Sue - 38 year old female
Sue presented with depression which had lasted three months. She has a history of depressive
episodes since she was 19 years old. She reported general continuous low mood, and a loss of
interest in activities she usually enjoys, like soccer, which she now avoids. She said that she
suffers from early morning waking with difficulty returning to sleep, lack of appetite and feels
lethargic. To get to sleep at night she drinks three or four glasses of wine, although more
recently this has increased to four – five glasses. Her movement is slow, her eyes droop and she
sits hunched in the chair. Her affect throughout interview is notably blunted. She feels
hopeless about her future and that life is meaningless. She said that she needs to rest. She
would like to quit her job and do nothing until she feels better. Then she could sleep when she
felt she could.
Sue denied thinking of suicide; however, she reported that she thinks about how good it would
be to die as it would be an escape. She has imagined knowing she is about to die and leaving a
letter telling everyone she loves them and is sorry to leave them. She maintained that she has
no plan to act to take her life. However, if she did, she would like a quick death and has
considered obtaining a gun to use from a cousin who hunts rabbits, but this thought frightens
her. She thought that suicide is a “selfish” and “greedy” act, causing terrible problems for the
people left behind. Sue was visibly distressed and tearful throughout this discussion.
The current episode of depression commenced when she recently moved. She relocated from
the town where she had previously lived and in which her mother remained. She moved to a
country town several hundred kilometres away. The move was to enable her husband to take
up a new job that looked promising. She too had found work as a primary school teacher.
Her mother rings her daily and tells Sue how lonely she is and how much she misses her. Sue
worries she too may be depressed and she feels guilty that she cannot support her mother
during this time because of the distance between them. Her mother also became depressed
when Sue was 19 years old and Sue’s father, who was a farmer and also struggled with
depression, took his own life. Sue’s older sister lives in a major city, further away, and is unable
to offer much support to either Sue or their mother. Her sister is well at the moment, although
she too suffered from depression when her father died, but has not had problems with
depression since.
Sue reports increased arguments with her partner, Tom. She says he is frustrated because she is
withdrawing from him and he complains she just comes home from work and goes straight to
bed, expecting him to do everything for her. He says that if she were terminally ill, like his
father, he would understand, but there is nothing wrong with her. He tells her he needs her
support after a hard time at work where things are not going as well as he had hoped they
would in his new job. Sue just does not have the energy to cope with his difficulties and she
retreats to her bedroom. She is afraid he will leave her. He too is drinking more than usual and
is more restless and irritable than usual.
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Question 1: What are four specific suicide risks for Sue?
Question 2: What four evidence-based treatment approaches or strategies would you consider
to address Sue’s specific difficulties?
Question 3: If Tom told Sue he would like you to refer him to a colleague, based on what you
know here, what diagnoses (including V Codes) would you expect your colleague to hypothesise
Tom may be experiencing?
Question 4: Undertake a demonstration of a suicide risk assessment. Give your conclusions
about level of risk, based on the responses of the examiner.
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NB While there are 5 potential answers given for 2 of these questions, only four are required.
Question 1: What are four specific suicide risks for Sue?
Her level of
depression/ the
underlying
genetics
contribution of
her depression
/1
Distance from
her mother/poor
relationship with
her husband
Hopelessness
Close family
member’s
suicide
/1
/1
/1
Alcohol intake
Question 2: What four evidence-based treatment approaches or strategies would you consider
to address Sue’s specific difficulties?
Referral for
medication or
medication
review for
depression
Psychoeducation
regarding the
lethargy cycle
and behavioural
activation/
pleasant events
scheduling
Interpersonal
psychotherapy/
couple therapy
such as EFT-C to
address
relationship
issues
/1
/1
/1
Cognitive
therapy to
address sense of
excessive
responsibility/
assertiveness to
manage
mother’s
persistent
negative
telephone calls
/1
Psychoeducation on the
depressive
effects of alcohol
and its impact on
sleep/plan for
decreasing or
eliminating
alcohol intake
Question 3: If Tom told Sue he would like you to refer him to a colleague for therapy, based on
what you know here, what diagnoses (including V Codes) would you expect your colleague to
hypothesise Tom may be experiencing?
Depression
/1
Partner relational
problem
/1
Occupational problem Alcohol related
problem
/1
/1
Question 4: Undertake a demonstration of a suicide risk assessment. Give your conclusions
about level of risk, based on the responses of the examiner.
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Evidence-based treatment references
Patkar, A. A., & Chi-Un, P. (2013). Atypical antipsychotic augmentation strategies in the context
of guideline-based care for the treatment of Major Depressive Disorder. CNS Drugs,
27(1), 29-37.
Spijker, J., van Straten, A., Bockting, C. L. H., Meeuwissen, J. A. C., & van Balkom, A. J. L. M.
(2013). Psychotherapy, antidepressants, and their combination for Chronic Major
Depressive Disorder: A systematic review. Canadian Journal of Psychiatry, 58(7), 386392.
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