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You are an F1 doctor working in a GP practice. You are just about to have a consultation with Anita Scalpel, a 30 year old lady whose husband had rang in this morning to make an appointment. He had told the receptionist over the phone that her mood had been “the worse it’s been” and that she needs to talk to someone. You see from her GP electronic notes she has been consulted once in the past year for ‘low mood’ but with very little other information provided. She has no repeat medications. The last time she presented to the GP practice was 3 years old for an urinary tract infection. There is little else in her past medical history.

Please take a history of Anita’s mood and complete a mental state examination; you will have a total of fifteen minutes to do both of these.

Your name is Anita, and you are a 30-year old lady who lives with her husband Paul and 8 year old son Thomas.

HPC – since the death of your mother one year ago and the building extra pressure from work deadlines in the last few months, you have noticed feeling more hopeless and guilty about not enjoying spending time with your family, or anyone else for that matter. You find yourself waking up a couple of hours before your alarm every morning, and nevertheless feeling exhausted throughout the whole day. Even making a phone-call seems like a massive effort. Your boss has noticed your work effort has slowed, and work colleagues have made concerned comments about your attention span and concentration during conversations. You find meeting discussions more and more difficult to remember and have very little motivation to do well at work. You have even had periods in the day when you feel completely out of it – as if you were watching yourself on a TV screen as the rest of life carries on around you. It is very hard to talk or relate to people, and you often would rather be left alone. Your mother died of a stroke, and you miss her a lot and think of her often. You often feel guilty for not contacting her more often in her later years, especially as she had been there for you a lot in your childhood. Your father, who you have no contact with now, physically abused you and your mother when you were a schoolchild, causing your mother to soon run away with you and start a new life. You do not remember a lot about that time. You remember being occasionally bullied at your secondary school as your mother could not afford the latest clothes and school-kit for you, but otherwise you remember the remainder of your childhood without unease. Today is the year anniversary of your mother’s death, and you have felt particularly low. Last night you couldn’t sleep at all, and swore you heard your mother’s voice calling out for you in the night. Paul awoke when you called back for her and started crying, but couldn’t console you. You have not seen or heard anything else that Paul couldn’t. Later, as Paul slept, you thought about how life might be easier for your family if you weren’t there, and thought about ways you could end your life. You have never had these thoughts before. You had made no formal plans about how and when you would do it, but crept downstairs to write a potential suicide note which Paul found early the following morning. You would never want to harm anyone else, and have never self-harmed yourself.

ICE – your main fear is that your mood will bring your family down, and you worry one day Thomas will become depressed like you too. You feel it might be better if you weren’t there at all, and then they could get on with a normal life. You were willing to come to the GPs today, as long as Paul wasn’t there too, as you thought he would just get upset listening to you speak. You would consider getting help and taking medication, if it solved everything and made your mood completely better. Can the tablets do that?

PMH – normally your mood is not an issue, although you did suffer from ‘baby blues’ after having Thomas. You take no regular medications and have had no psychiatric service input before.

SH - You love Paul, and both love your son very much. For the past eight months it has not been a sexual relationship with Paul, as you have no energy. Paul has been keen to try for another child, but you feel your energy levels would not sustain a pregnancy, let alone bringing up another child. Paul often works from home and looks after Thomas most days, with his parents living round the corner for extra support when needed. Paul comments you are eating less and you admit your clothes have felt looser over the course of the year. If Paul or Thomas aren’t around you, you sometimes forget to eat. You used to enjoy gardening and cake-decorating, but have avoided doing either for the past year. You have never smoked and drink very rarely.

FH – your mother had depression and your father had schizophrenia

The student should spend fifteen minutes exploring the biological and non-biological symptoms of depression, as well as exploring psychotic symptoms and a risk assessment. The mental state examination should cover the patient’s appearance, behaviour, speech, mood (both subjectively and objectively), perception, cognition and insight. The student’s MSE may sound like this: Anita looks tired but well-dressed, with poor eye contact and a quiet monotonous speech. Her speech is reactive but slow. She feels her mood is low, which I agree with, and has experienced one auditory hallucination of her dead mother calling her name. She feels her attention, concentration and memory have been poorer in the past year. She has admitted to suicidal ideation – although she has no set plans on when or how, she has already written a suicide note. She has some insight as she is aware her mood is an issue and would be willing to take part in treatment, although she still feels her family may be happier without her. Examples for discussion may include: - What psychiatric conditions can cause low mood? - What medical conditions can cause low mood? - How is depression managed? - Do you know of any questionnaires used in hospitals or the community for depressive symptoms? - What type of antidepressants are there? Give me one advantage and disadvantage for each drug class.