Station 13 · Low mood

Candidates: do not open until you have consulted.

Persona and manner

• Priya Shah, 34, an accounts clerk; tired, flat, apologetic for “wasting time”; tears close but controlled; you fold and unfold a tissue.
• You have three things to say and you expect to be allowed one.

Opening line (verbatim)

• “I've run out of my sertraline — could I have some more — and I need to be signed off, I can't face going back yet. And… my period's late. I'm not sure it matters.”

The story

• “Mum died in June. A heart attack, on the phone to me.” “I'm not sleeping.” “I cry at work.” “My manager's been OK but I can't concentrate.”
• “The tablets ran out five days ago and this week's been worse.”
• If asked: you took the sertraline every day until it ran out; no side-effects; mood 3 out of 10; nothing is enjoyable; four hours' sleep; poor appetite; poor concentration; guilt: “I wasn't there.”
• If asked directly and well about thoughts of not being here: “It would be easier not to wake up.” No plan, no intent. “I'd never do it. Dad needs me.” No self-harm; no previous attempts. Two glasses of wine at weekends; no drugs.
• If asked about the period: ten days late; normally regular; no contraception; “we weren't really trying, but we weren't not”; your partner is supportive; no test done; no nausea; breasts “a bit sore”.
• Work: you went back for two weeks in August “and it was awful”; off three weeks since; you want four weeks; a phased return “might be OK if they'd let me”.
• Your father lives alone; you visit daily; you are an only child. The bereavement leaflet is “in a drawer”.
• If asked how you would feel if you were pregnant: “I'd be happy… I think. Would the tablets hurt it?”

Ideas, concerns and expectations

• Idea: “Grief. And I stopped the tablets and it's all crashed.”
• Concern: Sertraline harming a pregnancy; being signed off meaning you have failed; your father coping.
• Expectation: Sertraline, a note, and to know what to do about the period.

Impact

• Work: you cannot concentrate; you cry at your desk; the manager has been kind so far.
• Home: you visit your father every day; your partner does the cooking; you are asleep by nine and awake at one.
• Money: the sick pay runs out next month.

Red flags

• Present: Passive thoughts of death with protective factors; a relapse after an abrupt stop of an antidepressant; a possible pregnancy on an SSRI.
• Absent: No plan, no intent, no previous attempt, no self-harm; no psychotic features; no alcohol or drug excess.
• Absent: No abdominal pain or bleeding with the late period.

Hidden facts and their triggers

• “It would be easier not to wake up” — released only only if mood has been explored properly and the doctor then asks directly; otherwise at minute seven if asked whether there is anything else
• “Dad needs me” — released only if asked what keeps you going, or about your father
• The soreness in your breasts and the absence of contraception — released only if asked about the period in any detail
• That a phased return might be acceptable — released only if the doctor asks what going back could look like, rather than how long you need off
• That the bereavement leaflet is in a drawer — released only if asked whether you used any support

Behaviour

• Minute 1: “I'm not sure it matters.” The period.
• Minute 4, only if mood is explored properly: “easier not to wake up”. Otherwise at minute 7 if asked whether there is anything else.
• Minute 6: “Dad needs me.”
• If the doctor names all three problems and orders them, assesses your mood and the risk properly, explains why stopping suddenly made this week worse and restarts the sertraline, says it can continue if you are pregnant, arranges a pregnancy test today and folic acid, negotiates the note (two weeks with a review, or may-be-fit with a phased return) and separates sick leave from failure, offers bereavement support and talking therapy, safety-nets and reviews in one to two weeks: relief, brief tears. “So I don't stop the tablets if I'm pregnant?” and “Can I have a note for two weeks and see you?”
• If the doctor issues the sertraline and a four-week note in three minutes and moves to the period: at minute 8, “I don't think you asked how I actually am.”
• If the doctor stops the sertraline in case you are pregnant: “But I feel awful without it…”
• If the doctor is brisk about the grief: fold the tissue and answer in single words.

Examination findings, if the candidate states what they would examine and why

• Video: no examination today. If the candidate states what they would check and why: you look tired and tearful; you can do a urine pregnancy test at the practice this afternoon or at home tonight; there is no pain, bleeding or faintness.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Issuing the sertraline and a four-week note in three minutes and moving to the period, so that she says “I don't think you asked how I actually am” (statement D5)
• Stopping the sertraline in case she is pregnant (statement C2)
• Asking about thoughts of death with a euphemism she can deflect, or not at all, so that “easier not to wake up” is never heard (statement D1)

What the examiner is listening for in the last four minutes

By 8:00 the three working diagnoses should have been stated: a depressive episode after bereavement with a relapse after an abrupt stop, a possible pregnancy, and passive thoughts of death with protective factors. The examiner is listening for: the sertraline restarted and the pregnancy question answered honestly; the test today and folic acid; the note as a short period with a review or may-be-fit with a phased return; the therapy and bereavement support; the safety plan in her words with the crisis contacts; the review in one to two weeks; and her own words on what she will do this week.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Discontinuation symptoms can occur within days of stopping an antidepressant abruptly, particularly one with a short half-life; a person should not stop an antidepressant suddenly, and a relapse after stopping is managed by restarting and continuing for at least six months after remission. NICE — NG222 Depression in adults: treatment and management, section 1.4, stopping antidepressant medication; section 1.7, preventing relapse, June 2022, checked 10 Oct 2026
2. Ask directly about suicidal ideation and intent in anyone with depression; where there is passive ideation with protective factors, agree a safety plan with crisis contacts, review within a short interval and document the assessment. NICE — NG222 Depression in adults: treatment and management, section 1.3, assessment and risk; section 1.4, safety planning, June 2022, checked 10 Oct 2026
3. A woman taking an antidepressant who becomes pregnant should be advised not to stop it abruptly; discuss the risks and benefits of continuing; sertraline is among the SSRIs with the most data in pregnancy and breastfeeding and continuing is reasonable where the woman has responded to it. NICE — CG192 Antenatal and postnatal mental health: clinical management and service guidance, section 1.4, considerations for women of childbearing potential; section 1.8, treating depression in pregnancy, 2014, last updated February 2020, checked 10 Oct 2026
4. Women planning a pregnancy or who may be pregnant are advised to take folic acid 400 micrograms daily before conception and until the twelfth week; a pregnancy test is positive from the first day of a missed period. NICE — NG201 Antenatal care, section 1.2, information and support in early pregnancy; folic acid, August 2021, checked 10 Oct 2026
5. Grief after bereavement is not itself a disorder; depression is considered when low mood, anhedonia and functional impairment persist and dominate, and bereavement support is offered alongside treatment of depression where both are present. NICE CKS — Depression, diagnosis: differential diagnosis, including bereavement, current online version, checked 10 Oct 2026
6. A fit note can state that the person may be fit for work with adjustments such as a phased return, altered hours or amended duties; a short note with a review supports continuity better than a long absence. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, may be fit for work; adjustments, 2022, updated 2024, checked 10 Oct 2026
7. Offer a psychological intervention (such as CBT or behavioural activation) alongside or instead of an antidepressant for a new episode of moderate depression, taking the person's preference into account; NHS Talking Therapies accept self-referral. NICE — NG222 Depression in adults: treatment and management, section 1.5, treatment for a new episode of less severe and more severe depression, June 2022, checked 10 Oct 2026
8. NG222 grades depression by the PHQ-9: less severe depression is a score below 16 (subthreshold and mild), more severe depression a score of 16 or more (moderate and severe). A PHQ-9 of 17 at diagnosis eleven weeks ago placed this episode in the more severe band, for which an antidepressant with a psychological intervention is offered; the score is repeated at review to measure response and to guide any dose change. NICE — NG222 Depression in adults: treatment and management, terms used in this guideline: less severe and more severe depression; section 1.6, treatment, June 2022, checked 10 Oct 2026
9. Sertraline for depression is started at 50 mg once daily and increased if necessary in steps of 50 mg at intervals of at least one week, to a maximum of 200 mg daily. The BNF advises that an antidepressant is not withdrawn abruptly: when stopping, the dose is reduced gradually over at least four weeks, longer where withdrawal symptoms appear. A woman who has been well on 50 mg restarts at that dose rather than re-titrating. BNF (NICE) — Sertraline, indications and dose; antidepressant drugs: withdrawal, current BNF online, checked 10 Oct 2026
10. At a woman's first contact in pregnancy and at the booking visit, the two depression identification questions and a two-item anxiety scale are asked. A woman with a current or past depressive episode is told that it may recur or worsen in pregnancy or after birth, is monitored through the pregnancy and the first postnatal year, and is offered psychological treatment; an antidepressant she has responded to may be continued after a discussion of risks and benefits, and the perinatal mental health service is consulted where the illness is severe. NICE — CG192 Antenatal and postnatal mental health: clinical management and service guidance, section 1.5, recognising mental health problems in pregnancy and the postnatal period; section 1.4, treatment decisions, 2014, last updated February 2020, checked 10 Oct 2026
11. Where an antidepressant is needed in pregnancy, an SSRI with the most safety data is usually chosen and sertraline is commonly used; paroxetine is avoided in early pregnancy because of an association with cardiac malformations. SSRI use in late pregnancy carries a small risk of persistent pulmonary hypertension of the newborn and of transient neonatal adaptation symptoms, which the maternity team is told about; these risks are weighed against the harm of untreated depression to mother and child. NICE CKS — Depression, antenatal and postnatal, management: prescribing antidepressants in pregnancy, current online version, checked 10 Oct 2026
12. When a pregnancy is confirmed the woman is referred for antenatal care so that the booking appointment takes place by 10 weeks, when the dating scan, screening and the mental health and social history are arranged; folic acid 400 micrograms continues to 12 weeks and vitamin D 10 micrograms daily is advised throughout. The safest approach to alcohol in pregnancy is not to drink at all, and smoking status is asked and cessation support offered. NICE — NG201 Antenatal care, section 1.1, organisation of antenatal care: timing of the booking appointment; section 1.2, information and support, August 2021, checked 10 Oct 2026
13. The Mental health Topic Guide expects the GP to distinguish a bereavement reaction and persistent grief from a depressive episode, to assess suicide risk directly and make a safety plan, to prescribe and withdraw antidepressants safely, and to use fit notes and the principles of return to work. The Maternity and reproductive health Topic Guide expects the GP to recognise perinatal mental health symptoms and to prescribe before and during pregnancy with teratogenesis in mind. RCGP — GP curriculum: Mental health, Topic Guide: knowledge and skills, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 734 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, 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 SCA-13