You are a child psychiatrist at a large medical center and occasionally take weekend call from home for the psychiatric emergency room. You receive an urgent phone call at 8:00 p.m. from the psychiatric emergency room resident. Ms. A, a 14-year-old ninth-grade student at a prestigious private all-girl school, is there, accompanied by her parents. According to the resident, Ms. A admits to taking "a big handful" of aspirin two nights earlier but did not tell anyone and was not treated. Tonight, after she had made superficial cuts on her right wrist with a razor blade, her parents brought her to the emergency department. Because the cuts did not require sutures, the attending emergency physician transferred her to the psychiatric emergency room for evaluation. The patient’s parents insist that their daughter is probably just worried about her end-of-year exams and is otherwise fine and that she needs to go home. The psychiatric resident feels that the girl is ambivalent about being suicidal, and he is not convinced that she is safe to go home. He is calling to ask for your opinion on whether Ms. A should be admitted.

Decision Point A

Given this history, which of the following would you do? (Select the best answer.)

Ms. A is admitted to the hospital’s child and adolescent psychiatry locked ward and placed on close observation. The resident explained to the parents that you, as the attending psychiatrist, would see her the following morning. Because they were in a hurry to go home and did not know whether they would be available to come in early the next day to sign consent forms, the resident sought consent for use of several medications that you might wish to prescribe for their daughter, depending on your evaluation. They agreed and anxiously signed consent forms for use of fluoxetine, lorazepam, ziprasidone, and chlorpromazine.

You visit Ms. A the next morning. During your interview with her, she speaks slowly and has poor eye contact. She reports that she feels "depressed" and "angry with her parents." You ask her why, and she replies, "They have unreasonable expectations of me. They never let me do what I want to do. They just keep grounding me for every little thing." She is tearful and her voice becomes louder. You note that her fists are clenched tightly. You ask how she is doing in school. She responds that she gets "B’s mostly, a couple of A’s." You ask about other activities. She says that she is on the school soccer team, takes extra French lessons outside of school, and has taken piano lessons since age 4 and that her mother recently encouraged her to volunteer at the hospital’s oncology department. At this, her eyes well up with tears: "I hate working in the hospital," she says. "Those patients, they’re are all just dying, and it makes me want to die too. I hate my life."

She reports that she has been sleeping "a lot" and as a result has fallen behind on some of her school assignments, which is unlike her. She says that she used to like all of the activities and schoolwork, but now "everything is such a chore. I feel like blowing it all off just to piss off my parents." She has lost about 10 pounds in the past 2 months without dieting or changing her routine. She says that her appetite is less than it usually is and she doesn’t know why, other than that she is "too busy feeling like my life is crappy and I’d rather not live." She says it has been more difficult for her to stay focused on her schoolwork over the past month and she has to try harder to accomplish the same tasks that she once found easy.

You ask how often she has thought about killing herself, and she replies that she thinks about it every day. She tells you that she recently took "a big handful" of aspirin. It made her sick to her stomach, but she did not tell anyone. "My parents grounded me when I didn’t make the varsity soccer team, too." She shows you her right wrist, which is bandaged. "I didn’t cut deep enough. That was stupid."

Decision Point B

Given this presentation, what is your next step? (Rank the following in the order in which you would perform them. Points are taken away for incorrect answers.)

Decision Point C

You make a preliminary diagnosis of a mood disorder. In children and adolescents, which of the following symptoms of depression is less likely to be considered in the diagnostic criteria for adult depression? (Rank as many as appropriate, in order of their likelihood.)

Decision Point D

When reviewing the important symptoms of depression, "SIGECAPS" is a helpful mnemonic. In the following, match each letter with the word it represents. (Answers may be used once, more than once, or not at all.)

You are paged by the desk clerk. Ms. A’s mother has arrived and has brought a knapsack containing a laptop computer for her daughter. She tells you that "it is imperative" that her daughter get the computer so that she won’t fall behind in her schoolwork. She remarks that "this sort of thing has been going on lately with her. I don’t know why she feels the need to pull these stunts except to hurt us." She holds out the knapsack for you to take. "I really must be going," she says. "My husband is double-parked."

Decision Point E

Given this information, how do you respond? (Rank as many as appropriate, in order of their likelihood. Points are taken away for incorrect answers.)

After 2 days on the ward, your patient feels more relaxed. She occasionally smiles, and she interacts with the other patients, but she still has a somewhat restricted affect. She begins complaining that she is not getting her schoolwork done and that "my parents are going to kill me." She denies that she is currently suicidal but cannot rule it out for the future. She is still sleeping excessively and did not make it to her morning group session, which kept her from advancing up the scale of earned privileges on the ward. She complains that she wants to go outside and is frustrated that she can’t. She no longer wants to talk about "my problems" and asks, "Is that all I’m going to do here? Talk about problems? Why do you think I have problems? Talk to my parents! They’re the ones with problems!"

You later ask her about substance use, and she admits to having tried marijuana and beer in the past but insists that it is not a problem for her. "Everyone does it," she says. "I mean at parties. I’ll have a beer or two, not enough to get trashed like some of my friends. My parents would kill me if I came home drunk. And I don’t like pot. I don’t like how it makes me feel."

Decision Point F

Given this information, what are your next steps? (Rank as many as appropriate in order of their likelihood. Points are taken away for incorrect answers):

Decision Point G

Depressed patients who exhibit difficulty concentrating can be misdiagnosed as having attention deficit hyperactivity disorder (ADHD). Match the following symptoms and signs with depression, ADHD, both, or neither. (Your score will be determined by the number of questions for which "both" is the correct answer.)

High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−3 and above) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2) indicate a decision that is nonproductive and potentially harmful. The lowest negative score (−1) indicates a decision that is not harmful but is nonproductive, time-consuming, and not cost-effective.

Decision Point A

Decision Point B

Decision Point C

Decision Point D

Decision Point E

Decision Point F

Decision Point G

Depressed patients who exhibit difficulty concentrating can be misdiagnosed as having attention deficit hyperactivity disorder (ADHD). Match the following symptoms and signs with depression, ADHD, both, or neither. (Your score will be determined by the number of questions for which "both" is the correct answer.)

Your total