In reply: Zimmerman correctly highlights the intrinsic limitations of applying the current “evidence base” for managing severe depression in young people. In part, our critique of the new guidelines1 stems from our shared concern about their real utility in clinical practice. As we have outlined elsewhere, we do not favour a simple “sequencing of treatments” model or recognise a clear separation between early phases of severe unipolar or bipolar depression.2 The real difficulty for clinicians is that young people presenting with severe depression are not only at high risk of immediate harm, but may also be on the path to a range of different psychiatric (and neurobiological) outcomes, including bipolar disorder, psychotic disorders and comorbid alcohol and substance misuse.2,3 Unfortunately, there are no clear clinical, neuropsychological or biomedical predictors of the relative risks of developing these adverse outcomes.2,3 Consequently, we have recommended the development of a broader clinical trials network that recognises this complexity and seeks to develop a more relevant evidence base in the future.4 For now, we need to continue to develop clinical service initiatives that not only engage young people but can provide the longitudinal and more specialised care that may be required for those who develop more complex disorders.5
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