EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Sarah’s depressive symptoms?

• Prompt: What risk factors and psychosocial elements should be explored?
• Prompt: How would you assess suicidal risk?

Q2. What are the possible differential diagnoses, and how would you confirm the diagnosis?

• Prompt: How would you differentiate between major depressive disorder and adjustment disorder?
• Prompt: What role do screening tools play in diagnosis?

Q3. Outline your management plan for Sarah, including pharmacological and non-pharmacological strategies.

• Prompt: Would you prescribe antidepressants at this stage?
• Prompt: What psychological interventions are recommended?

Q4. How would you address Sarah’s risk of deterioration and ensure appropriate follow-up?

• Prompt: What safety-netting strategies should be in place?
• Prompt: How frequently should she be reviewed?

Q5. Sarah returns in four weeks with worsening symptoms and passive suicidal thoughts. What would you do next?

• Prompt: What changes to her treatment plan are required?
• Prompt: When would referral to a psychiatrist be necessary?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Sarah’s depressive symptoms?

A comprehensive history is essential to assess Sarah’s depressive symptoms, identify underlying causes, and rule out differentials.

1. Symptom Exploration (DSM-5 Criteria for Major Depressive Disorder – MDD):

• Mood: Onset, duration, severity of low mood.
• Anhedonia: Loss of interest in previously enjoyed activities.
• Cognition: Difficulty concentrating, memory concerns.
• Energy levels and motivation: Fatigue, psychomotor changes.
• Sleep disturbances: Insomnia or hypersomnia.
• Appetite and weight changes: Loss or increase.
• Guilt and self-worth: Feelings of worthlessness or excessive guilt.

2. Suicide Risk Assessment:

• Current suicidal ideation? If yes, intent, plan, access to means.
• Past attempts? Methods, triggers, and outcomes.
• Protective factors? Family, relationships, goals.

3. Psychosocial Stressors:

• Breakup impact, workplace stress, financial or housing concerns.
• Social support network: Friends, family, hobbies.

4. Personal and Family Mental Health History:

• Previous depressive episodes, response to treatment.
• Family history of depression, anxiety, bipolar disorder, or suicide.

5. Substance Use and Lifestyle Factors:

• Alcohol, drugs, caffeine, exercise levels.

6. Organic Causes Screening:

• Recent illnesses, medication changes, thyroid dysfunction, anaemia.

A structured approach ensures an accurate diagnosis and targeted management.

---

Q2: What are the possible differential diagnoses, and how would you confirm the diagnosis?

Sarah presents with low mood, fatigue, sleep disturbance, and concentration difficulties. Possible differentials include:

1. Major Depressive Disorder (MDD) (Most Likely):

• Meets DSM-5 criteria (≥5 symptoms for ≥2 weeks, functional impairment).
• No history of manic episodes (excludes bipolar disorder).

2. Adjustment Disorder with Depressed Mood:

• Triggered by a clear stressor (breakup, work stress).
• Symptoms resolve within 6 months of stressor.

3. Generalised Anxiety Disorder (GAD):

• Excessive worry, restlessness, muscle tension.
• Overlaps with depression (can co-exist).

4. Hypothyroidism:

• Fatigue, weight gain, mood symptoms.
• Check TSH and free T4.

5. Anaemia:

• Fatigue, pallor, poor concentration.
• Check iron studies, FBC.

Diagnostic Tools:

• K10 Score (30 = high distress).
• DASS-21, PHQ-9 for severity assessment.
• Blood tests (TSH, FBC) to exclude organic causes.

---

Q3: Outline your management plan for Sarah, including pharmacological and non-pharmacological strategies.

Management is holistic, addressing biological, psychological, and social factors.

1. Psychoeducation & Support:

• Explain depression as a treatable condition.
• Encourage engagement in therapy.

2. Psychological Therapy (First-Line):

• Cognitive Behavioural Therapy (CBT): Address negative thinking.
• Interpersonal Therapy (IPT): Relationship stress focus.
• Mindfulness-Based Stress Reduction.

3. Pharmacological Management:

• Consider SSRIs (e.g., sertraline, escitalopram) if:
  • Symptoms are moderate-severe.
  • Psychological therapy alone is insufficient.
  • There is past SSRI response (fluoxetine).
• Monitor for side effects (nausea, agitation, sexual dysfunction).

4. Lifestyle & Self-Care Recommendations:

• Sleep hygiene: Limit screen time, bedtime routine.
• Exercise: At least 30 minutes, 5 days/week.
• Diet: Omega-3, reduced alcohol/caffeine.
• Social support: Encourage friend and family engagement.

5. Follow-Up & Safety Netting:

• Review in 1-2 weeks for risk reassessment.
• Create a safety plan if suicidal risk increases.

A multimodal approach is crucial for long-term improvement.

---

Q4: How would you address Sarah’s risk of deterioration and ensure appropriate follow-up?

Sarah has moderate depression with past self-harm history, requiring close monitoring.

1. Suicide Risk & Crisis Planning:

• Regular risk assessments at each visit.
• Encourage support seeking from family, friends.
• Provide Beyond Blue, Lifeline contacts (13 11 14).
• Discuss Emergency Plan (ED if acute suicidal crisis).

2. Structured Follow-Up Plan:

• Review in 1-2 weeks (earlier if worsening).
• Monitor therapy response, side effects if on SSRIs.

3. Referrals & Support:

• GP Mental Health Care Plan (Medicare-subsidised psychologist sessions).
• Consider psychiatrist referral if complex or treatment-resistant.

4. Address Lifestyle Factors:

• Alcohol reduction, physical activity, sleep hygiene.

Ensuring proactive follow-up reduces the risk of suicidal deterioration.

---

Q5: Sarah returns in four weeks with worsening symptoms and passive suicidal thoughts. What would you do next?

Sarah’s deterioration requires urgent reassessment and escalation of care.

1. Suicide Risk Reassessment:

• Passive or active ideation?
• Intent, plan, access to means?
• Previous suicide attempts?
• Protective factors?

2. Escalation of Care:

• Acute risk → Immediate ED referral (if suicidal intent).
• High risk → Crisis team or psychiatrist referral.
• Moderate risk → Increase GP review frequency, psychologist referral.

3. Pharmacological Adjustments:

• Optimise antidepressant dose if SSRI started.
• Consider medication switch (e.g., venlafaxine, mirtazapine if poor response).
• Monitor for SSRI-induced suicidality (early worsening risk).

4. Increase Psychological & Social Support:

• Engage family/friends in safety planning.
• Referral to social worker if financial or housing stressors.

5. Short-Term Monitoring:

• Next GP review in 3-5 days.

Rapid intervention can prevent crisis escalation.

---

SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking covering symptoms, risk factors, and suicide assessment.
• Accurate differentiation of MDD vs adjustment disorder vs anxiety.
• Holistic management incorporating therapy, medication, and lifestyle.
• Structured follow-up and risk monitoring to prevent crisis escalation.
• Appropriate escalation to psychiatry or crisis services when required.

---

PITFALLS

• Failure to conduct a suicide risk assessment.
• Overlooking lifestyle and psychosocial factors in management.
• Inappropriate prescription of antidepressants without psychological support.
• Lack of structured follow-up and safety planning.
• Delaying referral when high-risk features present.

---

REFERENCES

• RACGP – RACGP Mental Health Guidelines
• GP Exams – 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

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD