History Taking · Intermediate · Psychiatry

Low Mood Unresponsive to Therapy

Practise this PLAB 2 history taking station on Major Depressive Disorder. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in primary care. Halima Makinde, a 34-year-old woman, has come to see you because she has been feeling depressed for the past two years. She has completed a course of cognitive behavioural therapy but her mood has not improved. Please take a focused history of her depression and discuss medication options with her.

Background notes: PMH: Occasional migraines, History of depression x2 years post-divorce

What this station tests

  • Reassessing diagnosis before escalating treatment: screen for bipolar, anxiety, PTSD, thyroid
  • Dose adequacy check: sertraline 50mg for 8 weeks may be subtherapeutic, titrate before switching
  • NICE stepped care escalation: increase dose, switch SSRI, switch class, then specialist referral
  • Combined medication plus CBT: more effective than either alone for moderate-severe depression
  • Addressing psychosocial factors: divorce, single parenting, financial stress alongside pharmacotherapy

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Depression unresponsive to initial treatment requires reassessment of the diagnosis, review of current treatment adequacy, and escalation. Halima is 34, divorced, two children, on sertraline for 8 weeks with minimal improvement. She is frustrated and losing hope. Open with: 'Halima, I can hear how difficult this has been. Tell me how things have been since we started the sertraline.'

Core approach

Reassess before escalating. Is the diagnosis correct? Screen for bipolar (any hypomanic episodes?), anxiety disorder, PTSD, substance misuse, thyroid dysfunction. Is the dose adequate? (Sertraline starting dose is 50mg, therapeutic range up to 200mg. If she is on 50mg after 8 weeks with minimal response, increasing the dose is the first step.) Is she taking it consistently? (Adherence check.)

Assess current severity with PHQ-9. Functional impact: work (struggling as a teacher), parenting (feeling guilty about her children), social withdrawal. Suicidal ideation: screen at every review.

Her divorce 2 years ago and single parenting are contributing psychosocial factors. Is she accessing any talking therapy? (CBT or counselling should be offered alongside medication for moderate-severe depression per NICE.) She declined initially but may be more receptive now.

Closing and safety netting

Stepped escalation per NICE. Step 1: increase sertraline dose (titrate up, allowing 4 to 6 weeks at each dose). Step 2: if maximum dose ineffective, switch SSRI (e.g., to fluoxetine or citalopram) or switch class (venlafaxine, mirtazapine). Step 3: if two adequate trials fail, refer to psychiatry for specialist input (augmentation strategies, combination therapy).

Offer talking therapy alongside: CBT has strong evidence combined with medication. Practical support: is she accessing any help with childcare, finances, housing? Social prescribing. Safety net: if mood worsens significantly, suicidal thoughts develop, or she cannot manage the children, contact urgently. Follow-up in 4 weeks after dose increase.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for major depressive disorder. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Diagnosis reassessed (bipolar, anxiety, thyroid). Dose adequacy checked. Adherence confirmed. PHQ-9 repeated. Suicidal ideation screened.

Costs marks: Not reassessing diagnosis. Not checking dose. Not screening suicidality.

Domain 2 (Primary focus)

Scores well: Dose increase as first step. Switching pathway known. Psychiatry referral criteria. CBT offered. Social prescribing.

Costs marks: Switching before dose optimisation. No CBT. No psychiatry escalation pathway.

Domain 3 (Throughout)

Scores well: Validating her frustration. Providing hope about treatment options. Acknowledging the difficulty of single parenting while depressed.

Costs marks: Dismissing frustration. Not providing hope. Being purely pharmacological.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Switching medication before optimising dose: increasing sertraline from 50mg before trying a different drug
  2. Not reassessing the diagnosis: 'treatment-resistant depression' may actually be bipolar, anxiety, or thyroid dysfunction
  3. Not offering talking therapy: medication alone is less effective than combined treatment for moderate-severe depression

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the major depressive disorder history in this PLAB 2 station?

Depression unresponsive to initial treatment requires reassessment of the diagnosis, review of current treatment adequacy, and escalation. Halima is 34, divorced, two children, on sertraline for 8 weeks with minimal improvement. She is frustrated and losing hope.

What are examiners marking in this major depressive disorder station?

Marks are won for: Diagnosis reassessed (bipolar, anxiety, thyroid). Dose adequacy checked. Adherence confirmed. PHQ-9 repeated. Suicidal ideation screened. Marks are lost for: Not reassessing diagnosis. Not checking dose. Not screening suicidality.

What is the most common mistake candidates make in this major depressive disorder station?

Switching medication before optimising dose: increasing sertraline from 50mg before trying a different drug. Another frequent error: Not reassessing the diagnosis: 'treatment-resistant depression' may actually be bipolar, anxiety, or thyroid dysfunction.

How do I prepare for this station if I have not managed major depressive disorder in clinical practice?

Structure beats experience here. Focus on dose adequacy check: sertraline 50mg for 8 weeks may be subtherapeutic, titrate before switching. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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