Download depression

Patient Instructions
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John Moody - Recurrent Depression with overvalued ideas
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 financial concerns.
You have tried medication in the past (Prosac), and reluctant to try again. 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.
Doctor’s (GP ST) Instructions
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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
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
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CSA Case Marking Sheet
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Case Name:
John Moody
Centre: CRH Scheme name: Pennine
GP ST Name:
CSA Surgery Date:
Case Title Recurrent Depression & overvalued ideas
Context for case
 Recurrent diagnosis of depression
 Low mood, no triggers
 Overly concerned about ruining new relationship
 Extremely keen to try St John’s Wort
Assessment Domain:
1. Data-gathering, technical and
assessment skills
Positive descriptors:
Negative descriptors:
 Acknowledge and review PHQ9
 Not taking an adequate social history
 Brief appropriate depression history Poor depression history
what symptoms he is experiencing
 Not addressing his concerns
and comparing to past episodes
 Does not acknowledge his ideas
 Acknowledges recurrent nature of
regarding alternative therapies
depression and address his concerns
 Does not address psychosocial/social
 Explores possible triggers for
history
depression and social history
 Does not address suicide risk
 Ask red flags - suicide risk
 Not taking a focused PMH, DH.
 Explores what he has tried in the past
Forgetting about alcohol
 Identifies preference to alternative
consumption/smoking
therapies and reasoning
 Focused PMH, DH, inc alternative
therapies and smoking & alcohol
history
Assessment Domain:
2. Clinical Management Skills
Positive descriptors:
Negative descriptors:
 Reassurance that he has come early
 No reassurance
 Reassurance that depression affects
 Not offering alternative treatments
many and shouldn’t feel stigmatized,
or explanations
giving an explanation about
 No follow-up
depression
 Not explaining risks-medications or
 Negotiate medication – a good
not accepting help
explanation of St John’s Wort and the
 Failure to safety net
risks, and offering an explanation on
 Pressurising into treatments, not
alternative SSRIs (advantages and
offering choice
side-effects). Reassure that a decision
 Inappropriate management of
doesn’t have to be made
depression
immediately
 Offering follow-up



Offering a referral for
counselling/CBT
Giving written info (PILs)-e.g. on
SSRIs, depression and self help.
Verbal self-help advice-exercise,
reducing stress, sleep hygiene etc
Assessment Domain:
3. Interpersonal skills
Positive descriptors:
 Explores John’s agenda, health
beliefs and preferences
 Responds to feelings and
expectations
 Appears alert to verbal and nonverbal cues
 Elicits psychosocial and social
information to put into context
 Works in partnership, common
ground and develop a shared
management plan
 Enhances autonomy
 Patient centred and shows empathy
and interest
 Reassurance
Global Comments
Positive descriptors
 Click & enter
Grading
Clear pass
Marginal pass
Excellent
Serious Concerns
General Feedback Comments
Negative descriptors:
 Does not enquire sufficiently into
agenda, health beliefs and
preferences
 Pays insufficient attention to verbal
and non-verbal cues
 Fails to explore how it affecting his
life
 Does not appreciate the impact of
the patient’s psychosocial context
 Instructs patient rather than seeking
common ground
 Used a rigid approach, doesn’t offer
or respond to patient’s contributions
 Failure to empower
 Lacks warmth, empathy
 Little or no reassurance
Negative descriptors
 Click & enter
Marginal fail
Clear fail