Depression OSCE - Adjustment Disorder

Case Overview

• Age/Sex: 58-year-old male
• Occupation: Former warehouse supervisor (recently made redundant)
• Setting: Primary care / GP clinic
• Chief complaint: "Feeling low and tired"

Patient Script

Who I Am

Im 58, used to manage a warehouse, but Ive been out of work since they let me go about six weeks ago.

What Brings Me In

Ive been feeling low and tired for the last few weeks and thought I should get it checked out.

My Story

About six weeks ago I lost my job; it was sudden and Ive been worried about money since then. I started to feel down and easily tired about three to four weeks ago. I get up in the morning but I dont feel like doing much — Im not sleeping as well as I did before and Im exhausted by the afternoon. Im still managing basic things at home and have been looking at job ads, but Im slower at calling employers and I dont feel enthusiastic about the interviews.

Id say Im sad more than anxious. I sometimes get teary when I think about losing the job. I havent had thoughts of killing myself, but Im worried about how long this will go on and whether Ill find new work. I used to enjoy tinkering with my car and watching football; I havent felt like doing those the past few weeks, but I still follow matches on the radio.

A couple of things you might think matter but really arent central: I had a bit of chest tightness once a month ago when I was moving a heavy box at home — it went away after a few minutes and I didnt go to A&E. I also have a sore shoulder from gardening a couple weeks back. I drink beer most weekends, maybe a bit more since I lost the job, but I dont drink every day.

My Medical Background

• Past medical history: high blood pressure diagnosed 5 years ago (on treatment), no previous depression or psychiatric diagnosis
• Medications: lisinopril 10 mg once daily (take most days), over-the-counter ibuprofen occasionally for shoulder pain
• Allergies: none known
• Social: current smoker, ~20 cigarettes/day; drinks alcohol socially, 6-10 units on a typical weekend; lives with wife, two grown children live separately
• Family history: father had coronary artery disease; mother had "nerves" in later life (no formal diagnosis)

What I Think & Worry About

• I think Im exhausted because I lost my job and Ive been worrying about money and getting another job.
• I worry that Im getting lazy or that I wont get back to how I was before.
• Im anxious about telling potential employers the gap on my CV.

If You Ask Me About Other Symptoms...

• Sleep: I wake more than before, sometimes lie awake for an hour; I sleep in later when I can.
• Appetite/weight: my appetite is a bit less; Ive lost about 2 kg in the last month but not on purpose.
• Energy/concentration: I tire quickly and find it harder to concentrate on reading job ads or paperwork.
• Mood: mostly down and irritable at times; crying spells occasionally but brief.
• Suicidal thoughts: I havent had any thoughts of harming myself or plans.
• Anhedonia: I dont feel as interested in hobbies, but I can still enjoy football highlights.
• Anxiety/panic: I get worried about money and interviews, no panic attacks.
• Substance use: I smoke about a pack a day; Ive been drinking a bit more on weekends but not to blackouts.
• Physical symptoms: occasional shoulder pain and one brief episode of chest tightness a month ago after heavy lifting; no ongoing chest pain or breathlessness.

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Clinical Summary

Examination

• General: alert, cooperative middle-aged man, appears mildly tired but well kempt
• Vitals: BP 138/86 mmHg; HR 84 bpm; RR 14/min; Temp 36.7°C; SpO2 98% on room air
• BMI: 29 kg/m2 (overweight)
• Cardiovascular: heart sounds normal, no murmurs; no peripheral edema
• Respiratory: chest clear to auscultation
• Abdominal: soft, non-tender
• Musculoskeletal: mild tenderness over right shoulder with preserved range of motion
• Mental state examination: mood subjectively "down," affect mildly restricted but appropriate; speech normal rate and volume; thought content logical, no suicidal ideation or psychosis; insight present; concentration mildly reduced on serial 7s but orientated

Investigations

• PHQ-9: 8 (mild depressive symptoms)
• GAD-7: 5 (mild anxiety)
• FBC: Hb 14.2 g/dL, WCC 6.1 x10^9/L, platelets 240 x10^9/L (no anaemia or infection)
• TSH: 1.8 mIU/L (within reference range)
• Fasting glucose: 6.1 mmol/L (borderline elevated; consider impaired fasting glucose)
• Lipid profile: total cholesterol 5.6 mmol/L, LDL 3.4 mmol/L (borderline high)
• ECG: normal sinus rhythm, no acute ischaemic changes (prior chest tightness likely musculoskeletal)

Diagnosis

Primary diagnosis:

• Adjustment disorder with depressed mood (mild)
  • Evidence: onset of low mood and fatigue within 3-4 weeks after a clearly identifiable psychosocial stressor (job loss 6 weeks ago); symptoms are causing distress and some functional impairment (reduced motivation for job seeking), but there is no evidence of a major depressive episode (PHQ-9 in mild range, preserved interest in some activities, no suicidal ideation), and symptoms are of relatively recent onset.

Differential diagnoses (with reasoning):

• Major depressive disorder: less likely given symptom severity (PHQ-9 8), preserved functioning and absence of pervasive anhedonia or suicidal ideation.
• Dysthymia (persistent depressive disorder): unlikely given relatively short duration of symptoms (<2 years, recent onset)
• Generalized anxiety disorder: some overlapping worry but anxiety scores mild and worries are clearly tied to the stressor
• Substance-induced mood disorder: increased weekend alcohol use noted but pattern and amount do not suggest primary substance-induced mood disorder; alcohol use should be monitored
• Hypothyroidism or medical cause of low mood: unlikely based on normal TSH and FBC, but metabolic contributors should be considered

Management

• Safety: confirm ongoing absence of suicidal ideation; provide safety-netting advice and clear instructions to seek urgent help if thoughts of self-harm develop.
• Psychoeducation: explain likely diagnosis of adjustment disorder; reassure that this is a common reaction to a stressful life event and often improves with time and support.
• Brief psychosocial interventions: offer short-term structured support in primary care, problem-solving therapy, or referral to local counselling services/CBT focused on coping with job loss.
• Watchful waiting with active follow-up: review in 2-4 weeks to assess progress; earlier review if worsening or new symptoms.
• Social/occupational support: discuss practical steps — benefits advice, occupational services, help with CV and job applications; consider referral to employment support services.
• Lifestyle and symptomatic measures: encourage regular sleep routine, graded return to activity/exercise, limit alcohol, smoking cessation advice and offer smoking cessation referral.
• Medical management: do not start antidepressant at this stage given mild symptoms; consider pharmacotherapy if symptoms worsen or persist beyond several months or become moderate-severe.
• Investigations/follow-up tests: monitor fasting glucose and lipids with lifestyle advice; review BP control and cardiovascular risk factors given smoking and lipid results.

Key Learning Points

• Adjustment disorder is a time-limited, stress-related condition that occurs within three months of an identifiable stressor and typically causes distress and functional impairment without meeting criteria for major depressive disorder.

• Management emphasizes psychoeducation, brief structured psychological interventions or counselling, practical support (including occupational advice), safety assessment, and close follow-up rather than immediate pharmacotherapy for mild presentations.

• Always screen for medical causes and assess for suicidal risk; consider red herrings (e.g., isolated chest tightness after exertion, increased weekend alcohol) but interpret them in context to avoid misdiagnosis.