Suicide Risk Assessment OSCE - Suicidal Ideation in Depression | Free OSCE Practice

Case Overview

Age/Sex: 22-year-old female
Occupation: University student (final-year exams)
Setting: Student health clinic / primary care
Chief complaint: "Thoughts of self-harm"

Patient Script

Who I Am

I'm a 22-year-old university student living in a shared flat while studying for finals.

What Brings Me In

I've been having repeated thoughts of hurting myself and I thought I should talk to someone before it gets worse.

My Story

I've felt down for about 6 weeks, but it has been worse in the last 2 weeks. I can't enjoy things like I used to, I'm sleeping badly—mostly waking up at 3–4 am and can't get back to sleep—and I've lost a few kilos. I get very tearful doing coursework and I can't concentrate on revision. For the past 10 days I've had repeated thoughts of harming myself, sometimes when I'm alone and very stressed. I've thought about taking an overdose of tablets on a couple of occasions but I haven't done it, and I don't have any pills at home right now. I haven't told my flatmates because I'm embarrassed and I don't want to worry my parents. The last time I had a proper breakdown was when I was 18 and I cried for a few days, but I didn't hurt myself then.

I've been under a lot of pressure with end-of-year exams. The closer the exams get the worse I feel; some days I can't study at all. I sometimes have a drink to try to sleep—last weekend I had a heavy night drinking with friends and felt worse the next day. I also use cannabis occasionally when stressed, maybe once a month.

(Include red herrings: I also mention mild stomach cramps for a few days and one episode of sharp chest tightness last week that went away, and I recently started a new energy drink habit.)

My Medical Background

Past medical history: mild asthma as a teenager, no hospital admissions
Mental health: low mood episodes in late teens (self-resolved), no previous suicide attempts
Medications: combined oral contraceptive, salbutamol inhaler PRN, paracetamol PRN for headaches
Allergies: none known
Social: lives with two flatmates, single, non-smoker, drinks socially (one heavy night last weekend), occasional cannabis (~monthly)
Family history: mother treated for depression in her 30s

What I Think & Worry About

I think this is because of the pressure of exams and I'm failing
I'm worried I might let my parents down and they will be angry or disappointed
I'm scared that if I tell someone they'll make a big deal and make me miss my exams or send me home

If You Ask Me About Other Symptoms...

Sleep: "I'm sleeping less overall, wake early and can't get back to sleep."
Appetite/weight: "I've lost a little weight because I'm not eating; maybe 3–4 kg in 6 weeks."
Energy: "I feel tired all the time and can't be bothered to go to the library."
Concentration: "My mind goes blank when I try to study."
Anxiety/panic: "Sometimes my heart races and my chest feels tight — usually when I'm panicking about an upcoming exam." (red herring)
Substance use: "I had one heavy drinking night last weekend; I smoke cannabis roughly once a month." (red herring)
Past self-harm: "I've never actually tried to hurt myself, just thoughts; I haven't told anyone before."
Thoughts about death: "I sometimes think it would be easier if I wasn't here, but I don't want to hurt other people."
Access to means: "We don't keep many medications at home — just some paracetamol and cold tablets." (important for risk assessment)
Suicidal plan/intent: "I don't have a clear plan right now and I'm not going to hurt myself today, but the thoughts keep coming back."

Clinical Summary

Examination

General: Young woman, casually dressed, poor eye contact at times but cooperative
Vitals: BP 112/72 mmHg, HR 98 bpm, RR 14/min, Temp 36.6°C, SpO2 98% on air, BMI 20 kg/m2
Appearance/behaviour: Tearful at times, slowed movements, no agitation
Speech: Normal rate and volume, mildly reduced spontaneity
Mood: Reports feeling "very low"
Affect: Restricted, congruent with mood
Thought content: Recurrent thoughts of self-harm/suicidal ideation for ~10 days; denies current intent to act and denies imminent plan; denies hallucinations or paranoid ideas
Thought form: Coherent and goal-directed
Cognition: Oriented x3, attention and concentration reduced on testing
Insight/judgment: Partial insight into illness, judgment described as fair
Risk: Active suicidal ideation present (frequency daily), no recent attempt, no clear plan today but some access to household medications

Investigations

PHQ-9: 18 (moderately severe depressive symptoms; Q9 positive for suicidal ideation)
GAD-7: 13 (moderate anxiety)
C-SSRS (screen): Passive and active ideation present, denies intent and denies recent attempts (no lethal intent reported)
Pregnancy test (urine): Negative (important prior to pharmacotherapy)
Full blood count: Hb 13.0 g/dL (normal)
TSH: 2.0 mU/L (normal)
U&E: Na 139 mmol/L, K 4.1 mmol/L, creatinine 76 µmol/L (normal)
ECG: Sinus rhythm, HR 98 bpm, no QT prolongation

Diagnosis

Primary: Depressive episode with suicidal ideation
- Evidence: 6-week history of low mood and anhedonia, worsening over 2 weeks, sleep disturbance, decreased appetite/weight loss, concentration problems, PHQ-9 score 18, positive screening for suicidal thoughts (C-SSRS). Risk: daily ideation but currently denies clear plan or intent.
Differentials:
- Adjustment disorder with depressed mood — plausible given clear stressor (exams), but severity and duration (6 weeks, functional impairment) support major depressive episode
- Substance-induced mood disorder — occasional alcohol binge and monthly cannabis use are unlikely to fully explain persistent symptoms; drug screen not indicative of acute intoxication
- Thyroid dysfunction or other medical cause — basic labs (TSH, FBC, U&E) normal, less likely
- Emerging bipolar disorder — no history of hypomania/mania reported, less likely

Management

Immediate:
- Conduct a structured risk assessment (frequency, intensity, duration of ideation; intent; plan; access to means; protective factors)
- Remove or limit access to potential means (ask patient/flatmates to remove medications and alcohol where possible)
- If clear intent, active plan, or access with means → urgent psychiatric admission (section if necessary)
- In this case: patient reports ideation but denies current intent/clear plan; manage as urgent outpatient with close follow-up
Safety and support:
- Develop a safety plan with the patient (who to contact, coping strategies, remove means, crisis numbers)
- Provide crisis contact details (local mental health crisis team, emergency services) and advise to present to ED if intent escalates
- Consider involving family/flatmates with patient consent for support and means restriction
Pharmacological/therapeutic:
- Arrange urgent psychiatric liaison / community mental health referral within 24–72 hours
- Consider starting an SSRI (e.g., sertraline) after discussing risks/benefits and confirming pregnancy test negative; arrange monitoring for side effects and suicidal ideation worsening in early treatment
- Initiate referral for psychological therapy (CBT) or student counselling focused on depression and exam-related stress
Follow-up and documentation:
- Arrange follow-up contact within 48–72 hours (phone or face-to-face) to reassess risk and response
- Document assessment, risk formulation, management plan, and safety planning clearly in notes
- Consider routine baseline blood tests and ECG if starting an SSRI that requires it, and arrange contraceptive/pregnancy counselling as appropriate

Key Learning Points

Always ask directly and non-judgmentally about suicidal thoughts, intent, plan, and access to means; frequency and persistence of ideation guide risk.
Prioritize safety: remove access to means, develop a clear safety plan, involve support people with consent, and arrange urgent psychiatric assessment when risk is moderate-to-high.
Distinguish depressive episode from adjustment disorder and substance-related causes by assessing duration, severity, functional decline, and screening tools (PHQ-9, C-SSRS) to guide treatment decisions.