Psych CASC / OSCE · Specialty psychiatry — sexual medicine interface
Explain FSIAD care and negotiate SSRI options — CASC communication station
MRCPsych/FRANZCP-style communication station: explain female sexual interest/arousal problems, SSRI contribution, psychosexual stepped care, and why flibanserin is not an automatic first step — including alcohol safety.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry registrar in outpatient clinic.[4]
Candidate instructions. Explain that low desire/arousal with distress can be a treatable clinical problem (FSIAD/HSDD pathway), normalise using responsive-desire concepts, explore SSRI contribution, outline stepped care, and discuss flibanserin realistically including alcohol contraindication teaching. Negotiate a collaborative plan. Check understanding and address shame. The examiner plays the patient.[1][2][3][4]
Candidate scenario
Depression is largely stable. Sertraline 100 mg orally daily for 10 months. Symptoms: reduced interest, reduced arousal, preserved some pleasure when not anxious, marked distress. Evening wine most nights. No IPV on brief screen. Partner supportive but worried. Patient arrived requesting flibanserin (“Addyi”) today after social media reading. Local access may require specialist pathways; even if available, process-of-care and alcohol are issues.[3][4]
Marking domains
- Empathy, shame reduction, non-judgemental sexual history tone
- Accurate plain-language model (responsive desire; not “broken”)
- SSRI sexual side-effect literacy and options (dose/switch/adjunct) without destabilising mood carelessly
- Stepped care: education, psychosexual/couple options, medical review before specialised drugs
- Flibanserin: modest average benefits; daily bedtime; no alcohol; not automatic first script today
- Collaborative plan, follow-up, teach-back
- Credits process-of-care sequencing and alcohol safety teaching rather than an immediate script-only response [2][3][4]
Reveal assessor key
Open. “I’m glad you raised this — sexual side-effects are common and treatable, and you are not broken. Can we map what changed and build a plan that protects your mood and your relationship goals?”[2][4]
Model. Desire often builds with arousal and the right context; antidepressants can dampen that circuitry; stress and relationship worry add inhibition.[1][2]
Plan. Review sertraline options; consider bupropion strategies if appropriate; sex therapy referral; lifestyle/alcohol discussion.[5][4]
Flibanserin. May help selected premenopausal HSDD after other factors addressed; benefits modest; taken 100 mg at night; must not mix with alcohol because of dangerous blood-pressure drops — evening wine is a hard stop for that pathway right now.[3]
Close. Written plan, follow-up timing, crisis contacts if mood dips during medication change, teach-back of one safety point (alcohol and flibanserin).[3][4]
Common fails
- Shaming the patient or refusing to discuss sex
- Instant flibanserin without SSRI/alcohol review
- Promising a miracle “female Viagra”
- Ignoring partner/relationship context or coercion
- No follow-up plan after antidepressant changes
- Omitting SSRI review, alcohol safety, or ISSWSH-style process of care before specialised pharmacotherapy [2][3][4]
References
- [1]Basson R The female sexual response: a different model J Sex Marital Ther, 2000.PMID 10693116
- [2]Montejo AL, Llorca G, Izquierdo JA, Rico-Villademoros F Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients J Clin Psychiatry, 2001.PMID 11229449
- [3]Katz M, DeRogatis LR, Ackerman R, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial J Sex Med, 2013.PMID 23672269
- [4]Clayton AH, Goldstein I, Kim NN, et al. The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women Mayo Clin Proc, 2018.PMID 29545008
- [5]Segraves RT, Clayton A, Croft H, et al. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women J Clin Psychopharmacol, 2004.PMID 15118489