Cases/Maternity and Reproductive Health

Low Mood Asking If Antidepressants Are Safe — Free SCA Practice Case

Pregnant woman with low mood asking if antidepressants are safe

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

Esther Adjei

Age

29 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient.

Reason for Encounter

"Feeling very low since I lost my job. I'm 22 weeks pregnant. I took antidepressants years ago and want to know if they are safe now."

Medical Records

●PMH: Severe depression at 20 (PHQ 9 22, passive thoughts of death). Citalopram 20 mg for 11 months, good response, stopped at 21. Never seen by secondary mental health services.
●Medications: Multivitamin. Allergies: NKDA.
●Obstetric: First pregnancy, 22 weeks.
●Social: Events coordinator until recently.

Recent Notes

●Midwife booking visit, 12 weeks ago: Bloods normal. Depression screening recorded as "no".

Patient Script

For the friend playing the patient role

Character Overview: You are Esther Adjei, a 29 year old events coordinator who until two months ago worked for a hotel group in Southampton, for four years. The group closed its events team and you were made redundant. You live in a rented flat with your partner Jude, a personal trainer, and are 22 weeks into your first, planned pregnancy. At 20, in your final year at university, you went through a very bad patch: you stayed in bed, lost weight and took citalopram for 11 months, which put you right. Since the redundancy the same heavy flatness has crept back. You want to restart the citalopram, but Jude has read frightening things online and you are caught between the two. You have not told your midwife, because at booking you felt fine and said so. You sound tired and flat, a little brighter about the baby. You want straight facts and real numbers, not reassurance, so that you can explain them to Jude.

Opening Sentence: "Hi doctor. I've been really flat since I lost my job a couple of months ago and I'm 22 weeks pregnant. I took antidepressants years ago and they really helped, so I wondered about going back on them, but my partner says they'll harm the baby, and now I don't know what to do."

History if Asked (Data Gathering Phase)

●Mood and interest: "Low most days. It started when I got let go, about two months ago, and the last couple of weeks have been the worst. I haven't looked for work in weeks, and I keep cancelling on my friends."
●Sleep, energy and appetite: "I get off to sleep all right, but I wake in the early hours and my head just goes round and round. I'm wiped out all the time, more than I should be, even for pregnancy. I'm eating a bit less."
●Guilt, concentration and worry: "I feel like I've let everybody down. Jude's covering the rent on his own, and I keep thinking I'll let the baby down too. I read the same page three times. I worry at night about money and whether I'll cope with the baby."
●Day to day: "I still get up and cook, but I'm just getting through the day. I dropped out of my pregnancy yoga class."
●If asked to score the last two weeks (for example with a questionnaire): Interest, sleep, tiredness and feeling a failure, more than half the days. Feeling down, nearly every day. Appetite, concentration and feeling slowed or restless, several days. Thoughts of being better off dead or of self harm, not at all. Overall "somewhat difficult".
●Trigger: "The redundancy. I was good at my job and I keep going over it."

Ideas, Concerns, Expectations

Gating note: Esther does not volunteer any of this. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, what Jude thinks, or what she is hoping for.

●Ideas: She thinks the redundancy has set off the same illness she had at university, and that the citalopram is what put her right last time. "I think it's what I had at uni coming back. The citalopram sorted me out last time, so I thought that's what I need."
●Concerns: Jude has read online that antidepressants give babies heart problems and that babies are born addicted. He has asked her not to take anything and thinks she should exercise and talk to him instead. "I'm scared of doing something to her, but also of going back to how I was at uni. Whatever I pick, I'm risking something." Only if asked about telling the midwife or a specialist team: "If I tell the midwife, is that on my notes for ever? Will they think I can't cope, or that I'm not fit to look after a baby?"
●Expectations: She wants an honest answer on whether the tablets are safe, with real numbers she can show Jude, and would like to restart the citalopram if it is safe.

If Asked: Medical History and Medications

Gating note: Esther answers each of these plainly when asked.

●Her earlier illness and treatment: "It was my final year. I stayed in bed most of the day, lost loads of weight, put my exams back a term and couldn't see the point of anything. Citalopram, 20 milligrams, and about six weeks in I felt like myself again, plus a few counselling sessions. I stayed on it about eleven months and my GP weaned me off. I felt a bit sick the first week, that was all. I've been fine since."
●Specialist care, highs and psychosis: She has never seen a psychiatrist or been in hospital for it. No highs or overactivity, and she has never heard or seen things.
●Family history: "My sister Efua had a really low time after her second baby. Her GP put her on tablets and she's fine now. Nobody else."
●Physical health and medicines: No thyroid problems, palpitations, fainting or sudden early deaths in the family. "Just a pregnancy multivitamin. No herbal things." No allergies.

Social History and Lifestyle Impact

●Work and money: "I got a redundancy payment, but it won't last. Jude's wages cover the rent and we're counting every pound."
●Support: "Jude's lovely, he really is. He's just frightened for the baby. Efua phones most evenings from Manchester. My mum and dad are in Accra. I've been avoiding my friends." She feels completely safe at home.
●Alcohol, smoking and drugs: "Nothing since I found out I was pregnant. I've never smoked."
●The pregnancy: "It's our first and we planned it. The scan was normal and I feel her move every day. I'd like to use the midwife led birth centre."
●What the midwife knows: "At my booking visit she asked if I'd been feeling low and I said no, because I wasn't then. I haven't told her since. I didn't want it on my notes."

If Asked: Associated Symptoms

Gating note: Esther answers these only when the doctor asks directly.

●Thoughts of ending her life or harming herself: "No, not now. When I was ill at uni there was a stage when I didn't see the point of being here, but I never planned anything. It isn't like that now. I want this baby."
●Thoughts of harming the baby or intrusive thoughts: "No, never. If anything I worry about her too much."
●Other symptoms: No panic attacks, racing heart, heat intolerance or hair loss, and no bleeding, pain, leaking fluid or reduced baby movements. "She moves loads."

Responses to Management (The Negotiation Phase)

●
If the doctor discusses the safety of antidepressants (no detail, the baby's organs already formed, the remaining risks with rough figures, or the risks of untreated low mood):
- ●Reaction: To "safe" or "unsafe" without detail: unsatisfied. "How safe, though? Jude is going to ask me for numbers." If told the organs, heart included, are already formed: relieved but cautious. "So that bit doesn't apply now? Is there anything it can do at this stage?" Given the remaining risks with figures: "So 'born hooked' isn't right, it's more like the baby might be unsettled for a few days? And the lung thing is rare?" She wants to hear the chances are small without being told there is no risk. About untreated low mood: "I didn't know being like this could affect her."
●
If the doctor suggests a treatment (restarting citalopram, a different tablet, talking therapy, or therapy first with tablets held back):
- ●Reaction: Citalopram: interested. "How long before it works? Can I still breastfeed on it?" A different tablet: hesitant. "But citalopram worked for me. Why would I swap?" She accepts a clear reason. Talking therapy: "How long's the wait? I had to wait weeks at uni." Therapy first: "Okay. But if I'm no better in a couple of weeks, can I try the tablets?"
●
If the doctor suggests a specialist perinatal mental health referral, says they will tell the midwife, or mentions the baby being checked or the place of birth:
- ●Reaction: Alarmed. "Is that social services? Will they think I'm not fit to look after her?" She accepts once told what the team does and that it is about support. If told the midwife will be informed without being asked: "I haven't said yes to that." She agrees if the reason is explained and she is asked properly. About the birth centre: "Does that definitely change?" She accepts the midwives will advise.
●
If the doctor offers to speak to Jude, pushes her to start a tablet today, or asks what she would like to do:
- ●Reaction: "I'd rather tell him myself, but could you give me something I can show him? Or maybe a call together." If pushed to start today: "I'm not ready to decide in this appointment. I need to talk to Jude first. Can I come back in a couple of days?" Asked her preference, she leans towards citalopram plus talking therapy but wants Jude to hear the figures first.
●
If the doctor answers whether she will get better, or arranges review and safety nets:
- ●Reaction: "Will I get better? And will it come back after I've had her?" She wants an honest answer and takes comfort from a plan: "I don't want to be left on my own with this." To vague safety netting: "Worse how? Who would I ring in the middle of the night?"
●
If the doctor suggests simple measures (sleep routine, activity, practical help), or asks her to take her own blood pressure on camera:
- ●Reaction: Receptive to the first: "Jude's always on at me to go for a walk. I wouldn't know where to start with the money side." Declines the second: "I haven't got a machine. My midwife does 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 / 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 Dilemma and the Model Plan

●Esther is 22 weeks pregnant with a moderate recurrence of depression, a severe episode at 20 that settled on citalopram, and a partner who fears tablets will harm the baby. The task is a shared decision, not a ruling on whether antidepressants are allowed in pregnancy.
●Two guideline positions sit side by side. CG192 advises discussing a higher threshold for medicines in pregnancy and the likely benefit of a psychological intervention first. The NICE CKS on antenatal and postnatal depression notes that UKTIS does not advise an altered threshold and that antidepressants should not be withheld because of pregnancy.
●Model plan: assess severity and risk; explain that the organs are formed so the heart defects Jude fears do not apply now; set the late pregnancy effects against the risks of untreated depression; offer CBT and an SSRI; refer to the perinatal service; with her agreement tell the midwife; plan the birth and postnatal period; review within two weeks; safety net with dispositions.
●Acceptable alternatives: an SSRI now with CBT, or CBT first with review in about two weeks and an SSRI if she is not improving or prefers it.

Assessing Severity and Risk

●CG192 suggests the PHQ 9 or EPDS as part of a full assessment. Esther scores 14 on the PHQ 9, which is moderate, with daily tasks still managed. CKS notes a positive EPDS is not a diagnosis.
●Ask about unusually high mood, reduced need for sleep or overactivity, because an antidepressant can be hazardous in bipolar disorder, and about psychotic symptoms and family history. CKS suggests a blood count and thyroid function where fatigue is prominent.
●Ask directly about suicidal thoughts, thoughts of harming the baby, self neglect, alcohol and domestic abuse. Esther has no current suicidal thoughts and strong protective factors. Suicide remains a leading cause of maternal death in the first year after birth, so repeat the assessment at each review.
●Women hide low mood for fear of stigma or of the baby being taken into care (CG192). Esther answered "no" at booking for these reasons, so ask openly.

Why the Earlier Episode Requires Referral

●CG192 counts severe and incapacitating depression as severe mental illness. Esther's episode at 20 (PHQ 9 of 22, weight loss, exams deferred) fits, even though her GP managed it and she never reached secondary care.
●CG192 1.5.10 says to refer any woman with past severe mental illness to a secondary mental health service, preferably a perinatal one. Advice alone is not a substitute for referral, although a call for advice before starting a tablet is a reasonable extra step. The perinatal team should assess within about 2 weeks (CG192 1.7.3); if there is none locally, the general secondary mental health service is the accepted alternative.
●With her agreement, tell the midwife and obstetric team (CG192 1.5.2). Sharing without her agreement breaks trust unless serious risk of harm requires it.

Treatment Options for Moderate Depression

●CG192 1.8.3 offers CBT, or an antidepressant if she understands the risks and prefers medication, declines therapy or has not responded, or both together. An SSRI with CBT suits Esther, who prefers medication and responded before; CBT first, with review in about two weeks, is equally acceptable.
●NHS Talking Therapies accept self referral in most areas; waits vary, so say how soon she should hear. Support the non drug side too: sleep routine, gentle activity (Jude's suggestions are additions, not rivals) and practical help with money, such as Citizens Advice or a social prescriber.

What SSRIs Do and Do Not Do in Pregnancy

●CKS: no antidepressant has been proven to cause birth defects, absolute risks are low, SSRIs have the most safety data, and none is shown to be safer than another.
●Structural development is complete by about 12 weeks, so a drug started at 22 weeks cannot cause a structural defect. The background rate of birth defects is about 1 in 40, and first trimester SSRI use may add a small rise in heart defects (about 1.2 in 100 compared with 0.8 in 100).
●Late pregnancy effects matter now. Persistent pulmonary hypertension of the newborn (a rare lung blood pressure problem) is more likely after exposure beyond 20 weeks, at up to about 0.4% compared with 0.1% to 0.2% otherwise. Transient neonatal withdrawal is a withdrawal effect, not addiction (no reliable figure for frequency or duration, so do not quote one). The MHRA advises a small increased risk of postpartum haemorrhage with SSRIs in the month before delivery, so the maternity team should know.
●Links with miscarriage, preterm birth, low birth weight and child development are conflicting and confounded, because depression itself is linked to the same outcomes. Set this against untreated illness: CKS links severe depression with obstetric complications, preterm birth, low birth weight and impaired bonding, and treatment lowers the risk of depression after birth.

Prescribing in Practice

●Choose the drug with the lowest risk profile, taking previous response into account (CG192 1.4.12). Restarting citalopram 20 mg once daily (BNF adult starting dose, maximum 40 mg) is reasonable. Sertraline 50 mg once daily, increased in steps of 50 mg at least a week apart, is another sound SSRI.
●Use one drug at the lowest effective dose. CG192 asks for caution with paroxetine and venlafaxine, CKS describes tricyclics and SNRIs as not usually first line, and benzodiazepines are for short term severe agitation only.
●Explain that benefit takes up to about four weeks, that early nausea, restlessness or more anxiety can occur, and that the tablet must not be stopped suddenly.
●No antidepressant is licensed specifically for pregnancy, so record her informed consent (CKS). The BNF lists QT prolongation as a contraindication to citalopram, so ask about heart rhythm problems, fainting and sudden family deaths. Esther has none.

The Birth and the Postnatal Period

●Tell the maternity team she takes an SSRI so the baby can be checked after birth for withdrawal symptoms and PPHN (CG192 1.9.2). Place of birth is a shared decision with her midwife (CKS generally advises hospital delivery); Esther hoped for the birth centre.
●The risk of depression returning is highest after birth, so the plan continues then (CG192 1.9.1). SSRIs can be used with caution when breastfeeding, and continuing one that works may be better than switching; watch the baby for drowsiness and poor feeding.
●Past severe mental illness means alertness for postpartum psychosis in the first two weeks (CG192 1.5.11). Sudden confusion, strange beliefs or severe agitation need same day emergency assessment. Arrange an early postnatal review.

Follow Up, Duration and Safety Netting

●First review within 2 weeks of starting (1 week is also fine), then at intervals, repeating the PHQ 9 or EPDS and adjusting the dose; review more often in later pregnancy (NG222, CKS). If she chooses CBT first, review in about two weeks and say what would prompt a tablet.
●Treatment usually continues for at least 6 months after she feels well, and is not stopped abruptly.
●999 or A and E: thoughts of ending her life with a plan, thoughts of harming the baby, hearing or seeing things, or severe confusion. Same day call to the practice, perinatal team or midwife triage, or 111 with the mental health option: worsening mood, not sleeping for two nights, thoughts of not wanting to be alive without a plan, or marked agitation after starting the tablet. Samaritans (116 123) at any hour. "Come back if it gets worse" is not enough.

Talking with a Partner Who Disagrees

●When and how to involve Jude is her decision (CG192 asks for information to be shared with a partner if the woman agrees). Start with why he is worried, then answer his two fears plainly: the baby's heart is already formed, and newborn withdrawal is not addiction. Offer written information (UKTIS leaflets) or a joint call.

Common Mistakes in This Station

●Telling her antidepressants are not allowed in pregnancy, or that they are completely safe.
●Describing the risk of heart defects without noting that the organs are formed at 22 weeks, or calling newborn withdrawal "addiction", or leaving out the late pregnancy effects.
●Treating this as understandable sadness after redundancy and offering only reassurance.
●Missing the past severe episode and managing in primary care without a perinatal referral.
●Not asking directly about suicidal thoughts and thoughts of harming the baby, or about previous highs.
●Informing the midwife or hospital without her agreement, or ignoring her fear of being judged unfit.
●No review date, no plan for the birth and postnatal period, and safety netting limited to "come back if worse".
●Prescribing venlafaxine, a tricyclic or a benzodiazepine first when an SSRI that worked before is available.

Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.

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