ℹ️ This is the case information for the doctor.
Name
James Walker
Age
48 years
Address
12 Greenbank Road
Social history
Smoking status: Never smoked.
Past history
Eczema
Investigation results
None
Medication
None
No recorded allergies.
Booking note
Low mood, feeling tired all the time.
ℹ️ This is the information for the person role playing the patient.
Name
James Walker
Age
48 years
Address
12 Greenbank Road
Social history
Smoking status: Never smoked.
Past history
Eczema
Medication
None
No recorded allergies.
"I'm really struggling at the moment...I just feel like I’m slowly falling apart."
The low mood started around three months ago after the end of a long-term relationship, which was very painful.
Expected to feel better as time went on but instead has felt progressively worse.
Feels devoid of energy and simple tasks seem exhausting.
Your appetite has been poor and you have lost weight
Worried about performance at work and possible job loss.
Has never felt this low before.
Worried this may be “depression” - afraid he won’t recover; wonders if he might need “tablets” or counselling.
Fears becoming like his stepdad; concerned about job loss; doesn’t want to be labelled “mentally ill” or let anyone down.
Feels guilty for “wasting people’s time” and worries that he’s becoming a burden.
Unsure; open to suggestions; would like to feel “normal” again and get back to enjoying life.
Interested in talking therapies but isn’t sure how to access them; a bit wary about medications but wants honest guidance.
Affect: Low, flat; speech slow, eyes down, occasionally on the verge of tears but trying to be composed.
Engagement: Will open up if the doctor shows empathy and genuine interest; more closed and terse if rushed or dismissed.
Anxiety: Heightened if questions feel intrusive/impersonal; reassured by a calm, non-judgmental manner.
Motivation: Shows resignation but hope if management includes active listening and practical ideas.
Response to management suggestions:
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
Opens with explorative, open questions about James’s mood, sleep, appetite, and general wellbeing before moving on to clarify specific symptoms, red flags and triggers.
Structured and methodical.
Data gathering was incomplete, lacking structure and focus.
Fails to elicit a clear chronological account or skips between symptoms, missing key features such as changes in appetite or sleep.
Omits clarification of symptom onset/progression and does not systematically explore the effects on daily life and functioning.
Makes effective use of existing information and considers the wider context.
Recognises the relevance of the recent relationship breakdown and family psychiatric history when exploring James’s symptoms and risk factors.
Factors in James’s employment situation and social support network to contextualise his presentation.
Fails to use the information provided or understand the wider context.
Neglects to follow up on the break-up or past trauma; does not consider how James’s life events may link with current symptoms.
Ignores the impact of occupational and social circumstances on his mental health management.
The presence or absence of relevant red flags was established.
Actively and sensitively explores thoughts of self-harm, suicidal ideation, intention, and past attempts, including means, planning, and protective factors.
Assesses for psychotic symptoms, risk to others, and substance misuse.
Fails to assess key information necessary to determine risk.
Omits direct questioning about suicidal or self-harm thoughts, including previous attempts or current plans.
Does not address risks relating to substance use or potential harm to others.
Reaches an appropriate evidence based working diagnosis
Collects and synthesises symptom duration, core symptoms (low mood, anhedonia, sleep and weight changes), and functional impairment to form an evidence-based diagnosis of moderate/severe depression.
Considers differential diagnoses (e.g., adjustment disorder, bereavement, physical illness) based on symptomatology and context.
The evidence collected was inadequate to support the conclusions reached.
Reaches a diagnosis without sufficiently exploring symptom criteria, functional impacts, or excluding physical causes.
Jumps to conclusions (e.g., “just stress or bereavement”) without evidence or consistency with diagnostic standards.
Information gathered placed the problem in its psychosocial context.
Links James’s occupational challenges, fears of redundancy, and lack of local family with his symptom persistence and risk profile.
Recognises how low self-esteem and guilt (feeling a “burden”) influence management and support needs.
The social and psychological impact of the problem was not adequately determined.
Fails to examine the relevance of work performance, isolation, and past loss to James’s current mental health.
Ignores cues about guilt, low self-worth, and lack of confidence that may influence engagement with care.
Revises hypotheses as necessary in light of additional information.
Modifies the working diagnosis as new information arises (e.g., if James discloses self-harm thoughts, weight loss, family history)
Rigid consulting with new information not adequately considered and integrated into the working diagnosis.
Holds to an initial impression despite new or contradictory information (e.g., persists with low mood as normal relationship bereavement even after clear evidence of a significant depressive disorder).
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate
Explains a range of evidence-based options for treating depression (such as antidepressant medication, physical activity, digital CBT, face-to-face talking therapies), discussing likely benefits and risks.
Advises that regular exercise can be highly effective, , while acknowledging that motivation may be challenging.
Prioritises safety planning based on risk assessment, including clear advice on what to do if suicidal thoughts or intentions develop.
Fails to provide appropriate and/or safe management choices
Omits key first-line options (e.g., does not mention exercise or digital CBT).
Offers rigid or unsafe recommendations, such as prescribing SSRIs without discussing potential risk of self harm
Ignores the patient’s need for a clear safety plan when any risk is present.
Empowers self-care and independence
Offers practical strategies for self-help, signposting to resources such as NHS Moodzone, self-guided CBT, or local exercise groups.
Encourages James to reconnect with enjoyable activities and provides advice on sleep hygiene.
Management fails to foster self-care and patient involvement
Does not explain self-help techniques or resources.
Makes James feel passive in his own management, solely reliant on medication or referral.
Prescribes safely considering local and national guidance
If medication is recommended, prescribes at a safe starting dose, checks for contraindications, and discusses possible side effects and overdose risk.
Reviews James’s medical history and involves him in the decision, considering his concerns and family history.
Unsafe prescribing ignoring best practice
Prescribes antidepressants without discussing how they might affect appetite, sleep, or suicidal thoughts.
Ignores guidance on comorbidities or past suicide risk (with stepdad’s history) when considering medication.
Refers appropriately being mindful of resource
Offers referral to talking therapies (IAPT/CBT) and explains waiting times; discusses digital and group options.
Sends patients for specialist input unnecessarily
Refers directly to psychiatry without first-line interventions, despite absence of severe risk.
Omits signposting to community supports (social prescribing, support groups), missing holistic opportunities.
Arranges appropriate follow-up
Schedules an early review in 1–2 weeks to assess safety and response.
Provides clear advice on how to access urgent help if risk increases, including out-of-hours and crisis contacts.
Unclear or inadequate follow-up
Leaves timing and means of future contact vague.
Fails to advise James about when and how to seek urgent care for escalating mental health symptoms.
Manages uncertainty, including that experienced by the patient
Normalises distress and acknowledges that recovery can be gradual; discusses prognosis frankly.
Provides safety netting and reassurance about reaching out if things become more difficult.
Struggles with uncertainty, leading to inconsistent decisions
Fails to prepare James for possible fluctuations in symptoms.
Gives shifting or confusing advice about diagnosis, treatment timing, or risk management.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Explores the patient’s agenda, health beliefs and preferences:
Explores James’s understanding of depression, his fears about therapy or medication, and previous coping strategies.
Considers James’s priorities, such as improving sleep or regaining motivation for cycling and work.
Fails to recognise the patient’s agenda and impact of the problem:
Skips over James’s beliefs about what caused his symptoms or what might help.
Suggests interventions without discussing James’s expectations or any previous successes or failures in coping.
The patient’s agenda was understood:
Elicits James’s central worries (becoming a burden, fears of relapse, effect on job).
Checks what James hopes to achieve and aligns care with these goals.
The patient’s agenda was not well explored:
Does not probe James’s specific concerns regarding work, family history, or prognosis.
Misses cues about what matters most to James.
Recognises what matters to the patient and works collaboratively to enhance patient care:
Invites James to help shape the plan, incorporating his interest in digital tools or social engagement.
Explains evidence for lifestyle change in a supportive, non-judgmental way.
Fails to work with the patient to plan care:
Imposes a management plan without gauging James’s preferences or responding to his suggestions.
Ignores James’s feedback or questions about various treatment options.
Demonstrates flexibility of communication adapting to the patient and scenario:
Adjusts language if James becomes tearful or anxious, using plain, supportive language and avoiding jargon.
Recognises non-verbal cues (e.g., flat voice, withdrawn posture) and offers reassurance and space for James to respond.
Consults rigidly, providing generic explanations and management plans:
Uses impersonal scripts or sticks to checklist questions even if James is distressed.
Fails to notice when James becomes overwhelmed or disengaged, continuing without checking in.
Works collaboratively in a team showing respect for colleagues:
Explains role of practice mental health nurse, counsellors, and social prescribers in James’s care.
Encourages teamwork by involving other resources, with James’s consent, for holistic support.
Fails to work effectively with team members to deliver optimal care:
Omits reference to multidisciplinary team, giving the impression that management is doctor-only.
Undermines or does not acknowledge the input and expertise of mental health colleagues.
Respectfully challenges unhelpful health beliefs or behaviours:
Gently addresses James’s fears about stigma or being labelled, providing facts and reassurance without judgment.
Corrections about medication or therapy are framed respectfully, maintaining trust.
Fails to maintain a productive therapeutic relationship:
Responds harshly to James’s worries, minimising or dismissing them.
Engages in debate or contradiction that damages trust rather than encouraging openness.
ℹ️ Insights from the examiner
How to do well:
Encourage James to tell his story with open questions. You may have to persist with open questions until James is ready to open up. Be prepared to use silence and wait for responses. It may feel time inefficient but experience shows it is necessary. Candidates who switch to closed questions early do not gather the richness of information delivered by open interactions and consequently data gathering is either incomplete or drags on leaving inadequate time for clinical management.
Empathetic open questions:
"James, could you talk me through how things have been for you since the relationship ended?"
This lets him shape the narrative while you listen for mood, energy, and motivation clues.
Clarify missing data not elicited from the open story with short clear questions
"What have you tried so far"
"How have you been sleeping?"
Keep questions focused on the patient's account, not a scattergun checklist. It helps rapport to show you are listening by summarising as you go:
"So low mood, worse after the breakup, affecting your sleep and eating—how have you been coping at work?"
Examples of clear patient friendly language and phrasing
"It sounds like you’ve had a really tough few months."
"Losing interest in things you used to enjoy must be frustrating, it normal for that to happen when you mood drops and should come back when you feel better"
Avoid jargon: "sleep problems", not "insomnia".
"Some people find their appetite drops when they're low—does that fit for you?"
Notice and respond to the cues the patient mentions. There are no false trails in the SCA. If the patient says it, ask about it.
"You mentioned your stepdad’s death—does that come to mind a lot?"
Maintain logical order—use James's words to structure next steps:
"You said sleep’s a struggle—could you tell me more about what happens at night?"
Or after hearing about energy loss: "Does that affect your ability to work or socialise?" Acknowledge replies: "That makes sense, thanks for explaining."
Appropriate differential for this presentation:
Use short, clear sentences:
"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." Cut out unnecessary medical terms; get to the point.
Evidence-aligned management menu:
Check James’s understanding and feelings:
"How does that sound to you—do you think any of these options would work for you?"
"Does that explanation fit with your experiences?"
Bespoke solutions mean using all you now know about James:
"Would it help to involve your line manager or see what support work can offer?"
"You’ve thought about safety —let’s add a crisis contact just in case."
"Since you mentioned missing cycling, how would you feel about joining a local group or buddying up for short rides?"
