Low Mood – OSCE Case

How has your mood been recently?

“Pretty low”

How long have you been feeling low?

“A few months I think”

How often have you felt sad recently?

“Most days now”

Are there any particular times of day when you notice your mood is worse?

“It’s definitely worst first thing”

Does your mood vary throughout the day?

“A bit, but it’s generally just low now”

Have you ever had any other periods of feeling particularly low?

“Once or twice before, but never this bad or for this long”

Have you ever been told you have depression in the past?

“No”

Have you ever received any treatment(s) in the past for depression and if so, did they help?

“No”

Screening questions for low mood:

• During the past month have you felt low, depressed or hopeless?
• During the past month have you had little interest or pleasure in doing things?

“Yes to both.”

Sleep cycle disruption

• How has your sleeping pattern been recently?

“Really rubbish, to be honest”

• Have you had any difficulties getting to sleep?

“Yes, I normally go to bed around 9 pm but don’t fall asleep until nearly midnight”

• Do you find that you wake up early, and find it difficult to get back to sleep?

“Yes, I think I wake up between 4 and 5 am most days”

Appetite changes

• Have you noticed a change in your appetite?

“I haven’t got much of one”

• What is your diet like at the moment?

“Not great”

• What are you eating on a typical day?

“I’m mainly just having snacks, microwave meals, or takeaway when I feel like eating, but some days I won’t really eat anything”

Reduced libido

• Since you have been feeling this way, have you noticed a difference in your sex drive?

“Not really”

Reduced concentration

• How is your concentration at the moment?

“Not good and I’m really struggling with deadlines at university now”

• Can you follow TV programs without getting distracted?

“If they’re short, but anything over half an hour I struggle with”

Negative perception of current situation/future

• How do you feel about your current situation?

“A bit lost, I don’t really know what to do”

• How do you feel about the future?

“I can’t really see things getting any better at the moment”

Negative perception of self

• How do you feel about yourself?

“Like I should just be able to snap out of this”

• Do you often criticise yourself?

“I guess so, but I feel like it’s justified”

• Do you blame yourself when things go wrong?

“Yes, but it is my fault normally”

Past medical and surgical history

• Do you have any other medical problems?

Specifically, ask:

• Have you ever seen anyone about your mental health before?

“No”

Medication history/allergies

• Do you take any regular medication?
• Are you allergic to anything?

“I just take some painkillers like paracetamol or ibuprofen when I’m on my period, but that’s about it really. I’m allergic to nuts but not any medicine I know of.”

Family history

• Are there any medical problems that run in the family?

Specifically, ask:

• Does anyone in your family have any problems with their mental health?

“Not that I know of”

Social history

Work/study

• Are you working or studying currently?
• How are you managing it at the moment?
• Are there any concerns about your attendance?
• Are you managing to meet your deadlines?

“I’m in my second year studying history and I help out at open days sometimes too. I’ve managed to attend most things but I’m really struggling to finish my essays on time and I’ve needed to pull all-nighters for the last couple.”

Social support

• Do you live with anyone else?
• Do you get on well with the people you live with?
• Do you get on well with your family?
• Have you spoken to anyone about how you’ve been feeling?
• Do you feel like you have a good support network?

“I live in student halls still and we all get on pretty well but I’ve not really told anyone about what’s going on, I guess I probably should. I get on well with family but don’t want to worry them with this.”

Activities of daily living and hobbies

• How are you coping with essential tasks and chores?
• Are you managing to keep up with your hobbies?
• Are you still enjoying your hobbies?

“To be honest how I’m coping depends on what I have to do that day, if I’ve got to go in for a seminar then I manage to get washed and dressed fine. But if I’ve not got to leave the flat for any reason I tend to just stay in bed, my room is a bit of a state at the moment. I used to love reading but I can’t really concentrate on books for long enough now. I just seem to spend most of my time lying in bed staring at the wall, sometimes it will get to the evening and I don’t know where the day has gone.”

Alcohol/smoking/recreational drugs

• Do you smoke?
• Have you ever smoked?
• How many drinks of alcohol would you say you have in a week?
• Have you ever taken any recreational drugs?

“I don’t smoke and I haven’t taken any drugs before but probably have a couple of drinks most nights. It started as a social thing with my flatmates but I will still have some now even if they’re not in.”

Have you ever thought about hurting yourself?

“Yes, quite often”

Have you ever acted on those thoughts?

“Once or twice, but not for a few weeks”

Have you made any plans to hurt yourself?

“Not currently, because it just made me feel worse after”

Sometimes when people feel down or depressed they can feel that life is no longer worth living. Have you ever felt like this?

“Sometimes”

Have you had any thoughts of taking your life?

“Yes”

How often have you had these thoughts?

“Only once or twice”

Have you thought about how you would end your life?

“No, not really”

Have you made any plans to end your life?

“No”

What things do you feel would stop you from acting on thoughts about ending your life?

“Mainly my family and friends. I lost a friend to suicide when I was younger and it was awful to go through”

Do you feel that you are at risk from anyone else?

“No”

Are you drinking alcohol or using any recreational drugs at the moment?

“I have a few drinks most nights. I don’t use any recreational drugs”

Do you feel able to keep yourself safe at the moment?

“Yes I think so”

A risk assessment in psychiatric history taking needs to take into account risk to the patient and risk to others. 

Mental state examination

Examination findings

Appearance: “The patient has a slouched posture and walked into the consultation room quite slowly. She is wearing dark clothes that appear clean, although they are crumpled and some of the threads are frayed. She is also wearing a large coat even though the heating is on in the building. She appears to still be maintaining personal hygiene well.”

Behaviour: “The patient makes poor eye contact throughout and doesn’t use any gestures while answering questions. Her facial expression generally appears sad or tearful. It is quite difficult to establish rapport but improves throughout the consultation. You observe very little motor activity during the consultation.”

Speech: “She speaks quite quietly and you have to ask her to repeat herself a few times. She speaks slowly and often takes pauses while answering questions. There is very little change in tone while she speaks.”

Mood and affect: “She rates her mood as low and you also assess her mood as low. Her mood appears to remain stable throughout. You would describe her affect as “flat” and it is fairly restricted during the consultation.”

Thought: “There do not appear to be any abnormalities of thought form. She does appear to spend a lot of time ruminating about negative events from the past or future plans. She does mention that she experiences suicidal thoughts and thoughts of self-harm”

Perception: “There do not appear to be any abnormalities of perception.”

Cognition: “She appears to be well oriented and there are no issues observed with memory.”

Insight and judgement: “She is now starting to accept that her recent feelings are possibly due to illness and she wants help to deal with them.”

• Full blood count
• Thyroid function tests
• Vitamin D
• Vitamin B12 and folate

Anaemia, hypothyroidism, vitamin D deficiency, and vitamin B12/folate deficiency are all common causes of fatigue and share some of the symptoms of a number of mental health problems, so it is important to check them in patients presenting with low mood.

• Vascular: anaemia
• Inflammatory & infectious: multiple sclerosis
• Neoplastic: intracranial tumour
• Degenerative: dementia
• Idiopathic: chronic fatigue syndrome, anxiety, depression, borderline personality disorder, burnout/stress, normal variation of mood, substance misuse, schizoaffective disorder, bipolar disorder
• Congenital
• Autoimmune: Hashimoto’s disease, systemic lupus erythematosus
• Traumatic
• Endocrine: adrenal insufficiency, vitamin D deficiency, vitamin B12 deficiency, folate deficiency, hypothyroidism, Cushing’s syndrome

The most likely diagnosis here is depression. This patient is presenting with a very typical history of depression, with the core symptoms of low mood, anhedonia, and lack of energy. They also have a number of associated somatic and cognitive symptoms.

The PHQ-9 is a questionnaire that helps to assess the severity of symptoms of low mood.

Depression severity is classified according to the presence of core symptoms (low mood, anhedonia and lack of energy) and the presence of cognitive symptoms (decreased concentration, impaired memory, pessimism, self-blaming, nihilism, hopelessness and suicidal thoughts).

• Mild depression is defined as the presence of 2 core, and at least 2 cognitive symptoms
• Moderate depression is defined as the presence of 2 core, and at least 3 cognitive symptoms
• Severe depression is defined as the presence of 3 core, and at least 5 cognitive symptoms

It can then be further classified according to the presence of somatic symptoms, either “without somatic symptoms” (few, if any present) or “with somatic symptoms” (four or more present). Somatic symptoms include a change in appetite, change in weight, loss of libido, sleep disturbances, diurnal variation of mood, and psychomotor retardation or agitation.

This patient would meet the criteria for a severe depressive episode.

This patient meets the criteria for a severe depressive episode, therefore, the most appropriate first-line treatment would be to offer a selective serotonin reuptake inhibitor (SSRI), such as sertraline or citalopram. 

This should generally be offered alongside psychological therapies such as cognitive behavioural therapy (CBT), which can be delivered in a variety of formats depending on patient preference, the severity of the episode, and resources available in the area.

6 months after remission of symptoms. Patients may want to stop taking their antidepressant medication once their symptoms have resolved, however, it is important for them to continue their medication for a further 6 months after this as it greatly reduces the risk of relapse.

You should avoid giving definite time frames such as 6-8 weeks or 6 months, as it is impossible to predict how well or how quickly patients will respond to medication. Generally, they should see some improvement in their symptoms by 6-8 weeks.

Very few patients will need to take antidepressant medication for the rest of their lives, however, it may be necessary in some cases.

Generally, a second SSRI would be trialled if the patient did not respond to first-line drug therapy. However, if these were contraindicated or another SSRI did not show any benefit then other medication classes that can be used include:

• Serotonin-norepinephrine reuptake inhibitors (SNRIs), e.g. duloxetine, venlafaxine
• Tricyclic antidepressants (TCAs), e.g. amitriptyline, clomipramine, trazodone
• Monoamine oxidase inhibitors (MAOIs), e.g. isocarboxazid, phenelzine
• Noradrenergic and specific serotonergic antidepressants (NaSSA), e.g. mirtazapine

• Depression that is refractory to antidepressant therapy
• There is a need for rapid treatment response (e.g. pregnancy, persistent suicidal intent, food refusal leading to dehydration or nutritional compromise)
• Medical comorbidities prevent the use of antidepressant medication
• Previous response to ECT
• Depression with psychotic features
• Catatonia

• Suicide: the risk of suicide in patients with depression is four times higher than in the general population
• Reduced quality of life
• Antidepressant side effects (e.g. sexual dysfunction, risk of self-harm, weight gain)
• Persistent depression
• Exacerbation of the pain, disability and distress from any physical illnesses
• Increased risk of substance abuse

Around 10% of patients will develop persistent depression.