Cases/Mental Health

First Time Mother Who Says She Is Just Tired — Free SCA Practice Case

First time mother who says she is just tired

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Tessa Abrahams

Age

34 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient.

Reason for Encounter

"I've been very tired since the baby was born. Could we check whether there's a reason?"

Medical Records

●PMH: First baby 9 weeks ago after IVF. Emergency caesarean, blood loss 700 ml, haemoglobin 102 g/L on day 2, no bloods since. No previous mental health diagnosis.
●Medications: None. Breastfeeding.
●Allergies: NKDA.
●Social: Solicitor on maternity leave. Married. Non smoker.

Recent Notes

●Health visitor, 8 week contact: Baby feeding well, weight on centile. Mother "fine, just tired".
●Postnatal check: 6 to 8 week GP check not yet recorded.

Patient Script

For the friend playing the patient role

Character Overview: You are Tessa Abrahams, a 34 year old employment solicitor on maternity leave with your first baby, Florence ("Flo"), nine weeks old. You live with your husband Hugh, a civil engineer. You tried for four years because of blocked fallopian tubes: three rounds of IVF, the first two failing, then Flo. You have never had a mental health diagnosis or taken an antidepressant. Flo arrived by emergency caesarean and you lost a lot of blood, so you half hope you are anaemic, an easy explanation. For five or six weeks you have felt flat, then heavy, then desperate, and you tell everyone you are just tired. You feel you have no right to be unhappy after all it took to have Flo, and you fear that admitting how bad it is will make someone decide you are not fit to look after her. Hugh has taken Flo to the park and thinks this call is about tiredness. Your voice is polite and controlled and wobbles when someone asks how you really are. You open up slowly if the doctor is kind and gives you time.

Opening Sentence: "Hello, thanks for seeing me. I'm just really tired, to be honest. Ever since Flo was born, she's nine weeks now, I've been exhausted, and I wondered if I could have some blood tests to see if I'm anaemic. I lost a lot of blood when she was born."

History if Asked (Data Gathering Phase)

●How she is in herself (first asked in an open way): She deflects. "I'm fine, honestly. Just tired." Asked again, gently, her voice breaks and she is tearful. Only once the doctor has acknowledged the tears and made time does she say: "It's not just tiredness, if I'm honest. I don't know what it is."
●Sleep and tiredness: "Flo wakes about twice a night, and Hugh gives her a formula bottle on Friday and Saturday nights so I get a proper stretch. But I still wake in the early hours and just lie there. When she naps I can't sleep either. I'm exhausted and wired at the same time."
●Mood and timing: "Low, nearly every day. The first couple of weeks I was very emotional, the baby blues they said, and it didn't pass. Around three or four weeks it went flat, and this last month it's got worse. I cry most days, in the shower or once Hugh has left."
●Interest and enjoyment: "I used to run three times a week and I haven't put my trainers on since the birth. When Flo smiles I feel not very much, and then I feel awful about that."
●Appetite, concentration and guilt: "I forget to eat and my jeans are loose. My head's like cotton wool. I feel guilty all the time, as if I'm doing everything wrong."
●Anxiety and coping: "I'm on edge all the time. At night my heart races and I keep getting up to check she's breathing. Flo's fed and clean, but I don't feel like I'm really there."

Ideas, Concerns, Expectations

Gating note: Tessa does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, what she is afraid might happen, or what she was hoping for from the appointment.

●Ideas: She thinks it must be the blood loss. "It can't be anything else, can it? We waited four years. What right have I got to feel like this? I should be grateful."
●Concerns: Her main fear is losing Flo. "If I say how bad it really is, they'll decide I can't cope and take her away. I did a family law seat, and I've seen what gets read out in court." If the doctor explores further: "And I don't want Hugh to think I regret her. I don't. I'd do it all again."
●Expectations: Blood tests, iron tablets, maybe something for energy or sleep, and to be told she is basically fine.

If Asked: Medical History and Medications

Gating note: Tessa answers each of these plainly when the doctor asks about it.

●Birth and bleeding: "They said I lost about seven hundred millilitres, told me to eat iron rich food, and nobody's checked my blood since." Bleeding stopped at about five weeks, the scar is healed, periods have not returned.
●Physical symptoms: A bit breathless on the stairs, which she put down to tiredness. No fever, not hot or cold. Her heart only races at night when she lies awake worrying.
●Past, medicines and family: No previous mental illness; she was low after the second failed round and six counselling sessions helped, "but it never felt like this." No medicines (only paracetamol, ibuprofen and Hugh's vitamin D tablets at home). No allergies. No family history.
●Feeding and lifestyle: Breastfeeds about eight times a day and wants to carry on: "It's the one thing only I can do for her." A glass of wine on a Friday, no smoking or drugs.
●Examination: If asked to examine herself on camera she declines politely and offers to come in to the surgery.

Social History and Lifestyle Impact

●Work and money: She emailed her manager saying she is loving it. The third IVF cycle used most of their savings.
●Home: Hugh works long days and does Flo's bath every evening; Tessa told him her back hurts. "He's so proud of her. I don't want to worry him. He tells everyone I'm doing brilliantly." She feels safe at home.
●Family and friends: Her mother Judith lives in Dorset and rings daily: "Mum says I must be over the moon. I say yes." A friend, Amira, texts; Tessa replies with a smiley face. She has told nobody how she feels.

If Asked: Associated Symptoms

Gating note: Tessa answers these only when the doctor asks about them directly and with some care. If a question about harming herself or the baby comes abruptly and without explanation, she is shaken and says "Why are you asking me that?" before answering, and she opens up once the doctor says why such questions are asked of every new mother.

●Screening questions (feeling down or hopeless; little interest or pleasure): "Yes, nearly every day. Both." If a questionnaire is read out, she answers consistently with a PHQ 9 total of 19 and an EPDS total of 19: most items "more than half the days" or "nearly every day", the self harm item "several days" (EPDS "hardly ever").
●Thoughts of death or hurting herself (asked with care): quietly, "Sometimes at night I think they'd be better off without me, Flo and Hugh, with someone who's good at this. I think it would be easier if I just didn't wake up. It's not that I'd do anything." Plan or intent: "No. I don't think about how. I'd never leave her. I just want it to stop." What keeps her going: "Flo. And Hugh."
●Frightening or unwanted thoughts or pictures about the baby (especially after the doctor explains that many new mothers have them): she goes quiet, then, "I get these pictures. Out of nowhere. Dropping her on the stairs. Her slipping under the water in the bath. I feel sick afterwards. I've told Hugh my back hurts so he does the bath, and I grip the banister when I carry her down." If asked whether she wants to hurt Flo: "God, no. Never. That's why they scare me. I haven't told anyone because they'd think I'm dangerous." If asked bluntly with no explanation: "No! Why would you ask me that?" and answers only once the doctor explains why.
●Bonding and baby: "I love her. I just feel numb a lot of the time, like I'm acting being a mother." Flo is well and gaining weight. "Nobody could say I'm not looking after her."
●Negatives, grouped: no previous self harm; no hearing or seeing things, odd beliefs or confusion ("I know what's real, it's just awful"); never a time of feeling high or needing little sleep.

Responses to Management (The Negotiation Phase)

●
If the doctor says this is an illness, or that it is treatable:
- ●Reaction: Relief and shame together. "So it's an actual illness? But I've got everything I wanted." Asked about recovery, she is steadied by an honest, hopeful answer, not a promise.
●
If the doctor mentions telling someone, such as the health visitor, a perinatal team, her records or social services:
- ●Reaction: Alarmed. "Will that go on her record? Are they going to take her away from me?" If answered honestly and in proportion: "Okay. As long as you'd tell me first." If told "of course not, nothing will happen": "You can't promise that, can you?" About a perinatal team: "Isn't that for people who are really ill? Would I have to go into hospital?" She accepts once told it is a community team that supports mothers at home.
●
If the doctor offers talking therapy, an antidepressant or both:
- ●Reaction: Therapy interests her: "Could it be on video?" A tablet makes her cautious: "Will it go into my milk? I don't want to stop feeding her." Once told she can carry on breastfeeding and that Flo would be watched, she asks: "How long does it take to work? Will it make me worse at the start?" If told to stop breastfeeding: "I can't. I'd rather not take anything."
●
If the doctor suggests involving Hugh, or that he does one more night feed:
- ●Reaction: "I don't want him to think I regret her. Could you help me say it?" If offered a joint appointment: "Maybe. Could he come to the next one?" On an extra night feed she hesitates, then agrees.
●
If the doctor gives vague safety netting such as "come back if it gets worse", or asks about the night:
- ●Reaction: "It's the nights. The early hours, when it's all going round. I don't know who I'd even ring." She is reassured by named numbers, a review within about a week, and by saying her plan back.
●
If the doctor suggests A&E or hospital now:
- ●Reaction: Frightened and hurt. "Now? Because of what I've told you? I'm not going to do anything. If I go to A&E, will they take her?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Tessa books for tiredness and asks for blood tests, but cries when asked how she is. The skill is hearing the tears, looking beneath "just tired" while still taking the physical explanation seriously, and making a safe decision about a mother with death wishes and frightening thoughts who fears the truth will cost her Flo.
●Model answer: postnatal depression of at least moderate severity (PHQ 9 and EPDS both 19) with anxiety, unwanted intrusive images and passive thoughts of death, no psychosis and no bipolar features, baby well. Manage in the community with an early review, blood tests that do not delay treatment, a shared choice of therapy, a tablet or both, continued breastfeeding, the health visitor or perinatal team involved with her agreement, an honest answer about her fear of losing Flo, and a specific safety net.
●Also acceptable: therapy first with an explicit review; sertraline or paroxetine; a next day or same week review in person or by video; a perinatal advice call or referral, or primary care management naming the point at which perinatal advice would be sought.

Finding the Depression Beneath the Tiredness

●NICE CG192 (Antenatal and postnatal mental health) says to recognise that women may not disclose perinatal mental illness because of stigma, fear of being judged as a mother, or fear that the baby will be taken into care. Tessa fits all three.
●Ask the two identification questions (feeling down, hopeless or depressed, and little interest or pleasure, over the past month). Either positive answer calls for fuller assessment, such as the EPDS or PHQ 9. A questionnaire is not required, and a score is not a diagnosis.
●Tessa has low mood and loss of interest nearly every day, tearfulness, early waking, weight loss, poor concentration, guilt, anxiety and numbness. A PHQ 9 of 16 or more is more severe depression, and any positive self harm item needs a direct risk assessment.
●Assess past mental health, the mother and baby relationship, support, alcohol and drugs, safety at home and family history of severe perinatal illness.

Differential Diagnosis and Physical Contributors

●Baby blues appear around day 2 or 3 and usually resolve within about 2 weeks. Low mood that begins at three to four weeks and worsens, as Tessa's did, is not baby blues.
●Postpartum psychosis is rare, usually starts suddenly in the first two weeks, and presents with severe mood swings, delusions, confusion or hallucinations. It is an emergency needing assessment within 4 hours. Always ask; Tessa has none of it.
●Ask about unusually high, irritable or sleepless energy to consider bipolar disorder, which would need urgent specialist referral.
●Unwanted intrusive images of harm to the baby are a recognised feature of perinatal obsessive compulsive disorder and can accompany depression. The distinction from psychosis is insight: Tessa finds the images horrifying, avoids what triggers them and has no urge to act.
●Physical causes: with a 700 ml blood loss, a haemoglobin of 102 g/L on day 2 and no iron, a full blood count, ferritin and thyroid function are indicated. NICE Clinical Knowledge Summaries (CKS) suggest checking blood count and thyroid function where fatigue predominates. Treatment should not wait for results.

Risk: Thoughts of Death Versus Intrusive Images

●Ask plainly and kindly, and say why these questions are asked of every new mother. Asked abruptly, she says no and the images stay hidden.
●Tessa has passive thoughts that Flo and Hugh would be better off without her, no plan or intent, no previous self harm, only paracetamol and ibuprofen at home, clear protective factors and no psychosis. NICE NG225 (self harm) advises against low, medium or high labels to decide who is treated and asks for a risk formulation instead: describe plan, intent, protective factors and what would change the decision.
●That supports community treatment, not complacency. The thoughts need a safety plan, an early review and clear escalation triggers: a plan or intent to end her life, any urge to harm Flo, or hallucinations, delusions or confusion mean 999 or A&E the same day.
●Unwanted images that horrify the mother, that she avoids and has no urge to act on are a symptom to treat, not child protection evidence. They need urgent assessment with psychotic symptoms, if she does not find them distressing or feels they are justified, if she plans or acts on them, or if she cannot look after the baby.

The Fear That Flo Will Be Taken Away

●This fear is the hidden agenda. A mother who describes depression or intrusive thoughts is not by that fact a safeguarding concern; local protocols apply where there is a risk of maltreatment, and Tessa cares well for Flo.
●Answer honestly and in proportion. Do not promise that nothing will ever happen. Say that asking for help is right, that support comes first, that the record will be accurate, who will be told and why, and that children's services would only become involved if Flo were at risk of harm.
●Share information with the health visitor or perinatal team after telling her who and why, and asking her agreement. General Medical Council (GMC) confidentiality guidance says relevant information may be shared with those providing direct care unless the patient objects, and an objection should not be overridden unless disclosure is justified in the public interest, in which case she should be told where possible.
●Offer help telling Hugh at her pace, such as a joint appointment.

Treatment and Breastfeeding

●For moderate to severe postnatal depression, offer high intensity psychological therapy such as CBT, an antidepressant, or both together, agreed with her. CG192 puts therapy first, while NICE NG222 (Depression in adults) ranks CBT with an antidepressant first and allows all options first line, so any shared choice is correct. Therapy should be assessed within about 2 weeks and begin within about a month, local waits permitting; NHS Talking Therapies accepts self referral.
●Most antidepressants can be used while breastfeeding, but none is licensed specifically for it, so discuss the choice and document her consent. Sertraline and paroxetine are the SSRIs of choice, with sertraline generally preferred. Asking the perinatal team or UKDILAS (UK Drugs in Lactation Advisory Service) also passes. The BNF depression dose for sertraline is 50 mg once daily initially, in steps of 50 mg at least a week apart to 200 mg, and a lower first dose is not penalised.
●Use one drug at the lowest effective dose and watch Flo for drowsiness, poor feeding, weight gain, gut upset, irritability and restlessness.
●Warn about early anxiety, agitation and suicidal thoughts, review within 1 week where there is particular concern about suicide risk (otherwise 2 weeks), and explain that benefit usually takes up to 4 weeks and treatment continues for at least 6 months after remission. Do not withhold treatment because of suicide risk.

Perinatal Services, Follow Up and Safety Net

●Referral to secondary care, preferably perinatal, is required for severe mental illness or a history of it, and for urgent concerns such as considerable immediate risk, severe self neglect, possible bipolar disorder or inability to look after the baby. Tessa meets none of these, so a perinatal call or referral strengthens the plan but is not required. Telling no other professional and naming no point for specialist advice is not defensible.
●A perinatal team supports mothers at home; a mother and baby unit is for much more severe illness, and Tessa should be told so if she asks. This appointment is also the chance to complete her 6 to 8 week postnatal check.
●A good safety net is specific: 999 or A&E for a plan or intent to end her life, any urge to harm Flo, hallucinations or confusion; NHS 111 (mental health option) or a same day GP appointment if the dark thoughts grow or she cannot care for herself or Flo; Samaritans on 116 123 at any time.
●Book the review before the call ends. Ask Tessa to say what she would do in the middle of the night, because an unrehearsed list of numbers is easily forgotten. Peer support (PANDAS) and a longer block of sleep also help.

Common Candidate Mistakes in This Station

●Accepting "just tired" and ordering blood tests without asking about mood.
●Asking the risk questions abruptly, so she says no and the images and night thoughts never emerge.
●Treating the intrusive images as proof of intent, escalating to emergency services or children's services, and confirming her worst fear.
●Promising that nothing will happen, instead of an honest, proportionate answer.
●Telling her to stop breastfeeding, or prescribing without discussing it.
●Offering no treatment, or iron and sleep advice alone, to a woman with a PHQ 9 of 19.
●Telling her to be grateful after IVF, or leaving the guilt unanswered.
●Vague safety netting with no night time plan and no booked review.
●Telling no other professional and naming no point for specialist advice.

Mapped to the RCGP curriculum topic: Mental Health.

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