# Situation: Six weeks after a strong typhoon destroyed homes in a coastal barangay, a nurse from the Rural Health Unit (RHU) who is trained in the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) visits an evacuation center. She sees a 38-year-old fisherman and his 14-year-old daughter. Seven months later, the daughter has a moderate-severe depressive episode that has not improved despite 6 months of psychosocial interventions. Which plan BEST follows mhGAP-IG?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630205  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: Six weeks after a strong typhoon destroyed homes in a coastal barangay, a nurse from the Rural Health Unit (RHU) who is trained in the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) visits an evacuation center. She sees a 38-year-old fisherman and his 14-year-old daughter.

Seven months later, the daughter has a moderate-severe depressive episode that has not improved despite 6 months of psychosocial interventions. Which plan BEST follows mhGAP-IG?

## 보기

1. Sertraline, with monthly visits, as it is the usual first-line drug
2. Psychosocial support alone, as medicines are not allowed under 18
3. Amitriptyline at bedtime, as it also helps with her poor sleep
4. Fluoxetine under a specialist, with weekly visits for 4 weeks **✔ 정답**

**정답: 4**

## 해설

For adolescents aged 12 years or older with moderate-severe depression whose depression has not improved after at least 6 months of psychosocial treatment, mhGAP-IG allows fluoxetine only, not other selective serotonin reuptake inhibitors or tricyclic antidepressants, under specialist supervision. Because antidepressants may increase suicidal thoughts in young people, the adolescent returns weekly for the first 4 weeks.

## 심화 해설

The plan that follows mhGAP-IG
For an adolescent aged 12 years or older with moderate-severe depression that has not improved after at least 6 months of psychosocial interventions, mhGAP-IG allows consideration of fluoxetine only, and only under specialist supervision. Other selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are not used in this age group. Because antidepressants may increase suicidal thoughts in young people, the adolescent is seen weekly for the first 4 weeks.

Why the daughter now qualifies
The daughter is 14 years old, has a moderate-severe depressive episode, and has received 6 months of psychosocial interventions without improvement. Psychosocial care remains first-line for adolescents, and it continues alongside any medicine. The step to medication is made only when psychosocial treatment has not worked, and then only with the drug that has the most supportive evidence and acceptable safety in adolescents, which is fluoxetine.

| Option | Problem or strength |
| --- | --- |
| Sertraline with monthly visits | Not the SSRI allowed for adolescents in mhGAP-IG; monthly visits are too infrequent early in treatment |
| Psychosocial support alone; no medicine under 18 | Misstates the rule; the age limit is 12 years, not 18 |
| Amitriptyline at bedtime | Tricyclic antidepressants are not used in children or adolescents; also dangerous in overdose |
| Fluoxetine under a specialist, weekly visits for 4 weeks | Correct: right drug, right supervision, right monitoring |

Monitoring for suicidal thinking
Watch out! The first weeks of antidepressant treatment are a time of increased risk of suicidal thoughts and behavior in young people. Weekly contact lets the health worker ask directly about thoughts of self-harm, check for agitation or restlessness, review side effects, and support adherence. The family is taught warning signs and told to return at once if they notice talk of death, withdrawal, or sudden behavioral change. Medicines in the home are kept secured by an adult.

Nursing role
The RHU nurse coordinates the specialist referral, continues psychosocial interventions, explains to the adolescent and her father what the medicine can and cannot do, and stresses that improvement may take several weeks. The nurse documents mood, risk assessments, and functioning at each visit and keeps the family involved, especially after the losses caused by the typhoon.

Exam takeaway
Key point! Adolescent depression in mhGAP-IG: psychosocial treatment first; if no improvement after 6 months, consider fluoxetine only, from age 12, under specialist supervision, with weekly visits for the first 4 weeks. No tricyclics.

## 임상 시나리오

Antidepressants in AdolescentsApplying mhGAP-IG after failed psychosocial care
For adolescents aged 12 years or older with moderate-severe depression not improved after 6 months of psychosocial treatment, mhGAP-IG allows fluoxetine only, under specialist supervision.

Other SSRIs and tricyclic antidepressants such as amitriptyline are not used in this age group.

Continue psychosocial support, involve the family, and see the adolescent weekly for the first 4 weeks.

CautionAntidepressants may increase suicidal thoughts in young people. Ask directly about self-harm at each visit and teach the family warning signs and safe storage of medicines.

## 핵심 개념

- **Fluoxetine** — An SSRI antidepressant; the only one mhGAP-IG allows for adolescents, under specialist supervision.
- **Selective serotonin reuptake inhibitor** — An antidepressant class that increases serotonin by blocking its reuptake.
- **Tricyclic antidepressant** — An older antidepressant class, such as amitriptyline, not used in children or adolescents.
- **Psychosocial intervention** — Non-drug treatment such as psychoeducation, problem solving, and support for daily functioning.
- **Specialist supervision** — Oversight of treatment by a mental health specialist when medicines are used in adolescents.

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