Management: F32.1 Moderate Depressive Episode — 16-year-old Male

1. Initial Comprehensive Assessment (Before Any Treatment)

Diagnostic Clarification

• Confirm ICD-10 F32.1 (moderate depressive episode): ≥2 core symptoms (depressed mood, anhedonia, anergia) + ≥3–4 accessory symptoms, with functional impairment
• Exclude differentials:
  • Bipolar affective disorder (especially if family history, hypomanic features, or early onset)
  • Medical causes: hypothyroidism, anaemia, diabetes, autoimmune conditions, CNS disorders
  • Substance/medication-related (steroids, isotretinoin, substance misuse)
  • Psychotic depression, PTSD, ADHD, anxiety disorders

Formulation (3 Ps)

• Predisposing: family history of depression/psychiatric disorders, genetic vulnerability, early adverse experiences
• Precipitating: school stressors, bullying/victimisation, relationship issues, bereavement, trauma
• Perpetuating: negative cognitions, poor sleep, social withdrawal, family dysfunction, comorbid disorders

Baseline Severity Scales

Risk Assessment (MANDATORY)

• Suicidal ideation, intent, plan, means access
• Self-harm history and current urges
• Risk to others
• Safeguarding concerns (abuse, neglect, exploitation)
• If high risk → urgent psychiatric admission

Physical Investigations

• TFTs, FBC, renal/liver function, glucose, calcium
• Urine drug screen (if substance use suspected)

2. Psychoeducation and Safety Planning

• Explain depression, its course, and treatability to the patient and parents/carers (developmental language)
• Address stigma
• Safety plan: identify warning signs, coping strategies, support contacts, crisis numbers (e.g., CAMHS emergency line)
• Medication storage: a parent/carer should be responsible for secure storage of any prescribed medication (reduce overdose risk)
• Lifestyle advice: regular sleep schedule, physical activity, reduced screen time, social engagement

3. Treatment Decision: Moderate Severity (F32.1)

First-Line: Psychological Therapy (Alone or Combined with Medication)

• CBT (Cognitive Behavioural Therapy) — most evidence-based; target negative cognitive distortions, behavioural activation
• IPT-A (Interpersonal Therapy for Adolescents) — particularly if interpersonal triggers (grief, role transitions, conflict)
• Duration: typically 12–16 sessions weekly/biweekly
• If psychotherapy alone fails to respond after 4–6 weeks, add pharmacotherapy

Antidepressants should not be the sole first-line treatment for mild-moderate depression; psychological therapy must be offered.

When to Add Pharmacotherapy (Moderate Depression)

• Moderate-to-severe depression not responding to psychotherapy
• Severe functional impairment preventing engagement in therapy
• Patient/family preference
• Psychotherapy not available
• Evidence of melancholic or biological features

4. Pharmacotherapy

First-Line Drug: Fluoxetine

Second-Line Alternatives (if fluoxetine not tolerated):

• Sertraline: start 25–50 mg/day → titrate to 50–200 mg/day
• Escitalopram: start 5–10 mg/day → titrate to 10–20 mg/day (FDA approved ≥12 yrs)
  • Note: Shorter half-life than fluoxetine — consider twice-daily dosing to prevent discontinuation symptoms

Other Agents (Generally Avoided in Adolescents):

• Duloxetine / Venlafaxine: may be effective but relatively poorly tolerated
• Agomelatine: promising data, extremely well tolerated, but not licensed for adolescents
• Vortioxetine: insufficient paediatric data
• TCAs (e.g., imipramine): NOT recommended — no efficacy advantage, serious cardiotoxicity risk
• Paroxetine: NOT recommended in under-18s (poor evidence, increased suicidality signal)
• Mirtazapine: limited trial data in young people

⚠️ Black Box Warning (FDA): Increased suicidal ideation with antidepressants in under-18s

• Risk is suicidal ideation, not completed suicide
• Monitor closely in first 4 weeks, especially for:
  • Increased agitation, restlessness, emotional lability
  • New or worsening suicidal thoughts
  • Behavioural activation before mood improves (early weeks)

5. Monitoring Protocol

6. Management of Comorbidities

7. Duration of Treatment

• Acute phase: 12 weeks (assess full response)
• Continuation: maintain for at least 6–12 months after remission to prevent relapse
• Maintenance: consider if ≥3 episodes or chronic course
• Gradual tapering when discontinuing (especially sertraline, escitalopram — watch for discontinuation syndrome)

8. School and Social Interventions

• Liaison with school (educational psychologist, pastoral team)
• Phased return to school if absent
• Physical activity programmes (evidence for mood benefit)
• Family therapy if significant family dysfunction
• Peer support programmes

9. Escalation / Admission Criteria

• Active suicidal intent or plan with means
• Significant self-harm requiring medical attention
• Psychotic features
• Refusal to eat/drink
• Complete functional breakdown
• Inadequate home safety/supervision

Evidence Note (2025)

F32.1 (Moderate Depression) — 16-year-old male
         ↓
Full assessment + risk screen + safety plan
         ↓
Psychotherapy (CBT/IPT-A) — 12–16 sessions
         ↓
No response at 4–6 weeks? → Add Fluoxetine 10→20mg/day
         ↓
Monitor weekly (first 4 weeks), monthly thereafter
         ↓
Full remission → continue 6–12 months, then taper
         ↓
Non-response at 12 weeks → review Dx, switch SSRI, seek specialist input

F32.1 — Moderate Depressive Episode | 16-year-old Male

Step 1 — Comprehensive Assessment (Before Treatment)

• ≥2 core symptoms (low mood, anhedonia, anergia) + ≥3–4 accessory symptoms (poor concentration, low self-esteem, guilt, sleep/appetite changes, suicidal ideation) with functional impairment

• Bipolar disorder, hypothyroidism, anaemia, substance misuse, steroid/medication-induced, ADHD, anxiety disorders, early psychosis

• Suicidal ideation, intent, plan, access to means → high risk = urgent admission
• Self-harm, safeguarding concerns

• TFTs, FBC, glucose, LFTs, renal panel, urine drug screen

• CDRS-R (clinician), MFQ or RCADS (self/parent), CGAS (function)

• Predisposing (family history, genetics, early adversity)
• Precipitating (school, bullying, loss, trauma)
• Perpetuating (negative cognitions, social withdrawal, family conflict)

Step 2 — Psychoeducation & Safety Planning

• Explain depression, course, and treatment to patient and parents
• Safety plan: warning signs, coping strategies, crisis contacts
• Medication storage: parent/carer holds and dispenses medication (overdose prevention)
• Lifestyle: sleep hygiene, exercise, reduce social isolation, limit substances/screen time

Step 3 — Treatment (NICE/AACAP Guidelines)

First-Line: Psychological Therapy

• 12–16 weekly/biweekly sessions
• Reassess at 4–6 weeks — if no response, add pharmacotherapy

Antidepressants alone should not be first-line for moderate depression — psychotherapy must be offered

When to Add Pharmacotherapy

• Inadequate response to 4–6 weeks of psychotherapy
• Severe functional impairment preventing therapy engagement
• Psychotherapy unavailable
• Patient/family preference

Step 4 — Pharmacotherapy

First-Line: Fluoxetine (SSRI)

Alternatives (if fluoxetine not tolerated)

Shorter half-life of sertraline/escitalopram — consider twice-daily dosing to prevent discontinuation symptoms

Drugs to Avoid in Adolescents

• TCAs — cardiotoxic, no advantage
• Paroxetine — not recommended <18 yrs (increased suicidality, poor evidence)
• Venlafaxine/duloxetine — poorly tolerated; not first-line

⚠️ FDA Black Box Warning

Step 5 — Monitoring

Step 6 — Duration

• Acute: 12 weeks
• Continuation: minimum 6–12 months after remission (prevents relapse)
• Discontinuation: gradual taper — never abrupt

Step 7 — School & Social Supports

• Liaison with school (educational psychologist, pastoral care)
• Phased return if school-absent
• Family sessions if family dysfunction present
• Exercise prescription (proven mood benefit)
• Peer support programmes

Step 8 — Escalation / Admit If

• Active suicidal intent with plan/means
• Medically significant self-harm
• Psychotic features
• Refusal to eat/drink
• Unsafe home environment

2025 Evidence Update

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