Start with an open question

Begin by inviting James to tell his story rather than moving straight into a symptom checklist.

“Can you tell me what has been happening and how things have been for you since the breakup?”

This allows James to describe his experience in his own words and may reveal key information about mood, sleep, appetite, energy, work, relationships, coping and support.

Time-efficient data gathering

Empathic listening is not a delay; it can be efficient because it helps gather meaningful information while building rapport.

Explore:

• What happened around the breakup.
• When symptoms started.
• Whether symptoms are improving, stable or worsening.
• Mood and anxiety symptoms.
• Sleep.
• Appetite and weight change.
• Energy and motivation.
• Concentration.
• Interest in previously enjoyable activities.
• Social withdrawal and isolation.
• Work difficulties.
• Home functioning.
• Coping strategies.
• Support network.
• What James wants from the fit note.
• Whether he feels safe and able to cope.

Use clear, concise questions. Depression can affect thinking, so avoid asking several questions at once.

High-yield questions

Story and current symptoms

• “How have you been feeling day to day?”
• “When did you first notice things were becoming difficult?”
• “Are things getting better, worse or staying much the same?”

Mood, anxiety and function

• “How has this affected your sleep?”
• “How is your appetite?”
• “How is your energy?”
• “Are you still able to enjoy things you used to enjoy?”
• “How is your concentration?”

Work impact

• “How have these feelings affected your work?”
• “Are there particular aspects of teaching that have become unmanageable?”
• “What are you hoping time away from work would help with?”

Home and relationships

• “What about outside work — do you manage to keep up with things at home?”
• “Who have you been able to talk to?”
• “You mentioned feeling isolated. Has it been hard not having anyone to confide in right now?”

Risk and safety

• “Have there been times when you’ve felt unable to keep yourself safe?”
• “Have your thoughts changed in a way that worries you?”

Use these sensitively and in the context of what James has already shared.

Functional, psychosocial or contextual assessment

Understanding impact is essential for assessing severity and planning support.

Explore James’ ability to manage:

• Preparing food.
• Personal care.
• Sleep and daily routine.
• Appetite and weight.
• Concentration.
• Energy.
• Teaching responsibilities.
• Relationships.
• Social contact.
• Previously enjoyable activities such as swimming or running.
• Coping at home and work.
• Feeling safe and able to cope.

Also consider work-related support:

• School-based counselling.
• Occupational health.
• Line manager support.
• Teaching union support.
• Workplace adjustments or phased return.

Explore ideas, concerns and expectations

Clarify what James is hoping for from the consultation.

“Is your main goal to get some space to think, or are you hoping to talk through other support as well?”

Explore what he wants from:

• The fit note.
• Time away from work.
• Talking therapy.
• Lifestyle support.
• Medication.
• Occupational support.
• Follow-up.

This helps establish whether the immediate priority is a short period away from work, emotional support, practical help, treatment for depression or anxiety, or a combination.

Recognise and respond to cues

Important cues may include:

• Tearfulness.
• Silence.
• Reduced eye contact.
• Difficulty finding words.
• Feeling overwhelmed.
• Worry about work.
• Loss of interest in activities.
• Social withdrawal.
• Concern that he is not coping.

If James becomes tearful, pause and give space.

“I can see that just talking about this brings up a lot.”

Wait for him to be ready before moving on. Moving too quickly may appear lacking in empathy.

If he mentions feeling isolated:

“You mentioned feeling quite alone. Has it been hard not having anyone to confide in right now?”

Useful consultation phrases

“It sounds like things have been very tough, and you’re feeling really low since the breakup.”

“I don’t want this to be just about the fit note — I’d like to understand how you’re coping and what support would actually help.”

“Depression affects mood, sleep and energy. It’s common after difficult life changes.”

“We have several ways to help — some people feel better with therapy, some with medication, or a mix.”

“If I mention services like talking therapies, I’ll explain what they involve rather than using abbreviations.”

Consultation flow and signposting

1. Invite James to tell his story.
2. Explore the effect of the breakup and his current symptoms.
3. Clarify impact on work, home life and relationships.
4. Explore sleep, appetite, energy and interests.
5. Identify current coping strategies and support.
6. Assess whether he feels safe and able to cope.
7. Clarify what he wants from the fit note.
8. Discuss management options.
9. Agree follow-up and safety-netting.

Use signposting to make the consultation feel structured:

“We’ve talked about how this has affected your mood and work. I’d like to ask a bit about sleep, appetite and support, then we can decide together what would help next.”

Summarising and checking understanding

Before discussing the plan, summarise what James has told you.

“You’ve been feeling low and isolated since the breakup, your sleep and energy have been affected, and you’re finding work difficult. You’d like some time to recover but also want to understand what support could help.”

Check:

• Whether the summary is accurate.
• What James understands about his symptoms.
• Whether the proposed options fit his priorities.
• Whether he has questions or concerns.
• Whether he feels able to follow the agreed plan.

Data gathering self-check

Before moving to management, the trainee should know:

• What triggered the current difficulties.
• How long symptoms have been present.
• Whether symptoms are worsening or improving.
• Impact on work, home life, relationships and activities.
• Sleep, appetite, weight, energy and concentration.
• Whether James feels isolated and what support he has.
• Whether he feels safe and able to cope.
• What he hopes the fit note will achieve.
• Whether he is open to therapy, lifestyle measures, medication or workplace support.

Assessment domain mapping

Data gathering

• Mood, anxiety, sleep, appetite, energy and motivation.
• Functional impact at work and home.
• Social support and isolation.
• Risk, safety and ability to cope.
• Expectations around the fit note and treatment.

Clinical management

• Considering depression, anxiety, adjustment reaction or another condition.
• Fit note planning with reassessment.
• Talking therapies, lifestyle measures, medication and occupational support.
• Safety-netting and follow-up.

Relating to others

• Empathic listening.
• Allowing space for tearfulness.
• Clear, jargon-free explanations.
• Shared decision-making around time off work and wider support.

Prioritised differential diagnosis or clinical reasoning

James’ symptoms may represent low mood and anxiety following a significant life event.

The consultation should consider:

• Severity and duration of symptoms.
• Level of functional impairment.
• Whether symptoms are consistent with depression, an adjustment reaction or another condition.
• Effects on sleep, appetite, energy and motivation.
• Impact on work and daily life.
• Coping strategies and support network.
• Whether symptoms are improving, stable or worsening.

The fit note should form part of a broader assessment and management plan, not the whole consultation.

Clinical reasoning script

“What you’re describing can happen after a major life event, but it’s important we look at how much it’s affecting your sleep, energy, work and ability to cope. That helps us decide whether time away from work, talking therapy, lifestyle changes, medication, or a combination would be most helpful.”

Red flags and risk assessment

Assess and safety-net for:

• Significant worsening of mood.
• Feeling unable to keep himself safe.
• Thoughts of self-harm.
• Becoming unable to manage daily activities.
• Severe withdrawal or distress.
• Feeling overwhelmed or unable to access support.

These features should influence urgency, follow-up and crisis advice.

Decision points

Key decisions include:

• Is a two-week fit note appropriate?
• Would full absence or modified duties be more helpful?
• What does James hope time away from work will achieve?
• Is he interested in counselling or talking therapy?
• Is employer-based or union-based support available?
• Are lifestyle and routine measures realistic at this stage?
• Are antidepressants needed now, or should they be considered if symptoms persist or are severe?
• What follow-up interval is needed?
• What crisis or safety advice is needed?

Management priority

The management priority is to agree a compassionate, practical and personalised plan that addresses both:

• James’ immediate work-related difficulty and fit-note request.
• His wider emotional wellbeing, isolation, coping, safety and recovery.

Management options

1. Fit note and occupational management

A possible option is a two-week fit note with collaborative reassessment.

Discuss:

• What James hopes time away from work will achieve.
• Whether full absence or modified duties would be more helpful.
• Support available through his school.
• Whether he could access occupational health.
• How and when he might return to work.
• What would indicate that the plan needs to change.

Avoid issuing a fit note without arranging review.

2. Talking therapies

Discuss:

• Referral to counselling.
• Self-referral to talking therapies.
• IAPT or equivalent, explained in accessible terms.
• Likely waiting time.
• Counselling through James’ school.
• Support through his teaching union.

Explain that talking therapy may help him process the breakup, manage low mood and develop coping strategies.

3. Lifestyle measures

Encourage realistic re-engagement with physical activity and structure, such as:

• Brief walks.
• Returning gradually to swimming.
• Gentle exercise.
• Re-establishing a daily routine.

ETxercise has been shown to have a greater effect than many antidepressant medications. Present this positively without implying exercise is a substitute for all other support.

4. Sleep hygiene

Discuss:

• Regular sleep and waking times.
• Avoiding screens late at night.
• A wind-down routine.
• Reducing late caffeine or alcohol where relevant.
• Avoiding long daytime naps.
• Rebuilding a regular daily structure.

5. Alcohol

Gently explore whether alcohol use has increased.

Discuss:

• Whether alcohol is being used to cope.
• The potential effect on mood and sleep.
• Keeping alcohol within low-risk limits.
• Alternative coping strategies.

6. Online and self-help resources

Offer reliable resources such as:

• NHS Every Mind Matters.
• MoodGYM.
• Local mental-health resources.
• Reputable self-help information.

7. Antidepressant medication

Consider antidepressants if symptoms persist or are severe.

Discuss:

• Potential benefits.
• Possible side effects.
• Time taken for benefit to develop.
• James’ preferences.
• Whether psychological or lifestyle approaches should be tried first.
• How medication would be reviewed.

Avoid presenting medication as the only option.

8. Social prescribing and community support

Consider signposting to:

• Local wellbeing hubs.
• Community groups.
• Social prescribing.
• Housing support if relevant.
• Other local community resources.

This may help reduce isolation and support gradual reconnection with activities.

9. Occupational and workplace support

Explore support through:

• James’ school.
• His line manager.
• Occupational health.
• Teaching union.
• Workplace adjustments.
• Phased return to work.

A short fit note may be combined with a realistic plan for returning to work or reducing pressure.

Personalised plan

Use what James has shared to tailor the plan.

If he is wary of medication:

• Start with non-pharmacological options.
• Arrange talking therapy.
• Encourage gentle activity.
• Review progress before considering medication, unless symptoms are severe.

If work is the major pressure:

“Would it help to involve your line manager or see what support work can offer?”

If he has thought about safety:

“You’ve thought about safety — let’s add a crisis contact just in case.”

If he misses previous activities:

“You mentioned swimming and running used to matter to you. Would a very small first step back towards one of those feel possible, or does that feel too much right now?”

A personalised plan might include:

• A two-week fit note.
• Collaborative reassessment.
• Talking-therapy referral or self-referral.
• Contact with school counselling or occupational support.
• Sleep and routine advice.
• Gradual return to physical activity.
• Support to reduce isolation.
• Consideration of medication if symptoms persist or are severe.
• Clear safety-netting and crisis advice.

Shared decision-making

Ask James which options feel realistic and acceptable.

“How does that sound to you — do you think any of these options would work for you?”

“Does that explanation fit with your experiences?”

Discuss:

• Whether a two-week fit note feels helpful.
• Whether counselling, self-referral or employer-based support feels acceptable.
• Whether he would consider medication.
• Which activities he might be able to restart.
• What would make returning to work more manageable.
• What support he would accept for isolation.

Safety-netting

Provide clear advice about seeking urgent help if:

• His mood worsens significantly.
• He feels unable to keep himself safe.
• His thoughts change or he develops thoughts of self-harm.
• He becomes unable to manage daily activities.
• He becomes severely withdrawn or distressed.
• He is unable to access support or feels overwhelmed.

Explain how to access urgent help and identify appropriate crisis contacts or emergency services. Arrange follow-up so that safety is reviewed rather than relying only on James to reattend if he deteriorates.

Documentation points

Document:

• Presenting concern and request for fit note.
• Key symptoms and duration.
• Functional impact on work and home life.
• Social support and isolation.
• Risk and safety discussion.
• Fit note decision and rationale.
• Management options discussed.
• Shared plan and James’ preferences.
• Safety-netting and crisis advice.
• Review arrangements.

Common unsafe or weak management plans

Avoid:

• Issuing a fit note without assessing mood, function and safety.
• Treating relationship distress as automatically “normal” without assessing impact.
• Medicalising distress without exploring practical and occupational support.
• Offering medication as the only solution.
• Failing to discuss talking therapies or workplace support.
• Giving vague safety-netting.
• Not arranging follow-up.

Follow-up and coordination with other professionals

Arrange collaborative reassessment to review:

• Mood and anxiety symptoms.
• Sleep, energy, appetite and daily function.
• Work readiness and fit-note needs.
• Engagement with therapy or self-help.
• Safety and support.

Coordinate with services where relevant:

• Talking therapies or counselling.
• School counselling.
• Occupational health.
• Teaching union support.
• Local mental-health and wellbeing resources.
• Social prescribing or community support.

Learner checkpoint

Have I created a plan that supports James emotionally, practically and occupationally — not just administratively?

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Relevant guidance areas 

• Depression in adults.
• Depression in primary care.
• Self-help and online mental-health resources.
• Consultation communication and relating to others.
• Occupational and workplace support.

NICE guidance

• NICE: Depression in adults.

RCGP and SCA resources

• RCGP SCA Toolkit: Relating to Others.

Patient information websites

• Mind: Self-help resources.
• NHS Every Mind Matters.
• MoodGYM.
• Local mental-health and wellbeing resources.

Relevant research or educational references

• BMJ: Depression in primary care.
• Simulated consultations: Sociolinguistics.

Additional support resources mentioned

• Counselling through James’ school or teaching union.
• Occupational-health support.

Key principles to remember

• Use empathy and allow James to tell his story.
• Do not reduce the consultation to a fit-note request.
• Avoid a closed checklist approach.
• Use short, clear questions and avoid multiple questions at once.
• Give James space if he becomes tearful.
• Explore impact on work, home life, relationships and activities.
• Agree shared goals around time away from work and wider support.
• Discuss talking therapies, lifestyle measures, medication and social support.
• Use workplace and teaching-union resources where appropriate.
• Provide clear safety-netting if mood worsens or thoughts change.
• Arrange collaborative reassessment.

Transferable learning for future cases

When a patient presents with a fit-note request linked to emotional distress:

• Start with the person’s story, not the form.
• Clarify what time away from work is expected to achieve.
• Assess function, support and safety.
• Consider whether work adjustments may help.
• Offer a menu of support options rather than a single solution.
• Agree review, because mood and risk can change.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Warmth, empathy and appropriate pauses.
• Exploration of functional impact and occupational context.
• A clear but sensitive safety assessment.
• Shared decision-making about the fit note.
• Discussion of psychological, lifestyle, occupational and medication options.
• Jargon-free explanations.
• Clear follow-up and safety-netting.

Limitations or ambiguities

• Previously enjoyed activities are mainly described as swimming and running, with cycling given later as an example. The personalised plan should therefore focus on activities James has actually identified during the consultation.

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Final learner takeaway

A fit-note request for low mood is an opportunity to assess distress, function and safety — and to build a recovery plan, not just complete paperwork.

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