Patient Instructions o

John Moody - Recurrent Depression

You are a 60 year old man with a history of intermittent depression over the past 15 years,
and worried that the symptoms are returning.

You saw another GP two weeks earlier and declined any treatment. You filled in the
questionnaire given and brought it in today. You scored 17 but you unsure of the
significance.

This time there is no specific trigger for your low mood, disrupted sleep (difficulty getting to
sleep) and reduced appetite. Previous episodes were more severe and due to work and the
stress with running your own business, and in conjunction been through a divorce. Now you
are in a happy relationship but unduly worried that you are going to ruin things. She is
blissfully unaware. You have made some of your own changes by reducing your work to
part-time, and your son is taking over the business. You have stopped smoking in the last
year and you drink within 10-20 units per week. No drug use. No financial concerns. Not
suicidal.

You have tried medication in the past (Fluoxetine), and reluctant to try again as it caused
erection problems. You are concerned about your girlfriend knowing you are taking them,
the stigma of depression. They helped in the past but you are more worried about side
effects and what you read in the papers. Your sister is into herbal medicines and suggested
St John’s Wort, which you think sounds great. It is herbal and according to what you have
read - it works. You are not particularly aware of alternatives medications.

You have tried counselling but not cognitive behavioural therapy (CBT). Counselling was not
a great experience as you didn’t particularly like the counsellor. However, you are willing to
try again.

Your past medical history includes: recurrent depression and hypertension, and you only
take ramipril.

You are expecting reassurance particularly as no triggers, and to reassurance that you have
come early. You are very keen for St John’s Wort but willing to consider explanation of St
John’s Wort and other medications. You are very keen to hear about alternate ways so CBT,
exercise, and sleep hygiene etc.

Ideas – its depression again (but not as bad as before)

Concerns – what will your new partner make of your undisclosed hx of depression
Expectations – St John’s Wort and self-help advice not fluoxetine
Doctor’s (GP ST) Instructions s

John Moody

A 60 year old gentleman

Generally an infrequent attender. Attends for his annual check up for

hypertension.

Summary Card

1997 Depression

2003 Depression

2005 Hypertension

Case Notes

2 weeks ago John saw a colleague for low mood and declined any treatment
but was asked to complete a PHQ9 at home and to bring the questionnaire in a
2 week follow-up appointment

PMH

Hypertension

Regular Prescriptions

Ramipril

FH

Father had MI aged 59years

CSA Examination Card o

Examination findings:

John Moody

Review completed PHQ-9: Result 17 Moderate Depression

Mental State Examination - no concerns

Recent bloods – satisfactory

BP well controlled on medication

CSA Case Marking Sheet
Case Name: John Moody
GP ST Name:
Case Title Recurrent Depression & overvalued ideas
Context for case
 Diagnosis of recurrent depression
Assessment Domain:
1. Data-gathering, technical and
assessment skills
Positive descriptors:
 Acknowledge and review PHQ9
 Brief appropriate depression
history- what symptoms he is
experiencing and comparing to past
episodes
 SPICE explored
 Acknowledges recurrent nature of
depression and address his
concerns
 Explores possible triggers for
depression and social history and
partner’s perspective
 Ask red flags - suicide risk
 Explores what he has tried in the
past
 Identifies preference to alternative
therapies and reasoning
 Focused PMH, DH, inc alternative
therapies and smoking & alcohol &
drug history
Assessment Domain:
2. Clinical Management Skills
Positive descriptors:
 Reassurance that he has come early
 Reassurance that depression affects
many and shouldn’t feel
stigmatized, giving an explanation
about depression
 Negotiate medication – a good
explanation of St John’s Wort and
the risks, and offering an
explanation on alternative SSRIs or
alternatives to SSRIs (advantages
and side-effects). Reassure that a
decision doesn’t have to be made
o
Centre: CRH Scheme name: Pennine
CSA Surgery Date:
Negative descriptors:
 PHQ 9 interpreted incorrectly
 SPICE not clarified
 Not taking an adequate social
history
 Poor depression history
 Does not address psychosocial/social
history
 Does not assess suicide risk
 Not taking a focused PMH, DH.
Forgetting about alcohol
consumption/smoking/drugs
Negative descriptors:
 No reassurance
 Not offering alternative treatments
or explanations
 No follow-up
 Not explaining risks-medications or
not accepting help
 Failure to safety net
 Pressurising into treatments, not
offering choice
 Inappropriate management of
depression
 immediately
 Offering follow-up
 Offering a referral for
counselling/CBT
 Giving written info (PILs)-e.g. on
SSRIs, depression and self help.
 Discussed apps such as head space
 Verbal self-help advice-exercise,
reducing stress, sleep hygiene etc

Assessment Domain:
3. Interpersonal skills
Positive descriptors: Negative descriptors:
 Explores John’s agenda, health  Does not enquire sufficiently into
beliefs and preferences agenda, health beliefs and
 Responds to feelings and preferences
expectations  Pays insufficient attention to verbal
 Appears alert to verbal and non- and non-verbal cues
verbal cues  Fails to explore how it affecting his
 Elicits psychosocial and social life
information to put into context  Does not appreciate the impact of
 Works in partnership, common the patient’s psychosocial context
ground and develop a shared  Instructs patient rather than seeking
management plan common ground
 Enhances autonomy  Used a rigid approach, doesn’t offer
 Patient centred and shows empathy or respond to patient’s
and interest contributions
 Reassurance  Failure to empower
 Lacks warmth, empathy
 Little or no reassurance
Global Comments
Positive descriptors Negative descriptors
 Click & enter  Click & enter
Grading
Clear pass Marginal pass Marginal fail Clear fail
Excellent
Serious Concerns

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