Low Mood After A Bereavement Who Is Drinking to Cope — Free SCA Practice Case

Character Overview: You are Emma, 32, around 20 weeks pregnant with your second child. Your mother died suddenly six weeks ago and you have been overwhelmed with grief and low mood. You have been drinking wine in the evenings to cope and to sleep, which you feel guilty about. You are tearful and low, but you are not in acute crisis. You have come because you feel you cannot go on like this and think antidepressants might help. You will engage honestly if the doctor is warm and non-judgemental.

Opening Sentence: "Hi Doctor. I'm sorry… [tearful] … I've just not been coping. My mum died six weeks ago, really suddenly, and I've been in a terrible state. I'm about twenty weeks pregnant, and I've been drinking in the evenings to get through, which I know I shouldn't. I think I need to go on antidepressants."

History if Asked (Data Gathering Phase)

• ●Mood: "I'm low all the time, crying a lot, can't enjoy anything. I feel exhausted but I can't sleep. I feel like I'm failing — at being pregnant, at everything."
• ●The bereavement: "My mum died six weeks ago, out of the blue. We were really close. I haven't been able to take it in."
• ●Alcohol: "I've been having a few glasses of wine most evenings — three or four glasses maybe — to numb it and to sleep. I feel awful about it because I'm pregnant."
• ●Function: "I'm just about getting through the days. I've a three-year-old to look after, and I feel guilty I'm not being a proper mum to him either."
• ●Why she wants medication: "I just want to feel better. I thought antidepressants might be the answer."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Emma thinks she is depressed and that antidepressants are what she needs; she is unsure whether her drinking is a separate problem or part of the same thing, and is racked with guilt about it. "I think I'm depressed and need tablets. And I know the drinking is wrong in pregnancy — I feel so guilty, but it's the only thing that numbs it."
• ●Concerns: She is worried she is harming the baby with the alcohol, worried she is a bad mother, and frightened by how low she feels. When gently explored, she admits to fleeting thoughts that she "can't go on," but no intent to act and no thoughts of harming the baby. "I'm scared I've hurt the baby with the drinking. I feel like a terrible mum. And honestly, sometimes I feel like I can't go on — though I'd never do anything, and I'd never hurt the baby."
• ●Expectations: She wants to feel better and expects antidepressants; she is open to help. "I want to feel human again. I came expecting antidepressants, but I'll take whatever help there is."

If Asked — Mental-Health, Risk, and Alcohol Assessment (approached sensitively)

The patient answers these only when directly and sensitively asked.

• ●If asked about low mood, anhedonia, sleep, appetite, energy, concentration: "Low all the time, no pleasure in anything, terrible sleep, no appetite, no energy, can't concentrate."
• ●If asked about guilt/worthlessness/hopelessness: "I feel worthless and guilty, and pretty hopeless about the future right now."
• ●If asked, sensitively, about thoughts of self-harm or that life isn't worth living: "Sometimes I feel like I can't go on… but I wouldn't act on it. I have my little boy and the baby. I'd never do anything." (Passive thoughts, no intent or plan, protective factors present. The candidate should assess this sensitively; no method detail is sought or given.)
• ●If asked about thoughts of harming herself or the baby: "No — never anything like that. I love this baby."
• ●If asked about how much and how often she drinks / dependence features: "Three or four glasses of wine most evenings for the last few weeks. I don't drink in the day, no shakes or anything, I could stop — I just haven't managed to."
• ●If asked about support network: "My partner tries, but he's grieving too. My mum was my main support, and now she's gone."
• ●If asked about previous mental-health problems: "A bit low years ago after my first baby, but nothing diagnosed or treated."
• ●If asked about grief-specific support / how she's processing the loss: "I haven't had any support with the grief. I've just been bottling it up and drinking."

Responses to Management (The Negotiation Phase)

• ●If the Doctor assesses mood and distinguishes grief from depression: "So is this grief, or depression? Does it matter which?" (The tested point is assessing severity and functional impact and recognising a depressive illness complicating bereavement, rather than dismissing it as 'just grief'.)
• ●If the Doctor addresses the alcohol: "I know I shouldn't drink pregnant. I just can't cope without it in the evenings. Can you help me stop?" (The tested point is non-judgemental alcohol-in-pregnancy counselling and support, assessing dependence and advising safely.)
• ●If the Doctor discusses treatment options including therapy and possibly medication: "So it's not just tablets? What about the antidepressants I came for — can I even take them pregnant?" (The tested point is discussing psychological therapy and, where appropriate, a safe antidepressant, as a shared decision, and perinatal referral.)
• ●If the Doctor expresses concern about her low mood and safety: "You don't need to worry — I'd never actually do anything. But I do feel very low."
• ●If the Doctor suggests perinatal mental health referral and support: "Would that help? I don't really know what support is out there."