When CBT Fails: Depression Case in PLAB 2

Summary:

This scenario involves a patient presenting with depression who reports that their cognitive behavioural therapy (CBT) is ineffective. The aim is to assess the severity of the depression, rule out serious risks like self-harm or psychosis, and provide appropriate management options including medical, psychological, and lifestyle interventions.

Key Points:

Mental Health Assessment

• Focus on the current state of depression, not the detailed mechanics of CBT failure.

• Assess severity using core symptoms:

  • Mood (low or fluctuating)

  • Anhedonia (loss of interest or pleasure)

• Explore associated symptoms:

  • Guilt

  • Self-worth issues

  • Fatigue

  • Sleep disturbances

• Rule out suicidal ideation or self-harm, regardless of depression severity.

• Investigate psychotic features if severe depression is suspected:

  • Hallucinations or delusions

  • Paranoia or irrational beliefs

Risk Factors & History

• Ask about:

  • Family history of depression

  • Substance abuse (notably alcohol)

  • Previous episodes of depression or psychiatric illnesses

  • Recent stressors or life changes

  • Current and past medications (especially if stopped recently)

Important Considerations:

• Crisis planning is crucial for patient safety; use the term explicitly.

• Safety netting: Always provide a plan for worsening symptoms or emergent crises (e.g., helpline numbers, emergency services).

• Offer leaflets and pamphlets covering diagnosis, treatment options, lifestyle modifications, and support resources.

• Maintain empathetic but structured communication to ensure focus and patient-centred care.

Diagnostic Approach:

1. Confirm presence of low mood and anhedonia.

2. Screen for associated depressive symptoms.

3. Rule out:

   • Suicidal or self-harming ideation

   • Psychotic symptoms

4. Evaluate impact on daily functioning.

5. Assess contributing factors:

   • Substance misuse

   • Social isolation

   • Medical history

   • Medication changes

Management:

Immediate Management

• Reassure and validate the patient’s feelings.

• Explain the diagnosis of moderate depression.

• Address any misunderstandings about treatment response.

Pharmacological

• Consider starting antidepressants (e.g., SSRIs):

  • Explain that effects may take 4–6 weeks.

  • Discuss potential side effects (including sexual dysfunction).

  • Offer shared decision-making and ask about concerns.

Psychological

• Offer more intensive CBT or alternative therapy options if standard CBT failed.

• Consider referral to psychiatry for complex or resistant cases.

Non-Medical Management

• Recommend lifestyle changes:

  • Reduce or eliminate alcohol (address coping mechanism)

  • Reintroduce pleasurable activities (e.g., football)

  • Encourage physical activity and routine

• Explore options for family therapy or support groups

Follow-Up

• Arrange timely follow-up to assess response and adherence.

• Provide written safety and educational materials.

Communication Skills:

• Validate patient experiences and maintain empathy.

• Avoid overused or rehearsed phrases; personalize responses.

• Use open-ended questions, e.g., “What concerns do you have about starting medication?”

• Regularly check understanding.

• Maintain structure in consultation with clear transitions.

Ethical Considerations:

• Maintain confidentiality and professional boundaries.

• Use crisis planning for suicide prevention in line with Good Medical Practice guidelines​.

• Avoid overpromising or making unrealistic assurances.

Additional Resources:

• NHS Depression Leaflets

• NICE Guidelines: Depression in adults

• GMC’s Good Medical Practice and ethical guidance​

• Examiner insights on psychiatric station preparation and safety netting​​