PLAB 2 Psychiatry: Mastering the Depression OSCE Station

Ask any PLAB 2 candidate which stations they feared most, and a psychiatric presentation is almost always near the top of the list. Depression stations appear in candidate recall after recall — not because examiners lack imagination, but because a low-mood consultation quietly tests everything PLAB 2 exists to measure: structured history taking, direct-but-compassionate risk assessment, guideline-driven management, and genuine empathy under time pressure.

This guide gives you a complete, reproducible system for any depression-themed station — from your opening question to the final safety-net.

Why Depression Is Such a High-Yield Station

• One presentation, all three marking domains. A single low-mood consultation generates marks for data gathering, management and interpersonal skills simultaneously.

• Blueprint-friendly. Mental health presentations are core PLAB 2 content, and depression is the most common psychiatric condition you will encounter in UK general practice.

• A spectrum of difficulty. The same stem can serve as a simple history-taking station (fit for a nervous beginner) or a high-stakes risk-management station (sorting strong candidates from outstanding ones) — just by changing one line in the instructions.

The Four Faces of the Depression Station

Most depression stations in PLAB 2 are one (or a blend) of these formats:

1. Pure history taking — 'Ms Ahmed, 24, attends with low mood. Take a history and present your findings to the examiner.'

2. New diagnosis discussion — the patient already knows the diagnosis or you deliver it, then explore concerns and agree management.

3. Medication counselling — starting, reviewing or stopping an antidepressant.

4. Risk-focused consultation — suicidal ideation, self-harm, or intrusive thoughts in a postnatal mother.

Recognising the format within the first seconds of reading time dictates where your eight minutes should go.

Use Your Reading Time Like a Blueprint

Before you enter, extract three things from the stem:

• The age and sex. A 24-year-old with relationship breakdown suggests adjustment-triggered depression and an antidepressant-with-psychological-therapy discussion. A 70-year-old with weight loss and early-morning waking demands an organic screen (malignancy, hypothyroidism, anaemia) alongside the psychiatric review.

• The setting. GP surgery allows routine follow-up planning. Emergency department or out-of-hours shifts the station towards risk containment and escalation.

• The final sentence. 'Address her concerns', 'discuss management' or 'present to the examiner' tells you exactly how the last two minutes must be spent.

Your 8-Minute Skeleton

Drill this skeleton until it is muscle memory. Under adrenaline, structure is what survives.

Data Gathering: The Screen That Scores

The ICD-10 core triad

Establish, for at least two weeks:

1. Persistent low mood — most of the day, nearly every day

2. Anhedonia — loss of interest and enjoyment

3. Fatigability — reduced energy

Then sweep the wider symptom set: sleep disturbance (early-morning waking points to more severe depression), appetite and weight change, impaired concentration, loss of libido, guilt, worthlessness, hopelessness, diurnal variation, psychomotor retardation or agitation.

Ask ICE early

'Ideas, concerns and expectations' are not box-ticking. In depression stations they frequently hand you the ending: the patient who says 'I don't want tablets — my mother became dependent on them' has just told you your management discussion must lead with psychological therapies and myth-busting.

The Risk Ladder — Where Stations Are Won or Lost

The fastest way to fail a depression station is to leave the room without asking about suicidal thoughts.

Asking directly does not plant ideas — this is evidence-based and examiner-approved. Climb the ladder smoothly:

1. 'Sometimes when people feel this low, they feel life isn't worth living. Have you had thoughts like that?'

2. 'Have you had any thoughts of harming yourself, or of ending your life?'

3. 'Have you thought about how you might do it?' (plan — escalates risk)

4. 'Have you done anything to prepare, or acted on those thoughts?' (intent and means — highest risk)

5. 'What has stopped you so far?' (protective factors — children, faith, future plans)

Then complete the picture: previous self-harm or attempts, alcohol and drug use, thoughts of harming others, recent losses or stresses, and — critically — who depends on this patient. Children at home converts a clinical assessment into a safeguarding conversation.

Finish with a one-line risk formulation for the examiner or patient: risk is low/moderate/high because of intent, plan, means, protective factors and supports.

The Screens That Separate Good From Excellent

• Bipolar switch. 'Have you ever had periods of several days where you felt unusually high — full of energy, needing little sleep, spending more than usual?' Prescribing an SSRI to an undiagnosed bipolar patient can precipitate mania — asking this question is a mark-scoring discriminator.

• Psychotic features. Mood-congruent delusions (guilt, poverty, nihilism) or hallucinations define psychotic depression, which needs urgent specialist referral.

• Organic mimics. Hypothyroidism, anaemia, B12 and vitamin D deficiency, malignancy, steroids, isotretinoin, and alcohol or substance misuse.

• Postnatal red flags. Any presentation within a year of delivery — screen with the Edinburgh Postnatal Depression Scale and always ask about thoughts of harming the baby, which demands same-day urgent perinatal mental health input.

• Cognitive screen in older adults. Dementia versus pseudodepression/pseudodementia.

Investigations: Short, Confident, Correct

For a first presentation in general practice: FBC, U&E, LFTs, TFTs, glucose/HbA1c, calcium, plus B12/folate and vitamin D where clinically suggested. Request an ECG if you plan citalopram (QT prolongation — maximum 40 mg) or the patient has cardiac disease. Use the PHQ-9 to grade severity and monitor response — but remember it supports, never replaces, clinical judgement.

Management: The NICE Stepped-Care Ladder

NICE NG222 (2022) simplified the language into less severe and more severe depression, and emphasises patient choice:

Do not recommend St John's wort — variable potency and dangerous interactions with anticoagulants and oral contraceptives is a classic examiner question.

Your 60-Second Antidepressant Script

• Why: 'Sertraline can help lift mood and restore sleep and interest.'

• Timeline: 'Side effects like nausea or headache often come first; benefit usually builds over two to four weeks.'

• Review: 'I'd see you within one to two weeks — sooner because of your age/our concerns today.'

• Duration: 'Once you're better, we continue for at least six months to prevent relapse — longer after repeated episodes.'

• Cautions: never stop abruptly (discontinuation symptoms — taper over at least four weeks); watch for hyponatraemia in older adults; caution with NSAIDs/anticoagulants (bleeding); report new agitation or worsening thoughts urgently (activation risk in young adults).

• Non-drug layer: sleep hygiene, regular exercise, reducing alcohol, addressing social stressors, social prescribing.

When to Escalate — and How to Say It

Escalate urgently when there is active suicidal intent, a lethal plan or means, psychotic features, severe self-neglect, or thoughts of harming an infant. Your toolkit: crisis resolution and home treatment team referral, same-day liaison psychiatry via A&E if risk is immediate, the local 24/7 crisis line (in England, NHS 111 and select the mental health option), and Samaritans (116 123) as a safety-net number the patient takes home. Mention ECT only as a specialist option for severe, life-threatening or treatment-resistant depression.

For any at-risk patient, leave the station with a safety plan: agreed means restriction, who they will call, and when you will review — ideally next day.

How Marks Map to the Three Domains

Communication Moves That Lift Your Band

• Open with the patient's words. 'You mentioned feeling like a failure — tell me more about that.'

• Silence is a skill. After a risk question, wait. Patients fill silence with the truth.

• Validate before you investigate. 'That sounds incredibly difficult — thank you for telling me' earns marks no checklist can capture.

• Handle the bomb calmly. If a patient says 'I've been thinking of ending it all', do not visibly flinch and do not rush to management — explore, formulate, then act.

• Signpost transitions. 'I'd now like to ask some questions that might feel a little personal — is that okay?'

• Check understanding and share decisions. 'We could try therapy, medication, or both — what feels right for you?'

Ten Pitfalls That Fail Good Candidates

1. Never asking directly about suicide

2. Prescribing an antidepressant without screening for mania

3. Forgetting the children at home — safeguarding is not optional

4. Missing alcohol as both cause and maintenance of low mood

5. Leading with medication when the patient wants talking therapy

6. No review interval, no crisis plan, no safety netting

7. Jargon: 'SSRI-induced hyponatraemia' instead of 'this can occasionally upset your blood salts'

8. Mechanical empathy — the scripted head-tilt without warmth

9. Ignoring the postnatal trigger in any woman who has recently delivered

10. Stopping an antidepressant abruptly in a counselling station — always taper

Build Your Practice Loop

Rotate these scenario variants against the same skeleton until each becomes automatic:

• 24-year-old, six weeks of low mood after a breakup — history plus less-severe management

• 58-year-old man, weight loss and early-morning waking — organic screen alongside mood assessment

• Mother four weeks postpartum with intrusive thoughts about her baby — urgent risk and perinatal referral

• 19-year-old started on fluoxetine, more agitated at day five — activation risk review

• 70-year-old on sertraline for eight months, wants to stop — discontinuation counselling

• Patient refuses all treatment — shared decision-making under pressure

Practise timed, eight-minute runs, record yourself, and self-audit against the skeleton table. AI patient simulators excel precisely here: unlimited repetitions of the risk ladder — the part most candidates under-rehearse — with instant feedback on both content and empathy, before you spend a partner's goodwill on your fifteenth depression station of the week.

The Final Word

Depression stations reward candidates who combine a framework with humanity. Learn the skeleton until it is second nature, so that on exam day your conscious attention is free for the only thing that cannot be scripted — making a distressed person in a plastic chair feel genuinely heard, while quietly and competently keeping them safe.

Master that combination, and the depression station stops being the one you fear — and becomes the one you walk in hoping for.