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PLAB 2 Depression with Suicidal Ideation: Risk Assessment, Mark Scheme & Free Practice

Depression with suicidal ideation is one of the highest-stakes communication stations in PLAB 2. The eight minutes test whether you can assess mood and risk together, ask directly about suicide without flinching, build a safety plan in real time, and arrange urgent onward referral - all while showing the kind of unhurried, empathic presence that the interpersonal-skills domain rewards. You will face a quiet, withdrawn patient who will not volunteer their suicidal thoughts unless you ask directly. This guide walks through the structure that scores well, the questions you must ask out loud, and the single most common reason candidates fail this station.

Last reviewed 2026-05-15 · Reading time about 8 minutes

What the station is testing

The station is marked across data gathering, clinical management and interpersonal skills, plus three safety-critical checks: asking directly about suicidal thoughts (failure to ask is an automatic fail in real PLAB 2), developing a safety plan, and not discharging the patient with an SSRI prescription and routine follow-up when active suicidal ideation is present. The interpersonal-skills domain carries unusual weight in this station - tone, pacing and silence count as much as the questions.

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

  • Major depressive disorder
    Persistent low mood and/or anhedonia for at least two weeks, with biological symptoms (sleep, appetite, energy, concentration) and cognitive symptoms (guilt, hopelessness, suicidal ideation). The leading working diagnosis in this scenario.
  • Bipolar affective disorder - depressed phase
    Depressive episode in a patient with a history of mania or hypomania. Critical to identify because antidepressant monotherapy can precipitate mania. Always screen for past elevated mood.
  • Adjustment disorder
    Low mood developing within 3 months of a clear stressor (redundancy, bereavement, breakup) and not meeting full depression criteria. Treatment is psychological support and time, not antidepressants.
  • Generalised anxiety disorder
    Excessive worry, restlessness and physical anxiety symptoms. Frequently coexists with depression. Screen explicitly with at least one anxiety-focused question.
  • Alcohol-induced mood disorder
    Heavy alcohol use can cause and worsen depression. Always ask about alcohol intake in depression history - both as a differential and as a complicating factor.
  • Hypothyroidism and other organic causes
    Hypothyroidism, anaemia, chronic illness, vitamin B12 deficiency and some medications (corticosteroids, beta-blockers, interferon) can mimic or worsen depression. Take a medical and drug history.
  • Psychotic depression
    Severe depression with congruent psychotic features - delusions of guilt, nihilism or persecution, or auditory hallucinations. Briefly screen for psychosis and refer urgently if positive.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

  1. 1. Open the consultation - calm, unhurried, private

    Tone and pacing are graded items. Slow down.

    • Wash hands, greet, introduce yourself.
    • Confirm identity. Acknowledge that what you talk about will be confidential within the limits of safety.
    • Sit at the patient's level, leave a comfortable silence after greeting.
    • Use an open question to start: "How have you been feeling?"

  2. 2. Explore the presenting complaint with open questions

    Let the patient talk. Tolerate silence.

    • "Tell me a bit more about what you mean by feeling low."
    • "How long has this been going on?"
    • "When did things change?"
    • Allow long pauses. Do not fill the silence.

  3. 3. Screen the depression criteria

    Cover the diagnostic features systematically. PHQ-9 framework is fine.

    • Low mood most days for over two weeks.
    • Anhedonia - loss of interest or pleasure in usual activities.
    • Sleep - early-morning waking, insomnia or hypersomnia.
    • Appetite and weight change.
    • Energy and fatigue.
    • Concentration.
    • Feelings of guilt or worthlessness.
    • Psychomotor slowing or agitation.

  4. 4. Ask directly about suicidal thoughts

    This is the single most important question in the station. Failing to ask is an automatic fail.

    • Use plain language: "Sometimes when people feel like this, they have thoughts of harming themselves or ending their life. Have you had any thoughts like that?"
    • If yes: "Can you tell me a bit more about that?" - then ask about plan (specific method), means (access to the method), intent (how close they have come, when), protective factors (people, faith, reasons not to).
    • Ask about previous attempts and self-harm.
    • Be calm, non-judgemental, do not look shocked. The patient is reading your face.

  5. 5. Briefly screen for psychosis

    One question each is enough. You are ruling out psychotic depression and primary psychosis.

    • "Has anything been happening that has felt strange or unreal?"
    • "Have you heard voices when no-one is there?"
    • "Do you feel anyone is trying to harm you or talk about you?"

  6. 6. Take the contextual history

    Life stressors, substances, medical context and supports.

    • Stressors: job, relationships, finances, bereavement.
    • Alcohol - units per week, change recently, when they drink and why.
    • Recreational drugs.
    • Physical illnesses, current medications.
    • Past psychiatric history and family history.
    • Who lives with them, who they can talk to, social support.

  7. 7. Communicate your assessment honestly

    Name what you are seeing. Give the patient the working diagnosis in plain language.

    • "From what you've told me, I think you are going through a moderately severe depression."
    • Validate: "What you've described - the low mood, the trouble sleeping, the thoughts of not being here - these are symptoms of an illness, not a personal failing."
    • Check understanding: "Does that fit with how you've been feeling?"

  8. 8. Build a safety plan

    This is the safety-critical block. You cannot leave without one.

    • Address means: "You mentioned the rope in your garage. Could we agree to remove it - either you, or someone you trust?"
    • Crisis contacts: 999 / NHS 111 / Samaritans 116 123 / local crisis team number.
    • Identify one trusted person who can be with them tonight.
    • Agree what they will do if the thoughts get stronger - call who, go where.

  9. 9. Arrange urgent psychiatric input

    Do not discharge with an SSRI script and a six-week follow-up.

    • Urgent referral to the crisis team or liaison psychiatry today.
    • Consider psychiatric admission if risk cannot be safely managed in the community.
    • If managed in the community, follow-up within 1-2 weeks, not 6.
    • With patient consent, contact a family member to be with them.

  10. 10. Discuss treatment, lifestyle and close

    Briefly cover treatment, address the alcohol, invite questions.

    • Treatment - SSRI (sertraline first-line) and talking therapy (CBT). Explain that medication takes 2-4 weeks to work.
    • Warn about possible early worsening or activation on starting an SSRI - come back if it happens.
    • Advise reducing alcohol - it worsens depression and increases suicide risk.
    • Sleep hygiene and gentle exercise.
    • Invite questions, thank him, ensure he leaves with a specific plan for today.

Common pitfalls

  • Not asking directly about suicide - the single most common cause of fail in this station.
  • Euphemising suicide questions ("Have you had any dark thoughts?") rather than asking plainly. Plain language is the standard.
  • Looking shocked or judgemental when the patient discloses thoughts of suicide.
  • Rushing the consultation - asking depression questions in a tight 90-second sweep.
  • Forgetting to screen for alcohol and drug use.
  • Skipping the brief psychosis screen.
  • Prescribing an SSRI alone with a routine six-week follow-up when active suicidal ideation is present - a safety-critical fail.
  • Not addressing the rope (or whatever specific means the patient mentions) - means restriction is a graded item.
  • Forgetting to give a specific crisis resource (Samaritans 116 123, NHS 111, crisis team number).

Frequently asked questions

How do I ask about suicide in a PLAB 2 station?

Use plain language and ask directly. A standard phrasing is: "Sometimes when people feel like this, they have thoughts of harming themselves or ending their life. Have you had any thoughts like that?" If the patient says yes, ask about plan, means, intent and protective factors. Failure to ask directly is an automatic fail in real PLAB 2.

What is a minimal safety plan?

A minimal safety plan covers four things: means restriction (agreeing to remove the rope, medication, weapon or other method), a named trusted person who can be with them, a specific crisis contact (Samaritans 116 123, NHS 111, A&E or local crisis team number), and an action they will take if thoughts of suicide get stronger.

Can I prescribe an antidepressant in this station?

You can mention SSRI initiation (sertraline first-line per NICE) as part of the management plan, but a prescription alone is not enough when active suicidal ideation is present. The station expects urgent psychiatric input, a safety plan and short-interval follow-up alongside any medication.

When is urgent psychiatric admission considered?

Consider urgent psychiatric admission when the patient has active suicidal ideation with a specific plan, access to means, recent attempts, psychotic features, or when no safe community plan can be agreed. Discuss with the crisis team or liaison psychiatry the same day; the decision is theirs but the station expects you to raise it.

What if the patient asks me not to tell anyone?

Acknowledge confidentiality but be honest about its limits when safety is involved. You can say: "What we talk about is confidential, but if I think you are at serious risk, I have a duty to involve others to keep you safe - that's part of my job." Aim for a collaborative referral rather than confidentiality-breaking against the patient's will.

Can I practise the PLAB 2 depression and suicide-risk station for free?

Yes. Plabity gives every new user one free station credit on signup. The depression with suicidal ideation station is available immediately - you speak with a simulated patient in real time, work through the full risk assessment and safety plan, and receive a PLAB-rubric-aligned mark scheme with personalised feedback at the end.

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