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You are an FY1 doing a GP placement. Billie Rubin is your next patient. She is a 19-year-old art student presenting with a low mood. She has no significant past medical history of note and takes no regular medications.

Please take a history from Billie making sure you assess her risk of harm.

You are Billie Rubin, a 19-year-old student who has just started a fine art degree at Birmingham University. Over the last two months, you have noticed that you have been feeling much more down than usual. Usually you are a cheery person and extremely sociable with many friends.

HPC: You’ve been feeling this way for about two months and you’ve never had any episodes like this in the past. Your grandmother died two months ago and you feel like although you accepted her death, the sadness just stuck with you and won’t go away. You think it’s gotten worse over the last few weeks but you find it hard to remember how the low mood has changed over time. You don’t really have an appetite at the moment, although usually you’re able to eat a lot and enjoy your food. You haven’t weighed yourself recently, but you don’t think you’ve lost any weight. You’ve not noticed a change in your bowel habit, or any intolerance to cold.

Your friends keep calling you and asking you to hang out but you’re finding yourself not replying to texts or facebook messages, avoiding your flatmates and wanting to spend more time on your own although you’re usually very extroverted. You still enjoy painting and reading though and your interest in these hasn’t changed. However you do struggle to concentrate on doing these for long periods of time. You have however been skipping university seminars, particularly in the mornings, as you have started waking up really early, which makes you feel really tired and drained.

You have never felt very high or overly happy, or heard any voices or seen anything that has not been there.

You have not thought about harming yourself in any way, ending your own life or harming anybody else.

ICE: You think that you are going crazy. This is not you at all and you are finding it hard to see yourself like this. You hate that you’re pushing people away but are very anxious about letting people in. If you feel able, you can tell the doctor that you really miss your grandmother; you were very close and you could tell her anything, whereas you don’t have that relationship with your parents.

You think that your low mood is due to a lot of things happening at once. Your sister has mental health issues, but your parents like to pretend that these problems don’t exist and thus it falls on you to be the support, which as the younger sibling becomes a bit much. You are stressed about university and are most worried about your lack of attendance, and that you will fail the year. Your parents are pressuring you to do well and you’re worried about disappointing them.

You are concerned that you’re going to feel like this forever and are expecting the doctor to be able to give you a solution. You are keen to discuss options for ‘fixing’ you.

PMH: None significant

DH: None No allergies

FH: Dad – type 2 diabetes, depression Sister – anxiety

SH: You live in student accommodation with 5 other students; you all get on well and they are very supportive. Your parents live about an hour away by train. You study fine art at Birmingham University and are enjoying the course. You drink “student amounts” – when you feel well in yourself you will probably go out at least 3 times a week and drink about a bottle of wine each time. You don’t think you have any problems with alcohol. You’ve tried marijuana once but didn’t like how it made you feel.

Students should be able to elicit the core symptoms, and additional biological and cognitive symptoms that Billie is experiencing, and the effect that these symptoms are having on her life. Students should be able to explore Billie’s concerns about what she thinks may be causing the problems, and the worries she has about the future. It is important that students ask about Billie’s risk of self harm, suicide and the risk to others. An appropriate examination would be an MSE.

Differential Diagnosis:

My differential diagnosis would be a psychiatric diagnosis, more specifically, a mood disorder. This would include unipolar depression as Billie demonstrates two of the three core symptoms of depression- low mood and anergia. Additional symptoms of early morning wakening, reduced concentration and loss of appetite also indicate depression. Bipolar disorder is less likely as Billie has said that she has never experienced feeling overly happy or high in mood which would indicate a manic episode.


What are the core symptoms of depression? Based on her symptoms, how could you classify Billie’s condition? How would you describe Billie’s risk? How could you investigate Billie further? What are the options for managing Billie’s symptoms?