“I just need a sick note for work”

A request for "a sick note for work stress" in a withdrawn young man can be the only door he can bring himself to open. The skill is to look beyond the request: recognise the more severe depressive episode (NICE NG222 (2022, updated December 2025) terms; pervasive low mood/anhedonia >2 weeks with biological features — early waking, weight loss, poor concentration, withdrawal, loss of valued activities) and NOT simply process the note and end the consultation. The non-negotiable task is an EXPLICIT suicide-risk assessment — ask directly about thoughts of being better off dead, active ideation, plan, intent, means and protective factors (asking does not increase risk) — alongside severity, the relationship-breakup trigger and the alcohol that worsens both mood and risk. The examinable hidden agenda is male stigma: he cannot say "I’m depressed" or "I’ve had dark thoughts", so the note is a legitimate entry point and a test of whether the doctor looks past it. Create safety so he drops the "just stress" framing, name depression without stigma, negotiate an evidence-based plan (Talking Therapies/SSRI, the note as part of care, alcohol, reconnection), and safety-net robustly with crisis routes and follow-up within 1 week (NICE NG222); NICE NG225 (2022) warns against risk tools or risk ratings, so the risk conversation leads to a safety plan, not a score.