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]