Woman On Sertraline for Two Months Who Says It Has Done Nothing — Free SCA Practice Case

Character Overview: You are Bronagh Teague, a 38 year old dental nurse at a busy NHS practice. Your phone stays in a locker while you are in surgery. You live in a rented flat. Fourteen months ago you separated from Scott, your daughter Tilly's dad, after twelve years together. Tilly, who is 9, spends alternate weeks with each of you, swapping on Fridays after school. Six months ago Scott told you he had a new partner, Roz, and your mood dropped. Eight weeks ago a locum started you on sertraline and you have taken it, you would say, most days. Tilly is at Scott's this week. You have not taken a tablet for three days and woke this morning dizzy, sick and tearful, which is why you booked today. You have decided the tablets are not for you. You are quick, practical and a bit dry, but your voice goes flat when you talk about how you really feel. You are not hostile and will go along with a plan that makes sense to you.

Opening Sentence: "Hi doctor. I've been on sertraline for about two months now and honestly it hasn't done a thing. I feel exactly the same as I did before, so I'd like to stop taking it, today if that's all right."

History if Asked (Data Gathering Phase)

• ●How she is now: "Flat, mostly. No better than when I started. I get through work because I put a face on, then I go home and just sit." She has lost interest in things she loved, like doing Tilly's hair in daft plaits and cooking a big Sunday dinner. Sleep: "I get off a bit easier, maybe, but I wake in the early hours and don't go back." She is wiped out, skips breakfast without losing real weight, and last week forgot to book a patient's recall. Guilt: "When Tilly's home I feel I'm putting on a show, and when she's not I feel a rubbish mum for being relieved."
• ●If asked to score her last two weeks (for example with a questionnaire): Little interest or pleasure, more than half the days. Down or hopeless, nearly every day. Sleep, more than half the days. Tired, nearly every day. Appetite, several days. Feeling a failure, more than half the days. Concentration, more than half the days. Slowed or restless, several days. Thoughts of being better off dead or of hurting herself, not at all. Total 16, "very difficult". Compared with the start: "I think it was the high teens. About the same."
• ●How she takes the tablet: "Most days, in the morning with my tea." If asked what "most days" means: "The weeks Tilly's with me, every day, because the box lives next to the kettle. The weeks she's at Scott's I miss about half. I grab a coffee on the way in and the box stays in the cupboard. Weekends are worse, because I lie in." Last tablet: "Sunday. I thought, what's the point." About two weeks of tablets left; she has not ordered more.
• ●After a missed tablet (if asked about side effects or how she feels on skipped days): "Horrible. The day after I skip I get dizzy, sick, and a fizzy buzzing in my head, like little electric zaps, when I turn my head quickly. I'm snappy and I cry at nothing. It eases a few hours after I take one, but I always assumed that was just my body not liking the tablet." She woke like that this morning. On days she takes it she notices nothing, apart from a queasy, loose tummy in the first fortnight that went.
• ●The two week check: "It was a busy day and I never rebooked it. Nobody chased it."
• ●Talking therapy (if asked): "I put my name down online. Someone rang twice while I was in surgery, then a letter said they'd closed it. I thought that was that." After Tilly was born she had about eight weeks of CBT over the phone. "It did help, actually. I didn't take anything then."

Ideas, Concerns, Expectations

Gating note: Bronagh does not raise any of this herself. Each part comes out only when the doctor asks what she thinks is going on, what worries her, what she expected from the tablets, or what she hopes for today.

• ●Ideas: She thought antidepressants worked like antibiotics, so she would be better within a couple of weeks. After two months she has decided she is one of the people they do not work for, and that the dizzy, sick, fizzing days are the tablet harming her. "I think my body's rejecting it."
• ●Concerns: Her real fear is ending up like her mother. Janice has taken antidepressants since Bronagh was a teenager, tried twice to come off and ended up in bed, and says she will never be rid of them. "I don't want to wake up at sixty and still be taking them." Only if asked what worries her about the tablets themselves: "I hate that I feel poisoned some days. How do I know it isn't doing me harm?"
• ●Expectations: She came to stop today and hopes the doctor will say that is fine. If not: "Then I want to know what the plan is, because I can't carry on feeling like this."

If Asked: Medical History and Medications

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

• ●Earlier low mood: Once, after Tilly, nine years ago. This episode crept in about six months ago, after Scott told her about Roz. No highs, overspending or times of not needing sleep. No hearing or seeing things.
• ●Health and medicines: No other health problems or thyroid problem. Only the sertraline, plus ibuprofen once in a blue moon. No supplements or allergies. No contraception ("I'm not seeing anyone and I wouldn't want another baby").
• ●Family history: Her mum has been on tablets for low mood since Bronagh was a teenager.
• ●Alcohol, drugs and caffeine: A glass of wine most Saturdays, and in the weeks Tilly is away a glass on three or four nights, never more than two. No drugs. Three or four coffees a day. Does not smoke.

Social History and Lifestyle Impact

• ●Work and home: Dental nurse, eight till half past five, phone in the locker. Scott lives ten minutes away with Roz. "The weeks she's with me I'm fine in the mornings because I have to be. The weeks she's away the flat is so quiet I can't get going."
• ●Support: Her mum helps with Tilly; Bronagh does not tell her how bad it is. Karina on reception is a friend. She stopped her Thursday night Zumba class six months ago and the girls there have drifted.
• ●An empty week: "I wake in the early hours, doze, stay in bed too long, go to work, come home and sit with the telly on. I don't cook."

If Asked: Associated Symptoms

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

• ●Thoughts of harming herself or ending her life: "No. Never, not even on the worst days. I just want to hide under the duvet. I couldn't do that to Tilly." Never harmed herself, no plans. What keeps her going: "Tilly, mostly. And my mum. And the girls at work, who would notice if I stopped turning up."
• ●Negatives: Not agitated or wired ("a bit twitchy when I've skipped a few"). No panic attacks, racing heart, bleeding, bruising or black stools.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the dizzy, sick, fizzing days follow the missed tablets, including today:
  • ●Reaction: Surprised, then thoughtful. "So the horrible days are from skipping them? I thought the tablet was making me ill. That actually makes sense." Asked to restart tonight: "But I feel sick already." She agrees if told it should settle within days.
• ●If the doctor says she can stop straight away, or must stay on them:
  • ●Reaction: Told she can stop: relieved, then unsure. "So I just bin the rest? Will I get the dizzy thing every day then?" Told she must stay on: defensive. "It's my body. I've done what I was told for two months and I feel the same." A slow stop: "Is that a month of feeling rubbish?"
• ●If the doctor suggests carrying on at 50 mg every day, a higher dose, or a different tablet:
  • ●Reaction: Carrying on: doubtful, "What's different?" She accepts when told two months were not a fair test. A higher dose: alarmed, "If I feel sick on one, surely two is worse." She accepts if told most of her trouble came from the missed days and the dose can come back down. A different tablet: cautious, "Will I get all the sick feelings again?" She is open to it if told what to expect.
• ●If the doctor explains how long treatment lasts, or asks about her mother:
  • ●Reaction: Dismayed at "six months after I feel better": "That's what my mum says. I told you I don't want to be on them forever." She calms if told it is reviewed, has an end point and is stopped slowly. About her mother: "I worry that's me in twenty years." A flat "don't worry, that won't happen" leaves her quiet: "Easy for you to say."
• ●If the doctor suggests talking therapy again, or something for the weeks Tilly is away:
  • ●Reaction: Practical. "It helped after Tilly. But the last lot only ring in the day. Could they text me, or do video in the evening? On the weeks Tilly's away I'm free after six." For the quiet weeks: "Maybe I could go back to my Thursday class. Karina's been on at me. Or go round to Mum's on Sundays."
• ●If the doctor gives safety netting, offers a review, or asks her to check her own pulse or blood pressure:
  • ●Reaction: Vague netting such as "come back if you feel worse": "Worse how? What would mean I ought to ring you today?" A review: "Two weeks is fine. Can it be a video call, and can you text me?" Self checks: "I haven't got a machine. I can come in."