Patient Instructions o
John Moody - Recurrent Depression with overvalued ideas
You are a 60 year old man with a history of intermittent depression over the past 15 years, and worried that the symptoms are returning.
You saw another GP two weeks earlier and declined any treatment. You filled in the questionnaire given and brought it in today. You scored 17 but you unsure of the significance.
This time there is no specific trigger for your low mood, disrupted sleep (difficulty getting to sleep) and reduced appetite. Previous episodes were more severe and due to work and the stress with running your own business, and in conjunction been through a divorce. Now you are in a happy relationship but unduly worried that you are going to ruin things. She is blissfully unaware. You have made some of your own changes by reducing your work to part-time, and your son is taking over the business. You have stopped smoking in the last year and you drink within 10-20 units per week. No financial concerns.
You have tried medication in the past (Prosac), and reluctant to try again. You are concerned about your girlfriend knowing you are taking them, the stigma of depression. They helped in the past but you are more worried about side effects and what you read in the papers. Your sister is into herbal medicines and suggested St John’s Wort, which you think sounds great. It is herbal and according to what you have read - it works. You are not particularly aware of alternatives medications.
You have tried counselling but not cognitive behavioural therapy (CBT). Counselling was not a great experience as you didn’t particularly like the counsellor. However, you are willing to try again.
Your past medical history includes: recurrent depression and hypertension, and you only take ramipril.
You are expecting reassurance particularly as no triggers, and to reassurance that you have come early. You are very keen for St John’s Wort but willing to consider explanation of St John’s Wort and other medications. You are very keen to hear about alternate ways so CBT, exercise, and sleep hygiene etc.
Doctor’s (GP ST) Instructions s
John Moody
A 60 year old gentleman
Generally an infrequent attender. Attends for his annual check up for hypertension.
Summary Card
1997 Depression
2003 Depression
2005 Hypertension
Case Notes
2 weeks ago John saw a colleague for low mood and declined any treatment but was asked to complete a PHQ9 at home and to bring the questionnaire in a 2 week follow-up appointment
PMH
Hypertension
Regular Prescriptions
Ramipril
FH
Father had MI aged 59years
CSA Examination Card o
Examination findings:
John Moody
Review completed PHQ-9: Result 17 Moderate Depression
Mental State Examination - no concerns
Recent bloods – satisfactory
BP well controlled on medication
CSA Case Marking Sheet o
Case Name: John Moody / Centre: CRH Scheme name: PennineGP ST Name: / CSA Surgery Date:
Case Title Recurrent Depression & overvalued ideas
Context for case
· Recurrent diagnosis of depression
· Low mood, no triggers
· Overly concerned about ruining new relationship
· Extremely keen to try St John’s Wort
Assessment Domain:
1. Data-gathering, technical and assessment skills
Positive descriptors:
· Acknowledge and review PHQ9
· Brief appropriate depression history- what symptoms he is experiencing and comparing to past episodes
· Acknowledges recurrent nature of depression and address his concerns
· Explores possible triggers for depression and social history
· Ask red flags - suicide risk
· Explores what he has tried in the past
· Identifies preference to alternative therapies and reasoning
· Focused PMH, DH, inc alternative therapies and smoking & alcohol history / Negative descriptors:
· Not taking an adequate social history
· Poor depression history
· Not addressing his concerns
· Does not acknowledge his ideas regarding alternative therapies
· Does not address psychosocial/social history
· Does not address suicide risk
· Not taking a focused PMH, DH. Forgetting about alcohol consumption/smoking
Assessment Domain:
2. Clinical Management Skills
Positive descriptors:
· Reassurance that he has come early
· Reassurance that depression affects many and shouldn’t feel stigmatized, giving an explanation about depression
· Negotiate medication – a good explanation of St John’s Wort and the risks, and offering an explanation on alternative SSRIs (advantages and side-effects). Reassure that a decision doesn’t have to be made immediately
· Offering follow-up
· Offering a referral for counselling/CBT
· Giving written info (PILs)-e.g. on SSRIs, depression and self help.
· Verbal self-help advice-exercise, reducing stress, sleep hygiene etc / Negative descriptors:
· No reassurance
· Not offering alternative treatments or explanations
· No follow-up
· Not explaining risks-medications or not accepting help
· Failure to safety net
· Pressurising into treatments, not offering choice
· Inappropriate management of depression
Assessment Domain:
3. Interpersonal skills
Positive descriptors:
· Explores John’s agenda, health beliefs and preferences
· Responds to feelings and expectations
· Appears alert to verbal and non-verbal cues
· Elicits psychosocial and social information to put into context
· Works in partnership, common ground and develop a shared management plan
· Enhances autonomy
· Patient centred and shows empathy and interest
· Reassurance / Negative descriptors:
· Does not enquire sufficiently into agenda, health beliefs and preferences
· Pays insufficient attention to verbal and non-verbal cues
· Fails to explore how it affecting his life
· Does not appreciate the impact of the patient’s psychosocial context
· Instructs patient rather than seeking common ground
· Used a rigid approach, doesn’t offer or respond to patient’s contributions
· Failure to empower
· Lacks warmth, empathy
· Little or no reassurance
Global Comments
Positive descriptors
· Click & enter / Negative descriptors
· Click & enter
Grading
Clear pass Marginal pass / Marginal fail Clear fail
Excellent
Serious Concerns
General Feedback Comments