Model answer

Choice, dose, therapy and evidence (5). My first-line SSRI is fluoxetine, ideally combined with cognitive-behavioural therapy (CBT). Fluoxetine has the strongest paediatric evidence base and is the SSRI approved for paediatric depression down to age 8. The pivotal TADS trial showed that fluoxetine, CBT and their combination all beat placebo for adolescent depression, but combination therapy gave the best outcomes and lowered suicidality compared with fluoxetine alone — so medication plus therapy is safer and better than medication alone. I would start at about half the typical adult dose, taken in the morning, confirm the exact dose against the BNF for Children / AMH Children's Dose, and titrate after 4 to 6 weeks if response is partial. I would explicitly not use paroxetine first-line, because the Restoring Study 329 reanalysis showed its benefit was overstated and its harms understated. ^{[1] [2] [10]}

Suicidality warning, counselling and review (5). The FDA black-box warning covers all antidepressants in people under 25: paediatric antidepressant trials showed an increased rate of reported suicidal ideation and attempts (Bridge meta-analysis). The Gibbons reanalysis argues the absolute risk is low and that effective treatment itself protects against suicide, so the defensible position is close monitoring plus treatment, not avoidance of treating real depression, because untreated depression carries its own substantial suicide risk. I would counsel the family that the SSRI takes 4 to 6 weeks to work, that early agitation or worsening should prompt immediate contact, and that the main monitoring obligation is suicidality. My review schedule would be at 1 week, 2 weeks and 4 weeks, and at every dose change, with explicit suicidality assessment, a safety plan, removal of access to means, and an open-access pathway. ^{[8] [9]}