You are an FY2 in GP

Personal Details:

Name: David Chen

Age: 40

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

David presents with a six-month history of poor sleep. He reports difficulty falling asleep and waking up after only a few hours, feeling tired all the time. The problem started after his divorce.

Task:

1. Take a history.

2. Discuss the diagnosis and formulate a management plan.

Opening Sentence: “Doctor, I just can’t sleep anymore. I’m exhausted all the time.”

Open History (to give freely): “It’s been about six months now, ever since my divorce. I go to bed, but my mind just races. When I do fall asleep, I’m awake again at 3 AM and can’t get back to sleep. I’m so tired it’s affecting my work.”

Cues to give: “There just doesn’t seem to be any point to anything anymore.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think it’s just stress from the divorce.”

Concerns: “Am I ever going to feel normal again? I’m worried I’ll lose my job if I can’t function properly.”

Expectation: “Can you just give me some sleeping pills to get me through this?”

How to Act: You appear flat, tired, and withdrawn. You make little eye contact and speak in a monotone. You seem hopeless.

More History (only if asked): You have lost interest in everything you used to enjoy, like playing football and seeing friends. You feel guilty about the divorce, blaming yourself. Your appetite is poor. You have started drinking a bottle of wine most nights to try and help you sleep, and your smoking has increased. You live alone and have isolated yourself from family and friends. When asked directly about suicide, you admit that you have thought about it. You have bought some paracetamol with the thought of taking an overdose, but have not made a concrete plan or tried to act on it.

Social History:

Occupation: Works in a shopping centre.

Living situation: Lives alone.

Substance use: Increased alcohol and smoking.

Questions to ask:

“So you’re not going to give me any sleeping pills?”

“Do I have to take antidepressants?”

History of Insomnia:

You’ve come in because of poor sleep. Tell me more about that. Is the problem getting to sleep, staying asleep, or waking up too early? When you wake up, what’s going through your mind?

Screening for Depression (PHQ- components): “Over the last month, how have you been feeling in yourself? Have you been feeling low or down? Have you lost interest or pleasure in doing things you normally enjoy? How is your appetite? Have you noticed any change in your weight? How is your concentration? Have you been feeling hopeless about the future?

Risk Assessment (Crucial Step): Sometimes, when people feel this way, they can have dark thoughts. Have you had any thoughts that life is not worth living, or of harming yourself in any way? (If yes) Have you made any specific plans to act on these thoughts? What stops you from acting on them?

 Social Context: Has anything happened recently that might have triggered these feelings? Any major life events or stresses? Who do you have at home for support?

ICE (Ideas, Concerns, Expectations):

What did you think was causing the sleep problem? What are you most worried about?

You mentioned wanting sleeping pills. What are your thoughts on other treatments, like talking therapies or antidepressants?

Explain the situation, the likely diagnosis:

David, thank you for telling me all of this. It sounds like you’ve been going through an incredibly difficult time. The sleep problem you’re describing isn’t just a simple case of insomnia. The poor sleep, feeling tired, losing interest in things, and the feelings of guilt are all classic symptoms of depression. It’s a very common illness, especially after a major life event like a divorce.

Addressing and answering the patient’s ICE:

You’re worried about feeling normal again, and I want to reassure you that with the right help, you absolutely can. You asked for sleeping pills, and while they might seem like a quick fix, they don’t solve the underlying problem, which is the depression. They can also be addictive. A much better approach is to treat the depression itself, and as your mood improves, your sleep will too.

Next Steps:

The most important thing I’ve heard today is that you’ve had thoughts of harming yourself. I’m very glad you told me this. It takes great courage. Because you are having these thoughts, we need to act today to keep you safe and start your recovery. I would like to refer you urgently to our local mental health team, the Crisis Team. They can provide intensive support straight away. They can offer you cognitive behavioural therapy, which is one of the most effective ways to help you with your mood and improve your depression.

Self-help measures:

The alcohol you’re drinking to help you sleep is actually making things worse. It might help you fall asleep initially, but it disrupts the quality of your sleep later in the night, which is why you’re waking up. We can support you in cutting down. Setting up a regular sleep patter which we call sleep hygiene help you to sleep better. I will send you more information to help you do that.

Possible medication:

I would also like to start you on an antidepressant medication. These are not sleeping pills; they work by gradually correcting the chemical imbalances in the brain that cause depression. They can take a few weeks to start working. (e.g. sertraline 50mg OD). They are often well tolerated, but occasionally make people feel more stressed in the first few days, and occasionally cause stomach upset, but these side effects quickly settle. If it’s causing you intolerable side effects of suicidal thoughts, please let us know.

The combination of medication and support from the mental health team is the most effective way to treat depression.”

Addressing ideas, concerns, and expectations: Explain the diagnosis of depression. Gently refuse the request for sleeping pills and explain why. Manage expectations about the timeline for recovery.

The key management step is an urgent referral to the Crisis Team due to the active suicidal ideation. Discuss starting an antidepressant (e.g., an SSRI like Sertraline). Provide safety netting (e.g., who to call if he feels unsafe before the Crisis Team makes contact).

What is scenario testing? This case tests the candidate’s ability to recognise that a simple presenting complaint (insomnia) can be a symptom of a serious underlying mental health condition. The most critical skill is performing a structured and empathetic suicide risk assessment and taking appropriate, immediate action based on the findings. It also tests knowledge of the management of depression.