Child and adolescent depression — structured clinical viva

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]