Case Information
- Case ID: DEP-002
- Patient Name: Sarah Mitchell
- Age: 42
- Gender: Female
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: P76 – Depressive Disorder
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| Communication and Consultation Skills | Establishing rapport and using active listening, exploring the patient’s concerns with empathy, explaining diagnosis and treatment options clearly |
| Clinical Information Gathering and Interpretation | Taking a thorough biopsychosocial history, screening for risk factors including suicide risk |
| Diagnosis, Decision-Making and Reasoning | Using validated tools (e.g., K10, DASS-21) to assess severity, differentiating between major depressive disorder, adjustment disorder, and other mood disorders |
| Clinical Management and Therapeutic Reasoning | Developing a management plan including pharmacological and non-pharmacological treatments, engaging in shared decision-making |
| Preventive and Population Health | Providing psychoeducation on lifestyle modifications and self-care strategies |
| Professionalism | Maintaining patient confidentiality and discussing duty of care in risk situations |
| General Practice Systems and Regulatory Requirements | Referring appropriately for psychological support (e.g., mental health care plan) |
| Managing Uncertainty | Using a structured approach to managing ongoing symptoms and relapse prevention |
| Identifying and Managing the Patient with Significant Illness | Recognising when urgent intervention or hospitalisation is required |
Case Features
- Discussion on psychological therapy, antidepressants, or lifestyle interventions.
- A 42-year-old female presenting with low mood, fatigue, poor sleep, and loss of interest over the past six weeks.
- Increased workplace stress, marital conflict, and social withdrawal.
- Mild weight loss due to poor appetite.
- No prior mental health history.
- No substance use, but occasional alcohol.
- Requires assessment for suicidal ideation.
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: Sarah Mitchell
- Age: 42
- Gender: Female
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known drug allergies
Medications
- No regular medications
Past History
- No significant medical history
Social History
- Works as a marketing manager, high workload
- Married with two children (10 and 12 years old)
- Recently withdrawn from friends and family
- Stopped attending weekly yoga
Family History
- Mother had postnatal depression
- No family history of severe mental illness
Smoking and Alcohol History
- Never smoked
- Social drinker (2-3 drinks on weekends)
Vaccination and Preventive Activities
- Up to date with vaccinations
Scenario
Sarah Mitchell, a 42-year-old marketing manager, presents to the GP clinic with six weeks of worsening low mood, fatigue, and difficulty concentrating at work. She reports feeling emotionally drained, struggling to engage with her children, and has lost interest in previously enjoyable activities like yoga.
She also describes trouble sleeping, waking early in the morning with ruminating thoughts about work and her marriage. Her appetite is poor, and she has unintentionally lost 2 kg. She denies suicidal thoughts, but says she has felt hopeless at times.
Sarah states she has never had mental health issues before and is unsure about taking medication but wants help to feel better.
On examination:
- General appearance: Looks tired, maintains eye contact but subdued
- Speech: Slow but coherent
- Mood and Affect: Low, restricted affect
- Thought Process: No delusions or hallucinations
- Cognition: Mild difficulty with concentration
- Risk Assessment: No active suicidal ideation but expresses hopelessness
Investigation Findings
TSH and FBC: Normal
K10 Score: 28 (Moderate to Severe psychological distress)
DASS-21: Moderate depression, mild anxiety
EXAMINER ONLY INFORMATION
QUESTIONS
Q1. What are the possible differential diagnoses for Sarah’s presentation?
- Prompt: How do you differentiate between major depressive disorder and adjustment disorder?
- Prompt: What medical conditions could mimic depression?
Q2. How would you assess Sarah’s suicide risk?
- Prompt: What key questions would you ask?
- Prompt: What factors increase her risk of suicide?
Q3. What treatment options would you discuss with Sarah?
- Prompt: What are the first-line non-pharmacological and pharmacological treatments?
- Prompt: How would you discuss antidepressant options, considering her concerns?
Q4. How would you create a mental health care plan for Sarah?
- Prompt: What are the key components of a GP Mental Health Treatment Plan (MHTP)?
- Prompt: What support services would you recommend?
Q5. What follow-up and safety-netting advice would you provide?
- Prompt: When should she return for review?
- Prompt: How would you ensure she understands when to seek urgent help?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1. What are the possible differential diagnoses for Sarah’s presentation?
The competent candidate should:
- Consider major depressive disorder (MDD) as the primary diagnosis based on Sarah’s symptoms of low mood, fatigue, anhedonia, sleep disturbance, and weight loss persisting for six weeks.
- Differentiate between MDD and adjustment disorder with depressed mood by exploring whether symptoms are disproportionate to a recent life stressor (e.g., work or marital conflict).
- Assess for dysthymia (persistent depressive disorder), given the chronic nature of some depressive symptoms, but note the shorter duration in Sarah’s case.
- Rule out bipolar disorder, particularly bipolar II disorder, by inquiring about past episodes of elevated mood, impulsivity, or increased energy.
- Consider generalised anxiety disorder (GAD) due to Sarah’s excessive worry, sleep disturbance, and rumination, although her low mood and anhedonia suggest MDD.
- Identify potential organic causes such as:
- Hypothyroidism (fatigue, weight changes, low mood – rule out with TSH).
- Iron deficiency anaemia (fatigue, poor concentration – assess with FBC).
- Vitamin B12 deficiency (neurological and mood symptoms – check serum B12).
- Evaluate substance use disorders, particularly alcohol or medication side effects (e.g., corticosteroids).
- Consider perimenopausal depression if Sarah has perimenopausal symptoms such as hot flushes or irregular periods.
SUMMARY OF A COMPETENT ANSWER
- Major depressive disorder as the most likely diagnosis based on DSM-5 criteria.
- Adjustment disorder considered based on recent stressors.
- Dysthymia, bipolar disorder, and anxiety disorders appropriately ruled in/out.
- Medical causes such as hypothyroidism and anaemia considered.
- Substance use and medication effects assessed as possible contributors.
PITFALLS
- Failing to consider organic causes (e.g., hypothyroidism, anaemia).
- Overlooking bipolar disorder screening (e.g., not assessing for past hypomanic episodes).
- Not differentiating between MDD and adjustment disorder based on symptom severity.
- Ignoring potential perimenopausal depression in a woman in her 40s.
REFERENCES
- The Royal Australian College of General Practitioners (RACGP) on Mental Health: The role of the GP in management of depression.
- National Institutes of Health on Depression and Anxiety Management Guidelines.
- Beyond Blue. Clinical practice guidelines for depression.
MARKING
Each competency area is on the following scale from 0 to 3.
☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated
1. Communication and Consultation Skills
1.1 Communication is appropriate to the person and the sociocultural context.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations of healthcare.
2. Clinical Information Gathering and Interpretation
2.1 Takes a structured and hypothesis-driven history.
2.3 Screens for risk factors, including medical and psychiatric differentials.
3. Diagnosis, Decision-Making and Reasoning
3.1 Generates a relevant differential diagnosis.
3.5 Uses clinical reasoning to distinguish between psychiatric and medical causes.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD