Child and adolescent depression — assessment and TADS/ADAPT-informed management (MEQ)

(i) Assessment. Multi-informant: private youth interview and carer interview; school collateral if available. Risk: expand item 9 and NSSI — ideation frequency/intensity, intent, plan, means (medications at home, other means), preparatory behaviour, hopelessness, substance use, protective factors, and functions of cutting. Bipolar screen: elevated/irritable periods with decreased sleep need, grandiosity, risky behaviour, family history of bipolar. Confidentiality: explain limits at outset; with active suicide risk or need for means restriction, share necessary information with carers — Gillick/developmental competence assessed but does not abolish duty to protect. Organic: physical review, TSH/FBC as indicated, pregnancy test if relevant, substances. Safeguarding screen given family conflict. MSE and functional impairment (school, peers, sleep).^[5][6]

(ii) Diagnosis and differentials. Working diagnosis: major depressive disorder, current episode moderate–severe, with non-suicidal self-injury and elevated suicide risk needing active management. Differentials: bipolar depression (still open until screen complete); adjustment disorder (threshold/duration argue against); substance-induced; medical mimics; trauma-related disorders; primary anxiety with demoralisation. Discriminators: mania history, substance timeline, labs, trauma symptoms vs primary mood syndrome.^[5][6]

(iii) Initial management. Collaborative safety plan with carers for means restriction and crisis contacts; increase intensity if intent/plan emerges. Psychoeducation. Offer CBT (or IPT-A) with behavioural activation and parent sessions addressing conflict. School liaison for graded return and supports. Given moderate–severe illness with risk, discuss fluoxetine — e.g. 10 mg orally daily then 20 mg daily as tolerated, early review for activation/suicidality, document black-box style monitoring rationale (small absolute increase in ideation/behaviour signals in paediatric meta-analysis — monitor, do not abandon indicated care). Measurement-based follow-up. Avoid no-suicide contracts as the plan.^[1][4][5]

(iv) TADS vs ADAPT. TADS acute results support fluoxetine and combination fluoxetine+CBT over CBT alone and placebo — combination often preferred when feasible for moderate–severe adolescent depression. ADAPT shows that adding CBT to SSRI plus routine specialist care did not clearly improve primary outcomes — so do not claim CBT packages always add benefit on top of high-quality specialist medication care; tailor to access, preference, and residual symptoms.^[1][2]

(v) TORDIA next step. After an adequate first SSRI fails (dose, duration, adherence confirmed; diagnosis re-checked), switch antidepressant and add CBT rather than medication switch alone; consider specialist oversight if venlafaxine is among switch options because of tolerability/suicidality considerations.^[3]