Depression OSCE - Depression with Anxiety

Case Overview

• Age/Sex: 34-year-old female
• Occupation: Office administrator
• Setting: Primary care / GP clinic
• Chief complaint: "Feeling low and tired"

Patient Script

Who I Am

I'm 34, I work full time in an office doing admin work, and I've been under a lot of pressure at work recently.

What Brings Me In

I've been feeling low and really tired for weeks and it's getting in the way of everything — I thought I should get it checked.

My Story

For about three months I've felt increasingly down and tired all the time. At first I blamed a busy spell at work, but the low mood has become more constant over the last six weeks. I used to enjoy going out with friends and running at the weekend, but lately I don't want to — I find it hard to motivate myself and I don't get pleasure from things I used to. I sleep less than before, usually 4–5 hours a night, and I wake up early and can't get back to sleep. My appetite is smaller and I've lost a couple of kilos in the last month without trying. I find it hard to concentrate at work; I make mistakes and have missed a deadline last week.

I've also been feeling worrying thoughts a lot — about money and whether I've messed up my job — and my heart sometimes races when I'm on the phone or before a meeting. There were a couple of times in the last month when I've felt very shaky and a bit breathless for 5–10 minutes; it felt like panic but then it passed. I don't have any clear plan to hurt myself, but sometimes I think life would be easier if I weren't around — it crosses my mind briefly and then passes.

I had COVID about two months ago but it was mild and I recovered without problems. I started taking a vitamin D tablet a few weeks ago because a friend suggested it. I also started a combined oral contraceptive about four months ago for contraception; that hasn't felt related but I wondered if it could be affecting me.

My Medical Background

• Past medical history: mild eczema in childhood, otherwise well
• Medications: combined oral contraceptive pill, OTC vitamin D (started recently), occasional paracetamol for headaches
• Allergies: none known
• Social: lives with partner, non-smoker, drinks socially (about 6–10 units alcohol per week), drinks 2 cups of coffee daily, no recreational drug use
• Work: high workload, recently covering for a colleague on long-term leave
• Family history: mother had periods of low mood after childbirth; no known bipolar disorder or suicide in family

What I Think & Worry About

• I think something is wrong with me — maybe I'm "depressed." I'm worried I might lose my job or let my team down.
• I'm worried these feelings mean there's something physically wrong (like my hormones or a long COVID thing).
• I'd like help to feel like myself again and to be able to get back to running and socialising.

If You Ask Me About Other Symptoms...

• Mood/Thoughts: I feel tearful at times, mostly in the evenings; I have fleeting thoughts that life would be easier if I weren't here but no plan or intent.
• Sleep: I fall asleep reluctantly and wake early; I feel unrefreshed.
• Appetite/Weight: smaller appetite, lost about 2–3 kg in a month.
• Energy/Concentration: very low energy, poor concentration, making mistakes at work.
• Anxiety/Physical: occasional heart racing and trembling before meetings, muscle tension in my neck, headaches twice a week.
• Suicidal: I deny any current plan or intent, and no previous attempts.
• Menstrual: periods regular; no pregnancy — last period 2 weeks ago.
• Other: no visual changes, no neurological symptoms, no bowel/bladder change.

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Clinical Summary

Examination

• General: alert, cooperative, appropriately dressed, appears somewhat tired
• Vitals: Temperature 36.7°C; Heart rate 92 bpm; Blood pressure 118/76 mmHg; Respiratory rate 16/min; SpO2 99% on room air
• BMI: 23.5 kg/m2
• HEENT/Neck: no goitre, no cervical lymphadenopathy
• Cardiovascular: regular rhythm, no murmurs; occasional sinus tachycardia at rest
• Respiratory: clear
• Abdominal: soft, non-tender
• Neurological: no focal deficits
• Mental state examination:
  • Appearance/behaviour: appropriate, slow movements, reduced eye contact
  • Speech: slightly reduced rate and volume
  • Mood: patient reports feeling "down" and "anxious"
  • Affect: constricted, congruent with mood
  • Thought content: passive wishes for death reported (fleeting), no active suicidal plan, no psychotic symptoms
  • Cognition: orientation intact, impaired concentration on serial 7s
  • Insight/judgment: fair
• Standard questionnaires: PHQ-9 score 15 (moderately severe depressive symptoms); GAD-7 score 14 (moderate–severe anxiety)

Investigations

• Pregnancy test (urine): negative (rules out pregnancy before considering medication)
• Full blood count: Hb 12.6 g/dL (normal)
• Thyroid-stimulating hormone (TSH): 2.1 mIU/L (normal)
• Electrolytes, renal function: within reference range
• Liver function tests: within reference range
• Urine drug screen: negative
• ECG: sinus rhythm, rate ~92 bpm, no QT prolongation

Diagnosis

• Primary diagnosis: Major depressive disorder, moderate (evidence: persistent low mood and anhedonia for >2 months with significant functional impairment, PHQ-9 15, sleep and appetite disturbance, impaired concentration, passive death wishes without plan).
• Comorbid diagnosis: Generalised anxiety disorder / significant anxiety symptoms (evidence: excessive worry most days, GAD-7 14, physical symptoms of anxiety such as palpitations and tension).

Differential diagnoses considered:

• Adjustment disorder with depressed mood: considered given work stress, but symptoms have persisted >6 weeks with marked functional impairment, making major depression more likely.
• Thyroid disease or anaemia: unlikely given normal TSH and Hb.
• Substance-induced mood disorder: alcohol use is moderate and drug screen negative, so less likely.
• Bipolar disorder (depressive episode): no history of hypomania/mania reported; screening for prior mood elevation advised.

Management

• Immediate safety: perform a thorough suicide risk assessment now; given passive death wishes but no plan or intent, arrange a safety plan, provide crisis numbers, and ensure patient has social support; advise to re-contact if thoughts escalate.
• Psychoeducation: explain diagnosis of depression with anxiety, expected course, and treatments (talk therapies, medication), and normal investigations excluding thyroid/anaemia.
• Psychological therapy: offer referral for CBT or local low-intensity psychological therapies (e.g., IAPT or equivalent); consider urgent therapy access given functional impairment.
• Pharmacotherapy: consider starting an SSRI (e.g., sertraline 50 mg once daily) given moderate–moderately severe symptoms and functional impairment; discuss benefits, side effects, and need for follow-up. If pregnancy is possible in the future, discuss reproductive plans and risks/benefits.
• Short-term symptomatic management: advise sleep hygiene, regular exercise, reduction of caffeine late in day; avoid routine benzodiazepines—consider only very short-term if severe anxiety and discuss risks.
• Workplace adjustments: support for reduced hours or workload while treatment is initiated; provide fit note/sick leave if needed.
• Follow-up: arrange review in 2 weeks (earlier if worsening) to assess safety and response; monitor for side effects and suicidal ideation after starting medication; plan ongoing reviews at 4–6 weeks for efficacy.
• Further assessment: screen for past hypomanic symptoms to exclude bipolar disorder; consider referral to secondary mental health services if no improvement or if risk increases.

Key Learning Points

• Always assess suicidal ideation and risk in patients with depression; passive death wishes require safety planning and close follow-up.
• Depression commonly coexists with anxiety; use validated tools (PHQ-9, GAD-7) to quantify severity and guide management.
• Exclude common medical contributors (thyroid dysfunction, anaemia, substance use) before attributing symptoms solely to a primary mood disorder.