Major Depressive Disorder - OSCE
Table of Contents
History Taking * Presenting Complaint & Screening * Core Symptoms of Depression (SIGECAPS / SIG EM CAPS2) * Suicide/Self-Harm Risk Assessment * Other Associated Symptoms/Manifestations * Rule Out Other Psychiatric Conditions * Rule Out Organic Causes * Past Medical/Psychiatric History & Medications * Substance Use * Family History * Social History & Stressors * Patient’s Perspective (ICE) & Impact * Examination (Conceptual) * Investigations (Conceptual) * Management Plan
Information
Patient Brief Record / Brief Scenario
- Your next patient, Khalid (40 years old), is new to you.
- Adopt a patient-centred approach to maintain a good relationship with him and solve his problem.
- Vital signs were all normal (Temperature, Blood Pressure, Pulse Rate & Body weight).
- This is approximately an 8-minute consultation.
Task: What is expected from a student
- Take relevant history.
- Discuss the management plan with the patient.
Simulated Patient (SP) Instructions / Scenario
Patient Details & Opening Statement
- Your name is Khalid, 40 years old.
- You are married and have six children, all in school.
- You work as a Taxi Driver.
- Opening Statement: Start by saying, “Doctor, I want pills to help me sleep.”
Information to Reveal Upon Specific Questioning
(Tell the doctor these details ONLY if specifically asked)
- Duration & General Feeling: For the last month, you are feeling not like before; you feel sad and your mood is low.
- Mood & Anhedonia: During the last month or 2 weeks, your mood is low & you lost interest and pleasure in everything (anhedonia). You are not happy at all. You used to enjoy watching TV, but now you don’t.
- Irritability: You find yourself shouting at your children.
- Work Impact: You are not coping well with your job as a Taxi Driver.
- Sleep Disturbance: Your sleep is disturbed; you wake early and feel tired all the time. (This is why you initially asked for sleeping pills).
- Appetite & Weight: Your appetite is poor, and you have lost some body weight.
- Financial Stress: One year ago, you took a loan from the bank to buy your taxi. Due to family commitments and renting a house, you haven’t been able to make the monthly payments. The bank is threatening to take the car.
Additional Details to Reveal Upon Specific Questioning
- Concentration: You are unable to concentrate.
- Social Withdrawal: You want to be alone and are unable to talk to friends.
- Smoking: You are a smoker, 20 cigarettes/day for more than 10 years.
- Self-Neglect: You are neglecting yourself and your children.
- Hopelessness: You see the future as dark.
- Self-Harm Thoughts: You think of harming yourself (or think it might be better to be dead), BUT you have no active suicidal ideation or plan because you think about your children and because you are Muslim. (Reveal this carefully if asked about thoughts of death or self-harm).
Questions to Ask the Doctor
- Ask: “What is wrong with me?”
- If the doctor says it is depression, ask: “Is this a mental illness? Am I crazy?”
- Ask about the treatment options.
- Ask: “I heard this treatment can make you addicted. Is that true?”
- If the doctor offers both therapy and medication, say you want both treatments.
- Ask: “How long will I need to be on this treatment?”
OSCE - Depression
(Focus areas: Differentiating depression from bipolar/psychosis, typical vs atypical presentation, assessing abuse/violence, ruling out organic causes, ensuring patient safety regarding suicide risk, understanding different presentations).
Introduction
- Introduction & Rapport: Introduce self clearly, build rapport (good posture, appropriate body language, empathy, good eye contact). Use verbal/non-verbal encouragement.
- Patient-Centered Approach: Show respect, concern, and interest. Encourage the patient to talk.
- Communication: Use a mix of open and closed questions appropriately. Listen attentively, avoid interruptions, allow pauses. Use clear, easily understood language; avoid or explain jargon.
- Structure & Timing: Periodically summarize to verify understanding and invite corrections. Manage time effectively.
- Shared Decision Making: Promote informed decision-making, especially during management discussion.
History Taking
Presenting Complaint & Screening
- Explore the initial request for sleeping pills.
- Ask the two screening questions:
- “Over the last 2 weeks, have you been bothered by feeling down, depressed, or hopeless?” (Mood)
- “Over the last 2 weeks, have you been bothered by little interest or pleasure in doing things?” (Anhedonia)
- Clarify onset, duration, course, severity, aggravating/relieving factors of symptoms.
Core Symptoms of Depression (SIGECAPS / SIG EM CAPS2)
- Sleep: Explore insomnia (difficulty falling/staying asleep, early morning awakening - or hypersomnia. Ask about daytime fatigue/low energy .
- Interest: Loss of interest/pleasure (Anhedonia - ).
- Guilt: Explore feelings of worthlessness or excessive/inappropriate guilt.
- Energy: Low energy, fatigue )
- Concentration: Difficulty concentrating, indecisiveness.
- Appetite: Change in appetite (decreased ) or increased; associated weight loss () or gain.
- Psychomotor: Agitation (restlessness) or retardation (slowing down).
- Suicide: Assess thoughts of death or self-harm (see below).
Suicide/Self-Harm Risk Assessment
- Directly but sensitively ask about thoughts of life not being worth living, death, self-harm, and subsequebtly suicide.
- If thoughts are present, assess frequency, intensity, specific plans, intent, and access to means.
- Assess protective factors (children, religion).
- Ask about thoughts of harming others (homicide).
Other Associated Symptoms/Manifestations
- Mood: Low mood, sadness, hopelessness, diurnal variation (worse at specific times of day?), irritability.
- Sexuality: Loss of libido.
- Somatic Symptoms: Ask about unexplained body pains (headache, abdominal pain/IBS), shortness of breath, palpitations.
- Anxiety Symptoms: Co-existing anxiety, worry, panic attacks.
Rule Out Other Psychiatric Conditions
- Mania/Hypomania (Bipolar): Ask about distinct periods of elevated/euphoric/irritable mood, increased energy, decreased need for sleep, racing thoughts, impulsivity, grandiosity. (Mood swings).
- Psychosis: Ask about hallucinations (seeing/hearing things not there) or delusions (fixed false beliefs).
- Obsessive-Compulsive Disorder (OCD): Ask about repetitive thoughts or behaviors done to relieve anxiety.
- Trauma: History of significant trauma.
- Premenstrual Syndrome (PMS/PMDD): Relation of symptoms to menstrual cycle
Rule Out Organic Causes
- Thyroid Disease: Ask about heat/cold intolerance, bowel changes, neck swelling, palpitations, weight changes.
- Anemia: Ask about fatigue, pallor, shortness of breath.
- Cushing’s Syndrome: (Less common) Ask about easy bruising, striae, muscle weakness, central weight gain.
- Other Chronic Illnesses: e.g., Rheumatoid Arthritis, SLE.
Past Medical/Psychiatric History & Medications
- Past Medical History (PMH): Any chronic diseases.
- Past Surgical History (PSH): Any relevant surgeries.
- Past Psychiatric History: Similar episodes before? Previous diagnoses or treatments? Hospitalizations?
- Medications: Current medications (prescription, OTC), including those that can cause depression (e.g., steroids, some anti-hypertensives like beta-blockers, interferons, OCPs). Allergies.
Substance Use
- Alcohol: Quantity and frequency.
- Smoking: Quantify pack-years (SP: 20/day for 10+ years).
- Illicit Drugs: Ask about recreational drug use.
Family History
- History of psychiatric disorders (depression, bipolar, anxiety, suicide, substance abuse).
- History of chronic medical diseases.
Social History & Stressors
- Occupation: Taxi drive. Impact on work.
- Living Situation: Renting a house.
- Family: Married, 6 children. Relationship quality, support system. Any conflicts? (shouting at children, self-neglect).
- Stressors: Financial difficulties (bank loan, threats ), work stress, family stress. Recent losses (job, loved ones)?
- Abuse/Violence: History of abuse (physical, emotional, sexual) or current domestic violence.
Patient’s Perspective (ICE) & Impact
- Ideas: What does the patient think is causing the problem?
- Concerns: What worries the patient most? (SP: Sleep, impact on work, potential “mental illness” label, treatment addiction).
- Expectations: What does the patient hope to get from the consultation? (SP: Sleeping pills initially, then wants effective treatment).
- Impact: How are these symptoms affecting daily life, work, relationships, self-care? (SP: Affecting work, family interactions, self-care).
Examination
(Note: Vitals are stated as normal in the brief)
- General Appearance: Observe grooming, hygiene, eye contact, posture.
- Behavior: Assess psychomotor activity (slowed or agitated), abnormal movements, engagement in the interview.
- Speech: Rate, rhythm, volume, tone.
- Mood & Affect: Patient’s subjective report of mood vs. objective observation of affect (e.g., flat, labile, tearful, congruent/incongruent).
- Thought Process & Content: Assess for logical flow, delusions, obsessions, suicidal/homicidal ideation.
- Cognition: Assess attention, concentration, orientation. (Formal testing usually not done in brief OSCE unless indicated).
- Insight & Judgment: Assess patient’s understanding of their illness and situation, and their decision-making capacity.
- Screening Tools (Mention): Patient Health Questionnaire (PHQ-9), Edinburgh Postnatal Depression Scale (EPDS - for postpartum).
Investigations
(Routinely not indicated for diagnosis but useful to rule out organic causes or complications)
- Baseline Bloods:
- Complete Blood Count (CBC) - (Rule out anemia).
- Thyroid Stimulating Hormone (TSH) - (Rule out hypothyroidism/hyperthyroidism).
- Consider if indicated by history/exam:
- Iron studies (Ferritin, TIBC) - (If anemia present).
- Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP) - (Inflammation).
- Rheumatoid Factor (RF), Antinuclear Antibody (ANA) - (Autoimmune conditions like SLE, RA).
- Vitamin B12 / Folate levels.
- Liver Function Tests (LFTs), Renal Function Tests (U&Es).
- Blood glucose / HbA1c.
Management Plan
- Clarify Diagnosis & Psychoeducation:
- Explain the likely diagnosis is Major Depressive Disorder in simple terms.
- Reassure the patient that it is a common and treatable medical illness, not a sign of weakness or being “crazy” (). Explain it’s a real illness affecting mood, thoughts, and body.
- Explain the biological basis briefly (e.g., brain chemistry imbalance) and the role of stressors.
- Normalize the experience and reduce stigma.
- Address Safety: Discuss safety plan if any risk identified. Provide crisis contact information if needed. Psychiatry ER referral if acute high risk.
- Discuss Treatment Options (Shared Decision Making): Explain that treatment usually involves lifestyle changes, therapy, and/or medication. Acknowledge patient’s preference for both therapy and medication (as per SP prompt).
- Non-Pharmacological Therapy:
- Lifestyle: Encourage regular exercise, balanced diet, good sleep hygiene (despite initial difficulty), stress management techniques (relaxation, mindfulness), re-engaging in previously enjoyed activities gradually. Encourage seeking social support. Advise reducing/stopping smoking.
- Psychological Therapy: Explain options like Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT). Explain CBT helps identify and change negative thought patterns and behaviors. Mention it involves sessions over weeks to months (e.g., 6 months to 1 year).
- Pharmacological Therapy:
- First-line: Selective Serotonin Reuptake Inhibitors (SSRIs) e.g., Sertraline, Fluoxetine, Citalopram. Explain mechanism simply (helps balance brain chemicals).
- Counseling Points:
- Onset of Action: Explain it takes 2-4 weeks to start working, with full effect potentially taking 6-8 weeks.
- Side Effects: Discuss common initial side effects (e.g., nausea, headache, sleep changes) which often improve. Discuss potential long-term side effects (e.g., sexual dysfunction).
- Addiction: Explicitly address the patient’s concern - explain that SSRIs are not addictive in the way substances of abuse are, but stopping suddenly can cause withdrawal symptoms (discontinuation syndrome), so they should be tapered off under guidance.
- Duration: Explain treatment typically continues for 6-12 months after symptoms improve to prevent relapse.
- Other options (mention if relevant): SNRIs (e.g., Venlafaxine), TCAs (e.g., Amitriptyline - sometimes used for pain/sleep but more side effects).
- Referral:
- Consider referral to a psychotherapist for CBT/therapy.
- Consider referral to a psychiatrist if diagnosis is complex, severe symptoms, risk is high, or treatment resistance.
- Follow-Up:
- Arrange close follow-up, e.g., in 1-2 weeks after starting medication, to monitor:
- Symptom response.
- Side effects.
- Adherence.
- Safety (monitor for any worsening of mood or emergence of suicidal thoughts, especially early in treatment or with dose changes).
- Monitor for any signs of mania/hypomania (if starting antidepressant).
- Regular follow-up thereafter (e.g., monthly initially, then spaced out).
- Arrange close follow-up, e.g., in 1-2 weeks after starting medication, to monitor:
- Provide Resources: Information leaflets, support group details if available.