Cases/Mental Health

Low Mood and Money Worries Who Refuses Talking Therapy — Free SCA Practice Case

Farmer with low mood and money worries who refuses talking therapy

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

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Alan Beattie

Age

54 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've been really low for months. I don't want counselling — I've not got the time or the patience for it. I just want some tablets to sort me out."

Medical Records

●PMH: Nil significant. No prior mental-health diagnosis.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations. Rarely attends.

Patient Script

For the friend playing the patient role

Character Overview: You are Alan, a 54-year-old hill farmer. You are stoical and not one for talking about feelings — it has taken a lot to book this appointment. You have been low for months, weighed down by the farm's finances, which are dire. You are dismissive of "counselling" — you think it is a waste of time and you have none to spare. You want antidepressants to get you back on your feet. You will engage honestly if the doctor is respectful and does not push therapy at you; you are quietly desperate underneath the gruffness.

Opening Sentence: "Right, well… I'll be honest, Doctor, I don't do this sort of thing. But I've been really low for months now — no interest in anything, not sleeping, snapping at the wife. The farm's in a bad way financially and it's grinding me down. I don't want counselling, I've heard it's just talking in circles. I want some tablets to get me right."

History if Asked (Data Gathering Phase)

●Mood: "Low most of the time, for months now. No interest in things I used to enjoy — I've stopped going to the market, seeing the few mates I've got. I feel flat and worn out."
●Sleep: "Terrible. I wake at 3 or 4 in the morning and lie there churning it all over. Then I'm shattered all day."
●The farm/finances: "The farm's been in the family for generations, and I'm terrified I'll be the one who loses it. Debts mounting, bad prices, costs up. It's on my mind every waking minute."
●Function: "I'm dragging myself through the work. The wife says I'm not myself — short-tempered, withdrawn."
●Why he wants tablets, not therapy: "Counselling's not for me. When would I go? And sitting talking about my feelings to a stranger — no. Just give me something that works."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Alan thinks antidepressants are a quick fix that will let him carry on, and that talking therapy is useless and impractical for someone like him. "In my head, tablets fix it and I get on with things. Counselling's a waste of time for a man like me."
●Concerns: His overriding worry is losing the farm and letting down generations before him; beneath the gruffness he feels a real sense of failure and hopelessness. "The thing that keeps me up is losing the farm — I'd be the one who let it all go. I feel like a failure, if I'm honest."
●Expectations: He expects a prescription for antidepressants and to be spared a lecture about therapy. "I came for tablets. I don't want to be told to go and talk about my feelings."

If Asked — Medical History and Lifestyle

The patient confirms these details only when directly asked.

●Previous mental health: "Never had anything like this before. Never seen a doctor about my head."
●Alcohol: "A few more drams in the evening lately, to switch off and sleep. More than I used to."
●Medications/physical health: "Nothing regular, and I'm physically fine as far as I know."
●Appetite/weight: "Off my food, lost a bit of weight."
●Support: "The wife's supportive but she's worried sick too. It's an isolated life up here."

If Asked — Risk Assessment (approached sensitively)

The patient answers these only when directly and sensitively asked.

●If asked about hopelessness / how he sees the future: "Pretty hopeless, to be honest. Some days I can't see a way out of the mess."
●If asked, sensitively, about thoughts of not wanting to go on, or of ending his life: "There've been dark moments where I've thought everyone might be better off without me… but I've got the wife and the kids. I wouldn't do anything." (Passive thoughts, no active plan, protective factors present. Assess sensitively; no method detail is sought or given.)
●If asked about any plans or preparations: "No, no plans. It's more that I feel low and trapped than anything else."
●If asked about what keeps him going / protective factors: "My wife. My kids. And, deep down, not wanting to be the one who lost the farm without a fight."
●If asked about support and whether he's told anyone how bad it is: "I've kept most of it to myself. The wife knows I'm low but not how low."

Responses to Management (The Negotiation Phase)

●If the Doctor takes his low mood and risk seriously: "I didn't expect to be asked all that. I suppose I have been in a dark place." (The tested point is a sensitive, thorough risk assessment in a high-risk patient.)
●If the Doctor agrees an antidepressant is appropriate but suggests combining it with support: "So I can have the tablets? But you still think I need the talking stuff as well?" (The tested point is respecting his preference for medication while explaining that combined pharmacological and psychosocial support gives the best outcome.)
●If the Doctor explores why he refuses therapy and offers flexible options: "Well… if it was over the phone or online, and didn't mean driving miles and taking a morning off, maybe. I still don't love the idea."
●If the Doctor signposts farming-specific support: "There's help specifically for farmers? I didn't know that. It's a lonely business."
●If the Doctor arranges close follow-up: "You want to see me again soon? I'm not used to that."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Farming as a High-Risk Occupation

●Male farmers and agricultural workers are a recognised high-risk group for suicide, owing to isolation, financial and business stress, stoicism and stigma, and access to means. Depression in a farmer warrants a thorough, sensitive risk assessment and a low threshold for concern.

Assessing Depression and Risk

●Assess the core features (low mood, anhedonia, biological symptoms, functional impairment) and grade severity.
●Assess suicide risk sensitively — asking about hopelessness, thoughts of not going on, intent, plans, and protective factors — without introducing or dwelling on specific methods. Respond proportionately, with urgent mental-health input if risk is significant, and consider safety and support with family involvement where appropriate.

Respecting Treatment Preference

●An antidepressant (e.g. an SSRI such as sertraline) is a valid, guideline-supported option for moderate depression. Respect a patient's preference for medication rather than insisting on therapy first — while explaining that combined pharmacological and psychosocial support gives the best outcome.

Overcoming Barriers to Psychological Therapy

●Explore why a patient declines therapy (time, stigma, practicality, rural access) and offer flexible options — telephone or online CBT, guided self-help — that fit their life, rather than a one-size-fits-all clinic model.

Antidepressant Counselling

●Explain the delay to effect (2–4+ weeks), possible early increased anxiety/agitation, the importance of monitoring (with attention to mood/thoughts early on), and continuing the course; arrange early review, especially in higher-risk patients.

Occupational and Financial Support

●Signpost farming-specific support (e.g. the Farming Community Network and agricultural benevolent charities), Samaritans, and financial/debt advice — addressing the drivers of the depression, not just the symptoms.

Alcohol and Continuity

●Address alcohol as a modifiable factor worsening mood and sleep. Provide close follow-up and continuity, particularly for a rarely-attending, high-risk patient.

Common Candidate Mistakes in This Case

●Inadequate risk assessment: failing to recognise the occupational risk and assess suicide risk thoroughly and sensitively.
●Refusing or dismissing his medication preference: alienating a reluctant patient rather than respecting a valid option.
●Pushing therapy rigidly: ignoring his objections instead of exploring them and offering flexible alternatives.
●Missing the drivers: not signposting farming-specific and financial support, or ignoring the alcohol.
●No close follow-up: leaving a high-risk patient without early review and safety-netting.

Free MRCGP SCA practice case for GP registrars covering Low Mood and Money Worries Who Refuses Talking Therapy — Mental Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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