Third-Line SSRI CYP Depression — MRCPsych Paper B MCQ
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Correct answer: A — Citalopram is named alongside sertraline as a second-line option after fluoxetine, but NG134 does not specify a routine sequential third-line SSRI; renewed senior specialist review is required.
NICE recommends fluoxetine first when an antidepressant is indicated. If it is unsuccessful or not tolerated, sertraline or citalopram are the named second-line alternatives, subject to strict criteria including reassessment of treatment resistance, senior child and adolescent psychiatrist advice, informed consent and concurrent psychological therapy. NICE does not designate citalopram as a routine sequential third-line SSRI after sertraline failure. Further prescribing therefore requires renewed specialist multidisciplinary formulation rather than an automatic drug sequence. Citalopram use for depression under 18 is off-label. Venlafaxine should not be used for depression in children and young people, and neither should tricyclic antidepressants. NG134 does not recommend an MAOI at this stage. Thus, B most accurately describes the guidance without overstating citalopram as an established third-line treatment.
Reference: NICE. Depression in children and young people: identification and management (NG134), recommendations 1.6.12–1.6.14 and 1.6.22–1.6.27. 2019; last reviewed 7 May 2024. https://www.nice.org.uk/guidance/ng134/chapter/Recommendations