The following scenarios are fictitious but similar to those experienced by real patients and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.

Icon used to indicate Guidelines in Practice test and reflect content

The following case studies written by Dr Janice Allister relate to her expert article, Key learning points: NICE depression in children and young people. In this article, Dr Allister identifies five key learning points for primary care from the updated NICE guideline on depression in children and young people (NICE Guideline 134).

Sabine, age 14 years

‘I am just feeling really flat and I don’t feel like I can go back to school but mum and dad say I need to.

‘So basically I sent my boyfriend some pics a few weeks ago. I thought he was my boyfriend anyway, but then he showed them to his friend and his friend sent them to everyone. The school found out and now the police have spoken to him and his mate.

‘I haven’t been back to school since, but now on social media they all call me a slut. I can’t deal with them looking at me and I know what they’ll be thinking. Even the girls know all this detail about me.

‘The stupid thing is, everyone does it, everyone sends pics, but I was just unlucky to have a boyfriend who betrayed me. I will never trust anyone again. I feel like everything is over and there’s no going back now.’

Context

Mum and dad are together, both professional and busy with work. No-one in the family has known health problems. Sabine is the oldest of three children. Sabine has missed school for 1 month and is refusing to go back. Her mum is present at the consultation and has said she is worried about some of the ‘dark’ things Sabine has been saying.

Questions for reflection

  1. What risks are present here?
  2. Should you speak to the police?
  3. What do you say to the patient?
  4. What do you say to her mother?

Reveal how to manage this patient

According to police guidance, Sabine may have broken the law in sending ‘pics’ if they are considered indecent. Being able to check anonymously with a police contact is useful here.

Sabine is anxious to change her internet presence and regain confidence and may already have ideas about this. She may well have given up all her activities, which may all be school-based. There may be a family history of depression, domestic or substance abuse, or Sabine may have worries about family bereavements, financial commitments, or unrealistic expectations imposed on her by family members.

Sabine and her family may not be aware of good recommended practice with school refusal, where someone from the school is involved in a type of mediation. Once initial trust is established and risk explored, ‘watchful waiting’ may be appropriate. You make another appointment in 2 weeks’ time. Group cognitive behavioural therapy (CBT) or group interpersonal psychotherapy may be offered if Sabine’s anxiety and depression persist and you need to refer.

Avoid false reassurance or sentences beginning ‘at least’.

Matt, age 13 years

‘I need a note for PE because the games teacher said I can’t keep missing it. The other boys laugh at my body and because I’m not good at sport. I’m not muscly and tough like them and I’m still small. I feel like my body is stupid. I still look like a little kid.

‘Yes, I have been hurting myself. Sometimes I punch the brick wall in my room. It makes me feel like I can get through and be tough.

‘I prefer to stay in and play on the computer, because I can do that and no-one judges me on the games. No-one needs to know who I am. Everyone is trying to get me to go out but I don’t want to do anything. I just want them to leave me alone.’

Context

Matt is relatively small for his age but within normal range. He has no known medical problems. His parents have recently separated and have shared custody. His mum has moved in with her new boyfriend. His 18-year-old sister, Lucy, is present at the consultation.

Questions for reflection

  1. What risks are present here?
  2. What do you say about the note for PE?
  3. How serious does this seem to be?
  4. What are other possible diagnoses?

Reveal how to manage this patient

Matt is likely to have moderate to severe depression as this has been developing for several months. He has already started self-harming. His relationship with both parents needs to be checked and whether he can talk to one of them about how he feels, as well as to his sister. Immediate help from secondary care will likely not be available but Matt should still be referred urgently to child and adolescent mental health services (CAMHS). It might be possible to talk to CAMHS triage, although they usually require parental involvement.

Other options are for Matt to phone Childline, to access digital CBT, and for the GP to ask Matt for permission to speak to one of his parents. You make another appointment for Matt to see you with his sister soon (in 1 or 2 weeks). Supervised digital CBT or individual CBT is likely to be appropriate here.

Avoid false reassurance about Matt’s body shape and maturation.

Aleeza, age 17 years

‘You’re not going to tell any of this to my parents, are you? I am really unhappy. I don’t like anything about myself. My parents are talking about how I need to finish my A-levels, get good grades, and then they will help me find a man, but they don’t understand me. I find school really hard and I’m not doing very well. My parents don’t like anything I want to do. I feel like I’m useless. And I’m not really into boys, if you know what I mean. But I can’t tell anyone. I feel like I can’t be me.

‘I can’t sleep well at night and I really struggle to concentrate in school. I heard you can give me some antidepressants and sleeping tablets that might help?’

Context

Aleeza lives with her extended family, who are well respected in the local community but known for being religious and strict. She has come to the consultation alone.

Questions for reflection

  1. What risks are present here?
  2. What other questions do you ask Aleeza?
  3. You know her parents through a local club. Do you speak to them about Aleeza?
  4. Which other agencies do you contact?
  5. Do you prescribe?

Reveal how to manage this patient

This is a complex situation and careful medical notes must be made. Aleeza has symptoms of moderate to severe depression and is already subject to a form of emotional abuse, even though this may be unwitting. She may also be at risk of violence if she refuses to comply with her parents’ wishes.

Aleeza should feel that someone is listening and there may be a teacher at school to whom she can also speak in confidence. It may be appropriate to give a low-dose, limited prescription of fluoxetine to ‘play for time’.

After assessing the risk, the GP needs to discuss the case with the safeguarding or child protection lead and make a referral to CAMHS or if appropriate a transition or adult service. You make another appointment to see Aleeza soon (in 1 or 2 weeks). This is a case where Aleeza would not want her parents involved in treatment.

Avoid:

  • speaking to her parents even if you know them well
  • false reassurance
  • giving more than 1 week’s prescription as Aleeza is at risk of impulsive overdose or self-harm
  • insisting that her parents accompany her to the next consultation.

Finn, age 8 years (attends with mother)

Mum: ‘Finn is getting very upset and sometimes just starts crying or trying to hurt himself. He loses his temper and bangs his head against the wall. He says he thinks he is rubbish. He got very upset at a friend’s birthday party and I had to take him home. His school has also phoned to say they are worried about him.’

Finn: ‘I feel worried all the time. I don’t think anyone likes me. I don’t deserve anything. Sometimes Tom [mum’s boyfriend] makes fun of me and he doesn’t like me. My friends don’t understand. Sometimes Mummy gets sad and I want to look after her.’

Context

Finn’s parents are separated but have shared custody. He lives primarily with his mum, her boyfriend, and his half-sister who is 2 years old. He appears unhappy and slightly unkempt.

Questions for reflection

  1. What risks are present here?
  2. Is Finn depressed?
  3. What do you do?

Reveal how to manage this patient

Finn seems to have moderate depression but really wants to look after his mother. He is at risk of impulsive or ‘magical’ thinking, more self-harm, and further emotional (and possibly physical) abuse from Tom.

There is likely to be a waiting time for a CAMHS appointment. In the meantime, the GP can establish a relationship with Finn and arrange to see him and his mother regularly (every 1 or 2 weeks). His mother sounds as if she is struggling too and may need a separate appointment. You could consider arranging simultaneous appointments for Finn and his mother to see different GPs at the practice. If Finn is worried about confidentiality, this would provide an opportunity for him to speak on his own; he may not be willing to discuss certain problems in front of his mother (for example, difficulties with Tom, or domestic abuse). Family therapy may be offered here but depending on his level of maturity, Finn may cope with a form of CBT.

Avoid:

  • promising not to tell anyone what Finn says
  • presuming the relationships will be easy
  • ignoring missed appointments.