The Man Who Keeps Coming Back for Sick Notes

Formulation - think biopsychosocial:

• Biological: Normal investigations make occult physical disease less likely; poor sleep and increased alcohol are relevant. Screen for depression and anxiety formally (e.g., PHQ-9, GAD-7) and take an alcohol history (AUDIT-C).
• Psychological: Tearfulness, hopelessness language ('my family is finished'), poor sleep - features of a depressive or adjustment disorder in the context of work stress. He denies suicidal ideation but this must be actively and specifically assessed, not just accepted at face value.
• Social: Job insecurity, performance plan, financial responsibility for family - a major stressor driving the presentations.

What the repeated presentations tell you:

• Frequent attendance with medically unexplained symptoms is a recognised pattern of somatisation/distress presenting physically, especially in men who find it hard to disclose emotional problems. The sick note requests are a way of communicating distress.
• This is a consultation pattern, not a series of unrelated complaints - the exam rewards recognising the pattern and addressing the underlying issue rather than repeating normal tests.
• Do not collude with endless investigation or with automatic sick-noting; both reinforce the cycle.

Responding to the sick note request:

• Do not simply agree or refuse. Explore what he hopes the note will achieve - is it time to recover, or avoidance of a feared situation?
• Explain that a 3-month note is unlikely to be in his interest: prolonged absence can entrench avoidance, increase risk of job loss, and worsen low mood. Evidence supports early, supported return to work with modifications where possible.
• Offer a short, time-limited note (e.g., 1-2 weeks) with a review, and discuss workplace adjustments - talking to occupational health, phased return, reasonable adjustments.
• Be clear that the note is a clinical judgement, not a bargaining chip.

Management plan:

1. Risk assessment - explicit, documented suicide risk assessment; ask directly about thoughts, plans, means, and protective factors. Give crisis numbers.
2. Mental health assessment - formal depression/anxiety screening; consider referral to primary care mental health/IAPT or counselling.
3. Address alcohol - brief intervention, quantify intake, advise reduction.
4. Sleep hygiene and behavioural activation - practical, evidence-based.
5. Consider medication if moderate-severe depression - discuss with him; SSRIs are first-line.
6. Workplace liaison - with consent, contact occupational health.
7. Scheduled review in 1-2 weeks - do not leave open-ended.

Document the discussion, the risk assessment, and the agreed plan.

This is a rupture in the therapeutic relationship and must be addressed directly, not deflected.

Repair steps:

1. Acknowledge and validate - "I can hear that you feel I haven't taken you seriously. That's not what I want you to leave with." Do not become defensive.
2. Name the pattern honestly but kindly - "We've met many times and your tests have been normal, which can feel frustrating. I think there may be something else going on that we haven't talked about properly - your sleep, your drinking, and how you're coping at work."
3. Make a clear commitment - agree a specific follow-up, a named plan, and what will happen at each step. Continuity matters.
4. Share the decision - ask what would help him most; negotiate the sick note and the referral together.
5. Be explicit about what you are doing - risk assessment, mental health referral, review - so he sees action, not dismissal.
6. Document his concerns and your response.

The exam point: frequent attenders with distress often have a history of feeling dismissed. Repairing the relationship is itself therapeutic and reduces repeat attendance more than another set of blood tests.