“I’m not coping” — an urgent appointment for low mood

Candidates: do not open until you have consulted.

Persona and manner

• Daniel Ibrahim, 30. Flat voice, slow answers, little eye contact, shoulders down. Not tearful — emptied out. You answer what you are asked, briefly.

Opening line — say this verbatim

• “I’m not coping. I don’t really see the point any more.”

Volunteer freely if given the space

• About two months of feeling low most of the day, every day. Nothing is enjoyable — you have stopped going to five-a-side and stopped coding for fun.
• Waking at 4 am and lying there. Little appetite; you have lost some weight. You cannot concentrate.

Only if asked

• Your partner of four years, Leila, left ten weeks ago. You live alone now.
• You feel like “a burden” to your family, and guilty that you “drove her away”.
• Only if asked directly about suicide or ending your life: yes — most days for the past two weeks. You have thought about taking the zopiclone you have at home (a box of 28 left over from a prescription last year) with whisky. Three nights ago you took the box out and counted the tablets, then put them back. You have not written a note or made other preparations. You have never attempted suicide or harmed yourself before.
• What stopped you: your sister Amira — “she’d be the one to find me” — and your faith; you are a practising Muslim and believe it is forbidden.
• Alcohol: nothing in the week, but most of a bottle of whisky across Friday and Saturday nights. The drinking is new since Leila left and you are ashamed of it. It makes the thoughts worse. No drugs.
• No voices, no unusual beliefs, no periods of high mood or needing little sleep. No thoughts of harming anyone else.
• Your mother had depression. No family suicide. No physical symptoms — no weight gain, no feeling cold, no tremor.
• Tonight you would be at home on your own. Amira lives 15 minutes away and you speak most days; she knows you are low, not about these thoughts.

Impact on daily life — home and work (only if asked)

• Work: you have had a written warning about missed deadlines; you have been logging on late and avoiding calls.
• Home: the flat is a mess, you are living on toast and cereal, you have stopped answering friends’ messages.
• You have not been to Friday prayers for a month.

Ideas, concerns and expectations

• Idea: “I think I’m depressed.”
• Concern (only if asked what worries you about today, or when the crisis team or hospital is mentioned): being “locked up”, and work finding out.
• Expectation: you do not really know — “something to make it stop”. Perhaps tablets.

Cues to deliver, timed

• Minute 2: “Everyone would honestly be better off.” — then look at the floor.
• Minute 4, if suicide has not been asked about: “I’ve got those sleeping tablets at home… they don’t even work.”
• If the doctor asks about suicide using a euphemism only (“dark thoughts”, “doing anything silly”): “What do you mean?”

If the doctor summarises and asks whether you want to add anything

• If the tablets have not been discussed: “There’s a box of sleeping tablets at home. I counted them the other night.”
• If they have: “I haven’t told anyone any of this. Not even Amira.”

How to respond to the doctor

• If asked about suicide plainly and kindly: a long pause, then you answer honestly. You look relieved afterwards: “I’ve not said that out loud before.”
• If the doctor explains what they think is going on — depression, with thoughts of suicide that need help today — in plain words: you nod. “So I’m not just weak?”
• If the doctor makes a plan with you — being seen by the mental health crisis team today, Amira staying tonight and taking the tablets away, no whisky, numbers to ring, a follow-up appointment: you agree. You will let the doctor ring Amira with you in the room.
• If the doctor says “you need to be sectioned” or threatens admission: alarmed — “I came here for help, not to be locked up.”
• If the doctor just gives antidepressants and “come back in two weeks”: say “OK” flatly and get up to leave.
• If asked whether you can keep yourself safe tonight: “If Amira’s there, yes. On my own… I don’t know.”

Do not

• Mention suicide, the tablets being counted, or the whisky unless the doctor asks or invites you to add anything (apart from the timed cue).
• Become agitated or psychotic. You are low, slowed and honest.

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. Asking about suicide does not plant the idea. Ask plainly: “Have you had thoughts of ending your life?”
2. NICE NG225 (2022): do not use risk assessment tools or scales to predict suicide, and do not use “low / medium / high” risk labels to decide who gets care. Base the plan on a psychosocial assessment of needs, safety and vulnerabilities.
3. Features here that demand same-day specialist assessment: a specific plan, means at home, a preparatory act (counting tablets), alcohol, recent loss, living alone.
4. Differentials for low mood in a 30-year-old: depressive episode, adjustment disorder, bipolar depression (ask about past elevated mood before any antidepressant), alcohol- or drug-related mood disorder, psychosis, and physical causes — hypothyroidism, anaemia, medication.
5. A safety plan is written with the patient: warning signs, coping strategies, people and places for distraction, people to ask for help, professional and crisis contacts, making the environment safe.
6. Crisis routes in England: NHS 111 and select the mental health option; Samaritans 116 123 (free, 24 hours); 999 or the emergency department if life is at immediate risk. Local crisis team access varies across the four nations.
7. He has capacity and accepts help, so the Mental Health Act is not the starting point. Confidentiality: seek consent to involve his sister. If an adult with capacity refuses, you should usually respect that when he alone is at risk (GMC Confidentiality). If imminent suicide risk puts his capacity in doubt, share the minimum necessary in his best interests, with senior advice (Department of Health and Social Care consensus statement on information sharing and suicide prevention, 2021).
8. Antidepressants are not the emergency treatment. If started after assessment, NICE NG222 advises review within one week for people aged 18–25 or where there is concern about suicide risk, and consideration of toxicity in overdose and limited quantities.
9. Examination of mental state counts as clinical examination in PLAB 2 (GMC). Comment on appearance, behaviour, speech, mood and affect, thought content, perception, cognition and insight.

Where candidates lose marks at this station

• “Any dark thoughts?” — and moving on.
• Labelling him “medium risk” instead of making a plan.
• Sertraline and a fortnight.
• Ringing the sister without asking him.
• No numbers in his phone and nobody with him tonight.

Guidelines for this station

• NICE NG225 — Self-harm: assessment, management and preventing recurrence
• NICE NG222 — Depression in adults: treatment and management
• GMC — Confidentiality: good practice in handling patient information
• NHS — Where to get urgent help for mental health

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-03