As a final yr student, with final station 26yo patient male He was bought to ER by having been found unconscious by gf with empty botel of tequilla and lorazipa, psychiatry is sending him home with 2months later follow up Presciption is for fluoxetine (SSRI). Patient role Male investment banker fired and he might be banned and deported to face criminal charges and he is depressed and tried to suicide.... doesnt remember and remebers gf crying and heclaims it was impulsive not suicide but he has been feeling suicidal Our role, we need to take interview but patient doesnt wanna give but we need him to speak 1) how 2) if he speaks how the prescribed medication helps, take soap note and explain and notice mental capacity .....he is asking if his criminal charges will be dropped

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OSCE Station: 26M Suicidal Patient - Complete Clinical Guide

THE CLINICAL PICTURE (Quick Summary)

26M, investment banker, found unconscious - alcohol + lorazepam (mixed overdose)
Denies active suicidal intent; claims it was impulsive
Significant stressors: job loss, criminal charges, deportation threat
Depression likely underlying
Psychiatry: discharging with fluoxetine + 2-month follow-up
Patient is guarded, reluctant to talk

PART 1: HOW TO GET HIM TO OPEN UP - Real Doctor Questions

The key is normalizing, non-judgmental, open phrasing and following his emotional lead, not interrogating him. Here is a script broken into stages:

STAGE 1: Establish Rapport First (Don't Go Straight to Suicide)

Start warm, acknowledge the situation, sit at eye level, don't have clipboard in hand immediately.

"Hey, I'm [your name]. I know today has been absolutely horrible. You woke up in a hospital, your girlfriend's been worried sick - that's a lot. I'm not here to judge you or make your situation worse. I just want to understand what's going on with you. Is that okay?"

"Before I ask you anything clinical - how are you physically feeling right now? Head? Stomach?"

(This opens neutral ground - he can answer that without fear.)

"You've got a lot going on. I imagine your head is spinning. What's the first thing that came to your mind when you woke up here?"

STAGE 2: Normalize His Reluctance (He's Guarded Because He's Scared)

He's not talking because he fears legal consequences. Address it directly but carefully:

"I get the sense you're not sure how much to say. That makes complete sense given everything you're dealing with. I want you to know - what you tell me medically stays in this room to help you get the right care. I'm not the police, I'm not your lawyer, I'm not immigration. I'm just your doctor today."

Important boundary for you as a student: Do NOT promise full confidentiality. The correct phrasing is:

"Doctors do have to share information in certain situations - if there's a risk to your life or someone else's. But everything you tell me is used to help you, not to get you in trouble."

STAGE 3: Let Him Tell His Story - Open Ended First

"So just take me back - what has the last few weeks looked like for you? Not medically - just your life."

"When did things start feeling really bad? Was there a particular moment?"

(Let him talk about the job loss, the charges - don't interrupt. Nod. Let silence sit for 3-5 seconds after he speaks.)

STAGE 4: Normalize Suicidal Thoughts - The Key Move

This is from Kaplan & Sadock directly. The evidence-based normalizing question:

"I want to ask you something, and I need you to know it's a really common thing to experience - lots of people in situations like yours, where everything feels like it's collapsing at once, start having thoughts about not wanting to be here anymore. Has that been happening for you?"

(This is called the normalizing invitation - it removes shame from admission.)

If he minimizes - "it was just an accident" - follow up:

"I hear you that it may have felt impulsive in the moment. But sometimes our body acts on thoughts that have been building up. Before last night - in the weeks before - were there moments where you thought 'what's the point' or 'I'd be better off gone'?"

(This is the gentle assumption technique from Shea's CASE approach - it assumes some ideation exists and gives him permission to confirm rather than forcing him to admit it from scratch.)

STAGE 5: Explore the Event Itself

"Walk me through last night as much as you remember. You had the tequila - where were you? Were you alone to start with?"

"When you took the lorazepam - was it in one go? What were you thinking at that moment?"

"You said you don't remember much. What's the last clear memory you have?"

"You mentioned your girlfriend was crying - how did that make you feel when you saw that?"

(Guilt and connection to loved ones are protective factors - explore them.)

STAGE 6: Assess Current Risk (Direct but Warm)

"Right now, sitting here - do you have any thoughts of wanting to hurt yourself or end your life?"

"On a scale of 1 to 10, where 1 is 'none at all' and 10 is 'I'm planning to do it' - where are you sitting right now?"

"What stopped you from doing something more definitive last night? What held you back?"

(This explores protective factors - his girlfriend, future plans, fear of pain, etc.)

STAGE 7: His Specific Worry - Will Criminal Charges Be Dropped?

He will ask this. Your honest, safe response:

"That's a really fair question and I completely understand why it's on your mind. That's outside of what I can help with directly - you need a solicitor for that. What I can tell you is that your health comes first right now. Getting you stable and safe is the priority, and that actually does matter if your legal team makes any argument about your state of mind. But please - separate your health from your legal situation for this conversation. What happens here is about making sure you're okay."

Do NOT promise charges will be dropped. Do NOT link your assessment to legal outcomes. Just redirect compassionately.

PART 2: SOAP NOTE

S - SUBJECTIVE

26-year-old male investment banker, presented to ED following being found unconscious by girlfriend. Empty bottle of tequila and lorazepam (prescription benzodiazepine) at the scene. Patient denies active suicidal intent; describes the event as "impulsive" and states he does not remember taking the medication. Reports seeing his girlfriend crying as last memory. Endorses low mood, feelings of hopelessness, and passive suicidal ideation over the past several weeks. Significant psychosocial stressors: recent job termination, potential criminal charges (financial), risk of deportation. Denies command auditory hallucinations. No prior psychiatric history documented. No known drug allergies.

O - OBJECTIVE

Alert and oriented x3 on current presentation (post-resuscitation)
Vitals: stabilised in ED
Toxicology: mixed alcohol-benzodiazepine overdose (CNS depressant synergism)
No focal neurological deficits
Affect: flat, restricted, some tearfulness noted
Thought process: linear, no formal thought disorder
Insight: partial - acknowledges low mood but minimizes suicidal intent
Judgment: impaired at time of event
C-SSRS ideation intensity: active ideation with method, no clear plan on current interview
No access to current lethal means assessed (must document)

A - ASSESSMENT

Major Depressive Episode (F32.2 / DSM-5 296.23) - moderate to severe
- Depressed mood, anhedonia (implied), hopelessness, suicidal ideation, psychosocial stressors
Suicide Attempt (intent disputed by patient; clinical evidence supports intentional overdose)
- Mixed alcohol and benzodiazepine ingestion, alone, found unconscious
- Risk factors: male sex, 26yo, acute major stressor (job loss, legal, deportation), alcohol use, access to medications, social isolation (lives with GF but minimal wider support mentioned)
- Protective factors: girlfriend present, patient is alive and engaging (partially), no prior attempts documented
Alcohol misuse - context unclear, assess chronicity
Benzodiazepine misuse / prescribed lorazepam - review indication and prescribing appropriateness given this event

Mental Capacity Assessment:

At the time of the overdose - capacity was likely absent (intoxicated, altered consciousness).

Currently in ED - assess using the 4 domains:

Domain	Finding
Understand information	Can understand what fluoxetine is, what depression is - YES
Retain information	Appears to retain within session - YES
Weigh/use information	Partial - minimizing risk, dismissing suicidal nature of event - IMPAIRED
Communicate decision	Can communicate - YES

Current capacity: BORDERLINE - incomplete. Patient is minimizing risk in a way that may reflect depression's effect on weighing information rather than genuine insight. Discharge decision must factor this in. Psychiatry must reassess.

This is a key teaching point for your exam: capacity is decision-specific, and in this case the decision is "can he safely manage his care at home?" - the bar is higher than just being awake and talking.

P - PLAN

Fluoxetine 20mg OD - start in morning, with food
- Takes 2-4 weeks for mood benefit (explain this to patient - very important)
- May initially increase anxiety in week 1-2 (warn him)
- Black box warning: monitor for increased suicidality in first 2 weeks especially in adults under 25 - safety netting is essential
- Does NOT sedate or act immediately - it is not a PRN
Discontinue or review lorazepam - it was used in overdose attempt; prescribing must be reassessed. If anxiety requires management, safer alternative with supervision
Alcohol advice: abstinence until stable; alcohol worsens depression and dangerously potentiates CNS depressants
Safety plan before discharge (mandatory per evidence - Stanley & Brown, 2012):
- Identify warning signs
- Coping strategies (what to do if ideation returns)
- Contacts: girlfriend, crisis line (e.g., 116 123 Samaritans UK)
- Means restriction: who holds remaining medications? Remove access
Referral: 2-month follow-up is not adequate for this risk level - advocate for 1-2 week follow-up minimum. Flag concern formally.
Collateral history from girlfriend with patient consent
Confidentiality and legal: document that patient asked about criminal charges - explained that medical information is confidential except where safety requires disclosure; redirected appropriately; advised to seek legal counsel separately

PART 3: HOW FLUOXETINE HELPS - Explain to the Patient (Simple Language)

This is what you say to him when he asks "what is this pill going to do for me?"

"So your brain has a chemical called serotonin - think of it like a mood stabiliser your brain makes naturally. In depression, that system isn't working efficiently. Fluoxetine doesn't add more serotonin - it stops your brain from clearing it too quickly, so it stays active longer. Over 2-4 weeks, that starts to lift the floor of how you feel - the constant heaviness, the hopelessness. It won't fix your job or your legal situation - but it changes the lens through which you see those problems. Right now everything looks unsurvivable. With treatment, those same problems will feel manageable.

The first 2 weeks can actually feel a bit more anxious or restless before it gets better. That's normal. You must not stop it suddenly. And most importantly - if you feel worse, or find yourself thinking about hurting yourself more, you call the crisis line or come back here immediately. Don't wait 2 months."

PART 4: KEY EXAM POINTS to Say Out Loud in Your Station

"I want to assess his capacity before discharge" - this shows maturity
"I have safeguarding concerns about this discharge plan - a 2-month follow-up is insufficient for a recent suicide attempt" - say this, it's professionally correct
"I will complete a safety plan with him before he leaves"
"I cannot advise on his criminal charges, but I will document his mental state thoroughly as that is medically relevant"
Use the Columbia Suicide Severity Rating Scale (C-SSRS) - name drop this tool
Acknowledge the girlfriend - ask to involve her in safety planning with patient consent

QUICK REFERENCE: Red Flag Questions to ALWAYS Ask in Suicide Assessment

Question	Why
"Do you have a plan?"	Specificity = higher risk
"Do you have access to means (pills, weapon)?"	Means access = immediate risk
"Have you tried before?"	Prior attempt = strongest predictor
"What stopped you before/tonight?"	Protective factors
"Do you want to be alive?"	More powerful than "do you want to die?"
"Who knows how bad things are for you?"	Social isolation assessment

Good luck in your final station. The examiners want to see that you can hold a human conversation, not just tick boxes. The fact that he doesn't want to talk is part of the clinical challenge - show that you know how to sit in the discomfort with him rather than rushing to fill silence.

Now Summarize this is Good format to present in a medical university assesment

Here is a clean, structured summary formatted for a medical university assessment presentation:

PSYCHIATRIC OSCE CASE SUMMARY

Clinical Skills Assessment | Final Year MBBS

CASE OVERVIEW


Patient	26-year-old male
Presentation	Found unconscious by girlfriend - empty bottle of tequila + lorazepam
Setting	Emergency Department
Disposition	Psychiatry discharging home; fluoxetine prescribed; 2-month follow-up
Psychosocial context	Recently fired investment banker; pending criminal charges; risk of deportation

SECTION 1: APPROACH TO THE RELUCTANT PATIENT

Principles of Engagement

Sit at eye level, no clipboard initially
Use first name if permitted
Acknowledge distress before asking clinical questions
Separate the medical consultation clearly from legal proceedings

Opening Statement (Rapport Building)

"I know today has been incredibly difficult. I'm not here to judge you or make things harder. I just want to understand what you've been going through."

Normalising Suicidal Ideation (Kaplan & Sadock Technique)

"Many people dealing with everything collapsing at once - job, relationships, legal pressure - start having thoughts about not wanting to be here anymore. Has that been happening for you?"

If Patient Remains Guarded - Address the Legal Fear Directly

"What you tell me medically is to help you get the right care. I am not the police, not immigration, not your employer. My job today is just to make sure you are safe."

Important: Do NOT promise absolute confidentiality. Correct phrasing:

"I do have a duty to share information if I believe your life is at risk - but everything else stays here to help you."

Key Interview Techniques (Shea's CASE Approach)

Technique	Application
Gentle Assumption	"Before last night, were there moments where you felt like what's the point?"
Behavioral Incident	"Walk me through exactly what happened last night step by step"
Symptom Amplification	"When those thoughts came, how often were they? Every hour? Constant?"
Denial of the Specific	"Was there any part of you that wanted to not wake up?"

SECTION 2: SOAP NOTE

S - Subjective

26M investment banker found unconscious at home. Mixed ingestion of alcohol and lorazepam. Denies suicidal intent; describes event as "impulsive." Reports passive suicidal ideation for several weeks prior. Last memory: girlfriend crying. Significant stressors: job termination, criminal charges, deportation risk. No documented prior psychiatric history.

O - Objective

Alert and oriented x3 post-resuscitation
Toxicology: CNS depressant synergism (alcohol + benzodiazepine)
Affect: flat, restricted, intermittently tearful
Thought process: linear, no formal thought disorder
Insight: partial - minimises suicidal intent
Judgment: impaired at time of event
No focal neurological deficits

A - Assessment

1. Major Depressive Episode (DSM-5 296.23 / ICD-10 F32.2) - moderate to severe

Depressed mood, hopelessness, passive and active suicidal ideation, acute psychosocial stressors

2. Suicide Attempt (intent disputed by patient; clinical presentation consistent)

Intentional mixed overdose, found unconscious, alone

3. Alcohol Misuse - chronicity to be established

4. Benzodiazepine safety concern - lorazepam was used as overdose agent; prescribing must be reviewed

Risk Stratification:

Risk Factors (Present)	Protective Factors (Present)
Male sex, age 25-45	Girlfriend in attendance
Acute major psychosocial stressors	Alive and partially engaging
Alcohol intoxication	No prior attempts documented
Access to lethal means (medications)	Expresses future concerns (legal future)
Hopelessness, low mood

Mental Capacity Assessment:

Domain	Finding
Understand information	Intact
Retain information	Intact within session
Weigh / use information	Impaired - minimising severity, depression distorting judgment
Communicate a decision	Intact

Conclusion: Capacity is borderline/impaired for discharge decision. Depression itself impairs the ability to weigh risk accurately. This must be formally reassessed before discharge.

P - Plan

Priority	Action
1. Immediate	Complete safety plan before any discharge (Stanley & Brown, 2012)
2. Medication	Fluoxetine 20mg OD - morning, with food
3. Means restriction	Remove remaining medications from patient's access; involve girlfriend
4. Lorazepam	Review and discontinue or transfer to supervised dispensing
5. Alcohol	Advise abstinence; dangerous potentiation with CNS depressants
6. Follow-up	Advocate for 1-2 week review - 2-month interval is clinically inadequate for recent attempt
7. Collateral	Obtain history from girlfriend with patient consent
8. Documentation	Record patient's query about criminal charges; redirect to legal counsel

SECTION 3: PHARMACOLOGY - FLUOXETINE (SSRI)

Mechanism of Action

Fluoxetine selectively inhibits the serotonin reuptake transporter (SERT) at the presynaptic membrane, increasing synaptic serotonin availability in limbic and cortical circuits. It does not directly add serotonin - it prevents its premature clearance.

Expected Timeline

Timeframe	Effect
Week 1-2	Possible increased anxiety, restlessness, insomnia (warn patient)
Week 2-4	Early mood stabilisation, improved sleep, reduced anhedonia
Week 4-8	Full antidepressant effect

Key Counselling Points for This Patient

"This takes weeks - it is not a quick fix"
"Do not stop suddenly" - discontinuation syndrome
"Come back immediately if thoughts of self-harm worsen"
Black Box Warning (FDA / MHRA): Increased risk of suicidal ideation in patients under 25 in first 2 weeks of treatment - requires close monitoring and safety netting

Drug Interaction Alert

Fluoxetine + alcohol = increased CNS effects and risk. Patient must be advised to abstain completely.

SECTION 4: RESPONSE TO "WILL MY CRIMINAL CHARGES BE DROPPED?"

Correct approach:

"I understand why that's on your mind - it's a huge part of what's happening for you right now. That question is one for your solicitor, not your doctor. What I can tell you is that your mental health assessment is documented thoroughly, and that is medically and legally relevant. But today, my job is to make sure you are safe. Please keep those two conversations separate."

Do NOT: Promise any legal outcome. Do NOT make your clinical documentation contingent on legal implications. Document the exchange factually.

SECTION 5: KEY CLINICAL PEARLS FOR THE EXAMINER

Capacity is decision-specific - being alert does not equal having capacity to make a safe discharge decision in depression
2-month follow-up is inadequate - a recent suicide attempt warrants 1-2 week review minimum; voice this professionally
Safety planning is mandatory before ED discharge - not optional
Lorazepam must be reviewed - it was the overdose agent; continued prescribing is a significant risk
The SSRI black box warning - fluoxetine may transiently worsen suicidality in under-25s; safety net explicitly
Use named tools: C-SSRS (Columbia Suicide Severity Rating Scale) for structured risk assessment
Involve the girlfriend - with consent; she is both a collateral source and a key protective factor

REFERENCES

Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Clinical Interview; Suicide Risk Assessment
Stahl's Essential Psychopharmacology - Fluoxetine / SERT mechanism
Goodman & Gilman's Pharmacological Basis of Therapeutics - SERT and SSRIs
Stanley & Brown (2012) - Safety Planning Intervention
Shea SC (2009) - Chronological Assessment of Suicide Events (CASE Approach)
Columbia Suicide Severity Rating Scale (C-SSRS) - Posner et al., 2011

Prepared for Final Year MBBS Clinical Skills Assessment | Psychiatric Emergency Station

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