Depression OSCE - Major Depressive Episode | Free OSCE Practice

Case Overview

Age/Sex: 24-year-old female
Occupation: University student (undergraduate, final year)
Setting: Primary care / student health clinic
Chief complaint: "Feeling low and tired"

Patient Script

Who I Am

I'm 24, in my final year at uni, living in a shared flat and trying to get through exams.

What Brings Me In

I've been feeling really low and exhausted for a few weeks and it's getting in the way of studying and even getting out of bed.

My Story

It started about 6 weeks ago after a particularly stressful set of deadlines; at first I thought it was just stress from revision, but it's got worse over the last 3 weeks. I feel down most of the day, and I don't enjoy the things I used to — I used to go to yoga and meet friends, but I haven't felt like it for about a month. I'm tired all the time, even after sleeping, and lately I've been finding it hard to concentrate on reading for more than a few minutes. My sleep is mixed — some nights I can't sleep because I'm worrying, other nights I sleep for ages but still feel exhausted. My appetite is a bit lower and I've lost a couple of kilos since exams started. I sometimes feel really worthless and like I'm not coping with anything. I have had a few fleeting thoughts that "life would be easier if I wasn't here," but I haven't made any plans and I'm not going to hurt myself.

A couple of months ago I had COVID but I recovered — my friends say I still 'seem drained' sometimes. I've also been drinking a bit more at weekends because I'm trying to relax (a few glasses of wine, nothing every day). I take the combined oral contraceptive. I don't smoke and I rarely use other drugs (I had cannabis once at a party 2 months ago). I thought it was just exam stress at first, but it's not getting better.

My Medical Background

Past medical history: none significant; mild tonsillitis once as a teen
Medications: combined oral contraceptive pill (for 2 years)
Allergies: none known
Social: lives with 2 roommates, not working while studying, eats irregularly during exam season, drinks alcohol socially (2–6 units on weekends), occasional energy drinks late at night
Family history: mother had depression; no known bipolar in family

What I Think & Worry About

I think this is probably just stress from exams, or I'm exhausted from studying.
I'm worried this might be "more than stress" because it's not getting better and I'm falling behind work.
I want something practical — maybe someone to tell me what to do, medication if needed, or counselling through the university.

If You Ask Me About Other Symptoms...

Sleep: "I can't get to sleep some nights because my mind is racing; other nights I sleep a lot but still wake tired."
Appetite/weight: "I've been eating less, lost a little weight — maybe 2–3 kg in 6 weeks."
Energy: "Very low — I struggle to get out of bed in the morning."
Concentration/memory: "I can't concentrate on reading; I lose my train of thought when revising."
Anxiety/panic: "I feel anxious about exams and sometimes have a racing heart if I'm panicking, but no panic attacks really."
Suicidal thoughts/self-harm: "I've had fleeting thoughts that things would be easier without me, but I've never planned or tried anything. I don't want to hurt myself — I just feel hopeless sometimes." (If asked specifically: no access to means, no plan, no intent.)
Mania history: "No — never had periods where I felt unusually energetic or needed less sleep."
Physical symptoms: "I sometimes feel achy and slow but I think that's because I'm not sleeping properly."
Menstrual: "Periods are a bit irregular around exams but nothing unusual for me since starting the pill."
Substance use: "I don't use drugs regularly; had cannabis once a couple months back."

Clinical Summary

Examination

General: alert, cooperative young woman; appears tired; tearful at times
Vital signs: T 36.7 °C, HR 76 bpm, BP 112/70 mmHg, RR 14/min, SpO2 99% on room air
Weight/BMI: 58 kg, BMI 21.3 kg/m2 (approx. 2–3 kg weight loss over 6 weeks)
HEENT/neck: no goitre, no thyroid enlargement
Cardiovascular/pulmonary/abdominal: unremarkable on brief exam
Neurological: orientation intact, cranial nerves normal, no focal deficits
Mental state: mood low, affect constricted; speech slightly soft and slowed; psychomotor activity mildly reduced; thought content shows low self-worth and passive death ideation without plan or intent; no suicidal plan; no hallucinations; insight fair; concentration reduced on serial 7s (difficulty beyond first two subtractions)

Investigations

PHQ-9: 16 (moderately severe depressive symptoms) (interpretation: suggests major depressive episode likely)
GAD-7: 9 (moderate anxiety)
CBC: Hb 135 g/L (normal) (interpretation: no anaemia to explain fatigue)
TSH: 1.6 mIU/L (normal) (interpretation: unlikely hypothyroid)
Serum B12: 380 pg/mL (normal) (interpretation: not B12 deficiency)
Urine pregnancy test: negative (interpretation: safe to consider SSRI if indicated)
Urine drug screen: negative (interpretation: no substance-induced mood disorder identified)
ECG: sinus rhythm, no QT prolongation (interpretation: baseline acceptable if starting SSRI such as sertraline)

Diagnosis

Primary: Major depressive episode (moderate), supported by >2 weeks of depressed mood, anhedonia, fatigue, sleep disturbance, decreased concentration, reduced appetite/weight loss, feelings of worthlessness, and PHQ-9 score of 16; functional impairment (academic performance affected).
Differentials:
- Adjustment disorder with depressed mood — considered because of exam stress, but symptoms have persisted >6 weeks with marked functional impairment consistent with a major depressive episode.
- Substance- or medication-induced mood disorder — unlikely given negative drug screen, only occasional alcohol use, and stable OCP use for 2 years.
- Hypothyroidism or anaemia — less likely given normal TSH and Hb; investigations performed to exclude these.
- Bipolar disorder (depressive episode) — no history of hypomania/mania reported; family history of depression rather than bipolar makes unipolar depression more likely, but screen for past hypomanic symptoms remains important.

Management

Immediate:
- Conduct a thorough suicide risk assessment (patient reports passive suicidal thoughts but no plan or intent); establish safety plan, remove immediate means if present, involve family/friends with patient's consent, provide crisis contact information.
- Arrange prompt follow-up within 1 week (safety check) and again at 2–4 weeks for treatment response.
Psychological and social interventions:
- Offer referral to university counselling services or primary care psychological therapy (CBT) promptly.
- Discuss practical supports: temporary academic accommodations, time-limited reduction in study load if possible, peer support.
- Advise sleep hygiene, regular light exercise, structured daily routine, reduce late-night caffeine/energy drinks and limit alcohol.
Pharmacological:
- Consider starting an SSRI (e.g., sertraline 50 mg once daily) after discussing benefits/risks and confirming pregnancy test negative; explain 4–6 weeks for effect and potential side effects.
- Provide written information and plan for dose review in 2–4 weeks, with explicit advice to seek help if suicidal ideation worsens.
Investigations and referrals:
- No further immediate medical investigations required given normal initial labs; repeat tests if atypical course or poor response.
- Refer to psychiatry if symptoms severe, if suicidal risk increases, or if poor response to first-line therapy.

Key Learning Points

Major depressive episode is a clinical diagnosis: look for at least five symptoms including low mood or anhedonia for >2 weeks with functional impairment; screen severity with tools like PHQ-9.
Always assess suicidal risk and safety; differentiate adjustment to stressors from a major depressive episode by duration, symptom number, and degree of impairment.
Exclude common medical causes (thyroid dysfunction, anaemia, pregnancy, substance use) before initiating pharmacotherapy and offer combined psychosocial (CBT/support) and pharmacological treatment for moderate-to-severe depression.