In adolescent depression, fluoxetine still has the clearest drug signal, but medication is not the whole plan. Start with psychological therapy, review early for suicidality, and taper antidepressants slowly; TMS may have a role as augmentation for persistent symptoms where services and suitability align.

Suicide risk is not reduced by grandiosity. This psychiatric teaching point highlights that narcissistic and antisocial traits can coexist with severe self-harm risk, and that formulation should separate impulsivity, entitlement and planning rather than relying on loose labels such as the dark triad.