Start with an open question

Begin with an open question and be prepared to use silence.

“James, could you talk me through how things have been for you since the relationship ended?”

This gives James space to shape the narrative and allows you to listen for clues about:

• Mood.
• Energy.
• Sleep.
• Appetite.
• Motivation.
• Loss of interest.
• Function.
• Coping.
• Bereavement.
• Support networks.

Time-efficient data gathering

Open questions can be time-efficient because they reveal emotional and contextual information that a checklist may miss.

After James’ open account, clarify missing information with short, focused questions:

“What have you tried so far?”
“How have you been sleeping?”
“How has your appetite been?”

Avoid a scattergun checklist. Use James’ own words and summarise to show that you are listening.

“So your low mood became worse after the breakup, it’s affecting your sleep and eating, and you’re finding work difficult. How have you been coping?”

High-yield questions

Mood and interest

• “How has your mood been day to day?”
• “Have you lost interest in things you used to enjoy?”
• “You mentioned cycling used to matter to you — how does that feel now?”

Sleep, appetite and energy

• “How have you been sleeping?”
• “How has your appetite been?”
• “How is your energy during the day?”
• “How is your concentration?”

Bereavement and relationship loss

• “You mentioned your stepdad’s death. Does that come to mind a lot?”
• “How has the breakup affected you?”
• “Do the two losses feel connected in any way for you?”

Function and work

• “How is this affecting work?”
• “Are you managing day-to-day responsibilities?”
• “Are you still seeing people or have you been withdrawing?”

Coping and support

• “Who have you been able to talk to?”
• “What helps, even a little?”
• “Have you been using alcohol or anything else to cope?”

Safety

• “Have there been times when you’ve felt you cannot cope?”
• “Have your thoughts changed in a way that worries you?”
• “Have you had thoughts about harming yourself or not wanting to be here?”

Ask safety questions sensitively and in context.

Functional, psychosocial or contextual assessment

Explore how symptoms affect:

• Work.
• Relationships.
• Home responsibilities.
• Socialising.
• Exercise.
• Sleep.
• Eating.
• Personal care.
• Previously enjoyable activities.
• Confidence and sense of identity.

Ask specifically whether James can manage daily activities and whether he has anyone to confide in.

Explore ideas, concerns and expectations

Clarify what James wants from the consultation.

Possible goals include:

• Understanding what is happening to him.
• Getting support for low mood.
• Having time away from work.
• Returning to activities he used to enjoy.
• Improving sleep.
• Exploring therapy.
• Considering medication.
• Developing a safety plan.
• Managing work-related concerns.

Useful question:

“What feels most important for us to help with today?”

Recognise and respond to cues

Important cues may include:

• Tearfulness.
• Withdrawal.
• Loss of interest.
• Reduced eye contact.
• Pauses or silence.
• Feeling overwhelmed.
• Worry about work.
• Feeling unable to cope.
• Fear about medication or the future.
• Mentioning his stepfather’s death.

Respond directly and gently.

“You mentioned your stepdad’s death. Does that come to mind a lot?”

If James describes loss of interest:

“Losing interest in things you used to enjoy must be frustrating. It’s common for that to happen when mood drops, and it should come back as you start to feel better.”

Useful consultation phrases

“It sounds like you’ve had a really tough few months.”

“Some people find their appetite drops when they’re feeling low. Does that fit with what’s happening for you?”

“Depression can affect 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.”

“Medication is one option, but it may not be the best first step unless symptoms are severe or self-care and therapy are not helping. We can look at the options together.”

Consultation flow and signposting

1. Invite James to tell his story.
2. Explore mood and loss of interest.
3. Clarify sleep, appetite, energy and concentration.
4. Explore bereavement and relationship loss.
5. Assess impact on work, home life and social activities.
6. Explore coping and existing support.
7. Consider possible causes and severity.
8. Discuss management options.
9. Agree safety-netting and follow-up.

Use James’ words to guide the next question.

“You said sleep’s a struggle. Could you tell me more about what happens at night?”

Summarising and checking understanding

Before moving into management, summarise what you have heard.

“You’ve been feeling low and have lost interest in cycling and other activities. Your sleep and appetite have changed, and your energy is affecting work. The relationship ending and your stepdad’s death both seem to be important parts of what you’re going through.”

Check:

• Whether James agrees with the summary.
• Whether anything important has been missed.
• Whether he understands the possible explanations.
• Whether he feels ready to discuss support options.

Data gathering self-check

Before moving to management, the trainee should know:

• How long James has felt this way.
• Whether symptoms are improving, stable or worsening.
• Impact on sleep, appetite, energy, concentration and interest.
• Impact on work, social life and daily functioning.
• The role of the relationship breakdown.
• The role of his stepfather’s death.
• Current coping strategies and support.
• Alcohol or substance use.
• Past mental-health history and family history.
• Any physical health contributors.
• Safety and suicidal thoughts.
• James’ preferences about therapy, medication, self-help and work support.

Assessment domain mapping

Data gathering

• Mood, interest, sleep, appetite, energy and concentration.
• Bereavement and relationship loss.
• Work and social functioning.
• Coping, support and substance use.
• Safety and suicidal thinking.
• Physical contributors and family history.

Clinical management

• Depression, adjustment disorder, grief and physical causes.
• Talking therapies, digital CBT and self-help.
• Lifestyle and routine.
• Antidepressant discussion where appropriate.
• Safety plan, follow-up and occupational support.

Relating to others

• Open questions and silence.
• Responding to emotional cues.
• Plain-language explanations.
• Shared decision-making and personalised planning.

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Prioritised differential diagnosis or clinical reasoning

An appropriate differential includes:

1. Major depressive disorder, possibly moderate, with core symptoms and functional impairment.
2. Adjustment disorder with depressed mood.
3. Complicated bereavement or grief.
4. Thyroid disorder or anaemia.
5. Generalised anxiety disorder, which may overlap with low mood.
6. Physical illness-related fatigue, such as diabetes or another chronic disease.
7. Bipolar disorder, less likely if there is no history of elation or hypomania.
8. Alcohol or substance misuse, with no evidence provided but important to check.

The assessment should consider:

• Duration of symptoms.
• Severity.
• Functional impairment.
• Core depressive symptoms.
• Sleep and appetite changes.
• Anxiety.
• Bereavement.
• Substance use.
• Past mental-health history.
• Family history.
• Physical health contributors.
• Safety and changes in suicidal thinking.

Clinical reasoning script

“A difficult life event can trigger low mood, depression, grief or adjustment difficulties. The important thing is how long this has been going on, how much it is affecting your sleep, appetite, energy and work, and whether you feel safe. That helps us choose the right support.”

Red flags and risk assessment

Assess specifically for:

• Suicidal thoughts or worsening suicidal thoughts.
• Feeling unable to keep himself safe.
• Feeling unable to cope.
• Marked functional deterioration.
• Significant withdrawal or isolation.
• Alcohol or substance misuse.
• Features suggesting bipolar disorder, such as a history of elation or hypomania.
• Physical contributors such as thyroid disease, anaemia or diabetes.
• Concerns related to family suicide history, especially if considering medication.

Decision points

Key decisions include:

• Are symptoms consistent with depression, adjustment disorder, grief or another cause?
• How severe is the functional impairment?
• Does James need urgent mental-health support or crisis advice?
• Is medication appropriate now, or should non-pharmacological options be tried first?
• Would talking therapy, digital CBT or counselling be acceptable?
• Are physical-health checks needed?
• Does work need to be addressed through occupational support or adjustments?
• What safety plan is needed?
• When should follow-up occur?

Management priority

The management priority is to agree a safe, personalised and realistic plan that addresses mood, function, bereavement, work, support and safety.

Management options

1. Exercise and physical activity

Encourage gradual re-engagement with physical activity, such as:

• Walking.
• Cycling.
• Swimming.
• Short, manageable activities.
• Returning to previously enjoyable exercise.

ETxercise has been shown to have a greater effect than many antidepressant medications. Present this as one helpful treatment option, not as a substitute for all other support.

2. Digital cognitive behavioural therapy

Offer digital CBT where suitable, including:

• NHS-supported services.
• SilverCloud.
• Other reliable digital mental-health programmes.

This may allow James to begin support while waiting for other services.

3. Self-help resources

Offer:

• NHS Moodzone.
• Mental-health apps.
• Structured self-help.
• Information about sleep, mood and anxiety.
• Reliable written resources.

4. Talking therapies

Discuss:

• Referral to IAPT or equivalent talking therapies.
• Self-referral where available.
• Counselling.
• CBT.
• Expected waiting times.
• How James can access support while waiting.

Explain the service in accessible language rather than simply using the term “IAPT”.

5. Lifestyle and routine

Discuss:

• Regular sleep and waking times.
• Sleep hygiene.
• Regular meals.
• Gradual re-establishment of routine.
• Limiting alcohol.
• Daily structure.
• Time outdoors.
• Maintaining contact with supportive people.

6. Antidepressant medication

Consider antidepressants if symptoms persist or are severe.

Discuss:

• Potential benefits.
• Side effects.
• Time taken for improvement.
• How medication would be monitored.
• James’ preferences.
• Whether medication should be combined with therapy.
• Concerns related to family suicide history.

Monitoring is particularly important if there is a family history of suicide or if James develops worsening thoughts or significant agitation.

7. Safety plan

Develop a clear safety plan, including:

• What James should do if suicidal thoughts develop or worsen.
• Who he can contact.
• Supportive family or friends.
• Crisis-support numbers.
• Urgent GP or mental-health services.
• Emergency services if he cannot keep himself safe.
• When to seek urgent assessment.

Make sure James understands the plan and knows how to access help outside normal appointment times.

8. Social prescribing

Consider:

• Peer-support groups.
• Local wellbeing services.
• Social prescribing.
• Community activities.
• Support to reconnect with hobbies.
• Support with housing or other social needs if relevant.

9. Occupational support

Explore:

• Speaking with his employer.
• Contacting his line manager.
• Occupational-health support.
• Workplace adjustments.
• A phased return.
• Temporary changes to workload.
• Support through his teaching organisation, if relevant.

Example phrase:

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

10. Physical-health checks

Consider blood tests or other physical-health checks to exclude contributing causes such as:

• Thyroid disease.
• Anaemia.
• Diabetes.
• Other relevant physical illness.

Personalised plan

Use what you have learned about James to tailor the plan.

If he is wary of medication:

• Start with talking therapy, digital CBT, exercise and routine.
• Arrange review to assess progress.
• Revisit medication if symptoms persist or worsen.

If work is a major concern:

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

If safety has been discussed:

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

If he misses cycling:

“Since you mentioned missing cycling, how would you feel about joining a local group or buddying up for short rides?”

A personalised plan might include:

• A structured period of self-care and support.
• Digital CBT or talking therapy.
• Gradual return to cycling or another enjoyable activity.
• Sleep and routine advice.
• Occupational-health support.
• A safety plan.
• Physical-health checks.
• Review of whether medication is needed.

Shared decision-making

Involve James in choosing the next steps.

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

“Does that explanation fit with your experiences?”

Explore:

• Whether he feels ready for therapy.
• Whether he would consider medication.
• Which activities feel achievable.
• Whether he wants workplace support.
• Who he can contact if he deteriorates.
• What he wants any fit note or work plan to achieve.

Safety-netting

Ensure James knows to seek earlier help if:

• His mood worsens.
• He cannot cope.
• Suicidal thoughts develop or worsen.
• His thoughts change in a worrying way.
• He feels unable to keep himself safe.
• He becomes more isolated or unable to manage daily activities.

Agree who he can contact, including supportive people, crisis-support services, urgent GP or mental-health services, and emergency services if he cannot keep himself safe.

Documentation points

Document:

• Symptoms, duration and severity.
• Functional impact on work, social life and daily activities.
• Relationship breakdown and bereavement context.
• Sleep, appetite, energy, interest and concentration.
• Coping strategies and support network.
• Substance use where explored.
• Past mental-health history and family history.
• Safety assessment and suicidal thoughts.
• Options discussed.
• James’ preferences.
• Safety plan and crisis contacts.
• Follow-up arrangements.

Common unsafe management plans

Avoid:

• Treating the breakup as sufficient explanation without assessing severity.
• Ignoring bereavement.
• Moving straight to antidepressants without discussing other options.
• Avoiding medication discussion when symptoms are severe or persistent.
• Not exploring safety or suicidal thinking.
• Giving generic self-help advice without follow-up.
• Not considering physical contributors.
• Missing work-related impairment and support needs.
• Not addressing concerns about medication or family suicide history.

Follow-up and coordination with other professionals

Arrange follow-up to review:

• Mood.
• Sleep.
• Appetite.
• Energy.
• Function.
• Work situation.
• Engagement with therapy or self-help.
• Medication if started.
• Suicidal thoughts or changes in safety.

Coordinate with relevant services where appropriate:

• Talking-therapy services.
• Digital CBT services.
• Crisis-support services.
• Occupational-health or workplace support.
• Social prescribing or local wellbeing services.

Learner checkpoint

Have I agreed a plan that addresses James’ mood, grief, function and safety — not just one symptom or one treatment?

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Relevant guidance areas 

• Depression assessment and management.
• Antidepressant prescribing.
• Mental-health crisis support.
• Digital mental-health resources.
• Talking therapies.
• Workplace and teaching-union counselling services.

NICE guidance

• NICE Depression Guidelines.

Patient information websites

• NHS Moodzone.
• NHS digital mental-health resources.
• SilverCloud.
• Local talking-therapy services.
• Crisis-support services.
• Workplace and teaching-union counselling services.

Key principles to remember

• Encourage James to tell his story before moving to closed questions.
• Use silence and give him time to respond.
• Explore both the relationship breakdown and his stepfather’s death.
• Clarify sleep, appetite, energy, mood and function.
• Consider depression, adjustment disorder, grief and physical causes.
• Avoid jargon and explain treatment options clearly.
• Discuss exercise, digital CBT, talking therapies, medication and social support.
• Address workplace concerns and possible adjustments.
• Develop a clear safety plan.
• Arrange follow-up rather than leaving James with general advice alone.

Transferable learning for future cases

In consultations about low mood after life events:

• Do not assume distress is “normal” without assessing impact and risk.
• Start with the patient’s story, then clarify key symptoms.
• Explore losses, relationships, work and support networks.
• Consider both psychological and physical contributors.
• Offer a menu of treatment options and tailor them to readiness and preference.
• Always agree safety-netting and follow-up.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Effective use of open questions and silence.
• Recognition of both breakup and bereavement.
• Assessment of depressive symptoms and functional impairment.
• Sensitive safety assessment.
• Balanced discussion of therapy, self-help, lifestyle measures and medication.
• Consideration of physical-health checks.
• Personalised occupational and social support.
• Clear follow-up and crisis plan.

Limitations or ambiguities

• Support through a “teaching organisation” and workplace or teaching-union counselling services is mentioned, but James’ occupation is not clearly stated in the case overview.

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Final learner takeaway

Low mood after loss still needs a full assessment: listen to the story, assess function and safety, and build a personalised plan with follow-up.

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