Depression and Anxiety History OSCE — PHQ-9, GAD-7, Risk Assessment, and Safeguarding

Introduction

Depression and anxiety history is a common GP and psychiatry OSCE station. It differs from a full psychiatric history (which covers psychosis, MSE, and sectioning) by focusing on the current depressive or anxious episode, systematic symptom coverage, and a structured suicide risk assessment. Mark schemes heavily reward the risk assessment and safe closing.

Opening the Consultation

• "How have you been feeling in yourself lately?"
• "Some people feel low in mood or have lost interest in things they used to enjoy — has anything like that been happening for you?"
• Use open questions first; funnelling into the criteria comes later.

Core Diagnostic Criteria — Two Gateway Questions

PHQ-2 (screening tool):

1. 1"Over the past 2 weeks, have you felt down, depressed, or hopeless?"
2. 2"Over the past 2 weeks, have you had little interest or pleasure in doing things?"

A positive response to either warrants a full PHQ-9 / SIGECAPS assessment.

SIGECAPS — Depressive Symptoms

Duration and Impact

• "How long have you been feeling like this?"
• "How has this affected your work, relationships, and daily life?"
• Mild, moderate, or severe depends on number of symptoms and functional impairment

Anxiety Screen — GAD-7 Core Questions

1. 1"Have you been feeling anxious, nervous, or on edge?"
2. 2"Have you been unable to stop or control worrying?"
3. 3"Have you been worrying about many different things?"

Then assess:

• Physical symptoms of anxiety: palpitations, breathlessness, chest tightness, sweating, tremor
• Panic attacks: sudden onset, peak within 10 minutes, fear of dying or losing control
• Avoidance behaviours: things the patient has stopped doing due to anxiety
• Specific phobias, social anxiety, OCD features

Suicide and Self-Harm Risk Assessment

Escalate through these questions if the answer is yes:

High-risk features: active plan, access to means, previous attempts, social isolation, substance misuse, command hallucinations, terminal illness.

Safeguarding and Collateral

• Are there children or vulnerable adults at home?
• Does the patient's mental state affect their ability to care for others?
• If yes: duty to consider safeguarding referral

Past Psychiatric History

• Previous episodes of depression or anxiety
• Previous self-harm or suicide attempts
• Previous psychiatric admissions
• Known diagnoses: bipolar disorder, PTSD, personality disorder

Social and Precipitating Factors

• Stressors: bereavement, relationship breakdown, financial difficulties, job loss, trauma
• Substance use: alcohol and drugs (self-medication and mood destabilisers)
• Social support: who does the patient have around them?

Closing Sensitively

• Summarise: "It sounds like you have been feeling very low for several weeks and this has had a significant impact on your life"
• Validate: "Thank you for sharing this with me — it takes courage"
• Safety net: "If things get worse or you feel unsafe, please call 111, go to A&E, or call the Samaritans on 116 123"
• Next steps: discuss psychological therapy (IAPT referral), medication options, follow-up

"How do you screen for depression in an OSCE?"

Use the two PHQ-2 gateway questions: over the past 2 weeks, has the patient felt down, depressed, or hopeless? And have they had little interest or pleasure in doing things? A positive response to either warrants a full SIGECAPS assessment. Five or more SIGECAPS symptoms for at least 2 weeks, including depressed mood or anhedonia, meets criteria for major depressive disorder.

"How do you conduct a suicide risk assessment?"

Ask directly and escalate systematically: first establish whether there are suicidal thoughts (ideation), then whether the patient has thought about how they would do it (intent and method), whether they have made a plan or taken any steps, and whether they have access to means. Assess previous attempts, current protective factors (social support, dependants), and high-risk features (substance use, hopelessness, social isolation, previous serious attempt).

"What is the difference between depression and anxiety in terms of physical symptoms?"

Depression presents with psychomotor retardation or agitation, early morning wakening, decreased appetite and weight, fatigue, and loss of libido. Anxiety presents with autonomic arousal: palpitations, tachycardia, sweating, tremor, shortness of breath, chest tightness, GI upset, and a sense of impending doom or dread. Both can coexist — comorbid anxiety and depression is the most common presentation in primary care.

"What safeguarding considerations arise in a depression OSCE station?"

If the patient has children or vulnerable adults at home, their ability to provide safe care must be assessed. Severe depression can impair a parent's ability to meet a child's basic needs, creating a safeguarding concern. If there is concern, a referral to social services may be necessary, and this must be explained to the patient sensitively. Always document your risk assessment and any safeguarding actions taken.

Related guides: Psychiatric History OSCE | Mental State Examination OSCE | Angry or Distressed Patient OSCE