Low Mood/irritability and Cannabis Withdrawal — Free SCA Practice Case
Adolescent with low mood/irritability and cannabis Withdrawal
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Leo Thorne
Age
17 years
Consultation Type
VideoAge
17
Situation
Video Consultation.
Reason for Encounter
"Patient booked a routine video appointment. Triage note states: 'Feeling angry all the time and low mood. A-Levels are coming up.'"
Medical Records
- ●PMH: Asthma.
- ●Medications: Salbutamol inhaler PRN.
- ●Allergies: NKDA.
Recent Notes
- ●Has not been seen in the practice for 3 years.
Patient Script
For the friend playing the patient role
Character Overview: You are Leo, a 17-year-old student in your final year of Sixth Form (A-Levels). You are under immense academic pressure. You are speaking to the doctor via a video call from your bedroom. Over the last 6 months, you have been smoking cannabis (weed) to cope with the stress. It started as a weekend activity, but now you smoke 2 or 3 "zoots" (joints) every single evening to help you sleep and switch your brain off. The problem is the mornings and the daytime. When you are not high, you feel overwhelmingly irritable, agitated, and depressed. You snap violently at your mother over minor things, which makes you feel deeply guilty and lowers your mood further. You have recently run out of money to buy cannabis, and the last 48 hours without it have been intolerable—you feel furious, shaky, and unable to sleep. Your Belief: You believe you have clinical depression and anger issues, and that cannabis is the only thing keeping you sane. You want the doctor to prescribe you antidepressants or "something to calm me down" so you can focus on your exams. You do not realise that your extreme irritability and insomnia are classic symptoms of cannabis withdrawal. You will not volunteer your cannabis use unless the doctor explicitly asks about drugs, alcohol, or how you are coping with stress.
ICE — Ideas, Concerns, Expectations
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Ideas: You believe you are suffering from clinical depression and possibly an anger management problem. You think the stress of A-Levels has triggered a mental health condition. You have no awareness that cannabis withdrawal could be causing your symptoms — as far as you are concerned, weed is your medicine, not the problem.
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Concerns: You are terrified of failing your A-Levels and losing your university place. You are deeply worried about your relationship with your mum — the guilt of snapping at her eats away at you. Underneath the bravado, you are scared that something is genuinely wrong with you and that you are losing control of your emotions.
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Expectations: You want the doctor to prescribe antidepressants or "something to calm me down" so you can get through exam season. You want to be taken seriously as someone who is struggling, not dismissed as a moody teenager. You are not expecting to be asked about cannabis and would be surprised if the doctor connected it to your symptoms.
(ICE is not volunteered. It surfaces only when the candidate directly explores your perspective — e.g. "What do you think is causing this?" or "What were you hoping we could do today?")
If Asked — Medical History and Medications
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If asked about any other medications or supplements: "No, nothing. I don't take anything else."
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If asked why he hasn't been to the GP before: "I just haven't needed to. I've been healthy. This is the first time I've felt like something is actually wrong."
Social History and Lifestyle Impact
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Occupation / daily life context: You are in Year 13, studying three A-Levels. You are predicted good grades and have a conditional offer for university, which depends on your results. Your daily life revolves around school, revision, and — until two days ago — smoking weed in your bedroom each evening. You live with your mum. Your parents separated when you were 14 but this is not something you dwell on — you mention it matter-of-factly only if asked directly about family.
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Lifestyle impact of the condition: The impact is concrete and escalating. You cannot revise in the evenings anymore because the irritability makes it impossible to concentrate — you end up staring at your notes and then slamming your laptop shut. You have stopped going to your part-time job at a local cafe because you are too agitated to deal with customers. You missed two days of school this week because you couldn't sleep at all without the weed and were too exhausted and angry to face anyone. Your predicted grades are slipping and your teachers have started asking if everything is okay, which makes you feel embarrassed and defensive.
(This information is shared naturally in conversation — for example, when asked how things are at school, or what the anger is doing to your day-to-day life. It is not delivered as a monologue.)
Consultation Flow & Responses:
- ●The Opening:
- ●If the doctor asks an open question: "Hi Doctor. I just feel awful lately. I'm constantly angry, I'm snapping at my mum, and my mood is just rock bottom. I've got my A-Levels in a few months and I can't concentrate. I think I need antidepressants."
- ●Data Gathering (The Layers):
- ●Layer 1: Remote Safeguarding & Confidentiality (Crucial for 17yo):
- ●If asked who is in the house/room: "I'm in my bedroom. My mum is downstairs, but my door is locked. She doesn't know I'm speaking to you."
- ●If asked about confidentiality concerns: "You aren't going to tell my mum about this, are you? If she knew how bad things were, she'd freak out."
- ●Layer 2: The HEADSS Assessment (Home, Education, Activities, Drugs, Suicidality):
- ●If asked about Drugs/Alcohol/Coping mechanisms: "Well, I smoke a bit of weed. Just to help me sleep and relax. But it's not the weed causing the problem, it's the only thing that actually helps my mood."
- ●If asked about frequency of use: "Usually 2 or 3 joints a night. But I ran out of money two days ago, so I haven't had any, and my anger has been completely out of control since then."
- ●Layer 3: Psychiatric & Risk Screen:
- ●If asked about self-harm or suicidal thoughts: "No, I'd never hurt myself. I just feel exhausted and angry."
- ●If asked about psychotic symptoms (paranoia, hearing voices): "No, nothing weird like that. I just feel highly stressed."
If Asked — Associated Symptoms
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If asked about appetite: "I've barely eaten in the last two days. I just don't feel hungry at all. When I was smoking I'd get the munchies and eat loads, but now I feel a bit sick at the thought of food."
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If asked about sweating or feeling hot: "Yeah, actually — I've been sweating loads at night even though my room isn't warm. I keep waking up with my t-shirt soaked."
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If asked about headaches: "Yeah, I've had a constant dull headache since I stopped. Like a pressure behind my eyes."
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If asked about tremor or shaking: "My hands have been a bit shaky the last couple of days. I noticed it when I was trying to write revision notes."
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If asked about anxiety or panic attacks: "I wouldn't say panic attacks, but I feel wound up all the time — like something bad is about to happen. My chest feels tight sometimes."
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If asked about concentration or memory: "My concentration is shot. I can't focus on revision at all. But honestly, that's been getting worse for months, even before I stopped smoking."
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If asked about hallucinations or unusual experiences: "No, nothing like that at all."
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If asked about paranoia or feeling watched: "No. I'm stressed, not paranoid."
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If asked about chest pain or palpitations: "No chest pain. My heart does feel like it races a bit sometimes, especially when I'm lying in bed trying to sleep."
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If asked about coughing or breathing problems: "I cough a bit sometimes after smoking but nothing major. No blood or anything. My breathing is fine."
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If asked about weight changes: "I don't weigh myself, but my jeans feel looser. I think I've probably lost a bit of weight recently."
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If asked about vivid dreams or nightmares: "When I do manage to sleep, the dreams are intense — really vivid and weird. That's never happened before."
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If asked about any other drug use: "No, just weed. I don't touch anything else. I've tried a vape a few times but I don't really like it."
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If asked about alcohol: "I drink a bit at parties, maybe a couple of beers, but I'm not a big drinker. I haven't had anything to drink in weeks."
Negotiation & Collaborative Management Plan:
- ●If the Doctor lectures you to "just stop smoking weed" or tells you it's bad for your brain:
- ●Reaction: Defensive and withdrawn. "You don't get it. It's the only thing that stops the stress. If I stop, I can't sleep and I fail my exams." (Candidate fails for poor adolescent engagement and lacking Motivational Interviewing skills).
- ●If the Doctor agrees to prescribe Antidepressants (SSRIs) over the video call:
- ●Reaction: "Okay, great. Will they work immediately? Because I need to study tonight." (Candidate critically fails for inappropriate prescribing in an adolescent with an active substance dependency).
- ●If the Doctor formally links the irritability to Cannabis Withdrawal:
- ●Reaction: "Wait, you're saying the anger and the not sleeping is because my brain is withdrawing from the weed? Not because I'm actually depressed? I didn't know weed had withdrawals."
- ●If the Doctor uses Motivational Interviewing and suggests a Young Persons Substance service:
- ●Reaction: "So if I can get through this first week or two, the anger might actually fade? I don't want to talk to CAMHS, but a specific young person's worker to help me cut down sounds okay. I just need help getting to sleep without it."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnostic Distinction: Cannabis Withdrawal Syndrome vs Primary Depression
The central diagnostic challenge in this case is distinguishing Cannabis Withdrawal Syndrome (CWS) from a primary depressive or anxiety disorder. This distinction has direct management implications and must be made before any psychiatric diagnosis is formulated.
- ●Cannabis Withdrawal Syndrome (recognised in DSM-5 and ICD-11) occurs following abrupt cessation or significant reduction in heavy, prolonged use. It is not a behavioural quirk — it is a physiologically mediated syndrome.
- ●Chronic THC exposure downregulates CB1 cannabinoid receptors, leading to a hyper-aroused, dopamine-depleted state on cessation. This directly produces the mood and neurovegetative symptoms that mimic depression.
- ●The withdrawal symptom cluster includes: irritability and anger (often the most pronounced feature), insomnia, vivid and disturbing dreams, depressed mood, reduced appetite, nausea, night sweats, tremor, headache, and restlessness. Onset is typically within 24–72 hours of cessation, peaking at days 2–6.
- ●The diagnostic key is temporal correlation: symptoms that emerge or acutely worsen within 48 hours of stopping cannabis are withdrawal, not a primary disorder. Candidates must establish the timeline explicitly.
- ●A reliable diagnosis of a primary mood disorder cannot be made while a patient is actively withdrawing from a substance that directly disrupts mood, sleep, and neurochemistry. Psychiatric assessment should be deferred until a sustained period of abstinence (typically 3–4 weeks) has been achieved.
Safe Prescribing in Under-18s: SSRIs and Hypnotics
Two prescribing decisions are tested in this case. Both require a firm, professionally explained refusal.
SSRIs (NICE CG28 / NICE NG134):
- ●GPs must not initiate antidepressants for depression in under-18s in primary care. This is a hard boundary — not a preference.
- ●SSRI initiation in adolescents requires a formal CAMHS assessment and, where prescribed, weekly monitoring for the first four weeks due to the documented risk of paradoxical agitation and emergent suicidal ideation.
- ●The rationale for declining must be explained to the patient clearly and non-punitively: not that the GP doubts their distress, but that the diagnosis cannot be confirmed while withdrawal is active, and that prescribing requires specialist oversight in this age group.
- ●The candidate should commit explicitly to reassessing mood once the withdrawal period has resolved and to referring to CAMHS if depression is confirmed at that point.
Hypnotics and Sedating Agents:
- ●Do not prescribe zopiclone, promethazine, melatonin, or any sedating medication for withdrawal insomnia in a 17-year-old.
- ●There is no evidence base for pharmacological sleep aids in adolescent CWS, and substituting one dependency risk for another is clinically and ethically inappropriate.
- ●Withdrawal insomnia is best managed with structured non-pharmacological sleep hygiene advice (see Section 4).
Adolescent Confidentiality and Gillick Competence
This is a video consultation with a 17-year-old disclosing substance use. Confidentiality must be addressed explicitly and early.
- ●At 17, a young person is presumed to have capacity to consent to medical treatment under the Family Law Reform Act 1969. Gillick competence applies to those under 16; at 17, capacity is presumed as for an adult.
- ●The GMC requires that a competent young person's confidentiality be respected to the same standard as an adult's, unless there is a serious and immediate risk of harm to themselves or others.
- ●Routine disclosure about cannabis use and low mood does not meet the threshold for breach of confidentiality. The candidate must make this explicit to Leo — not a vague reassurance, but a clear statement of the rule and its exception: "Everything you tell me today is confidential. The only exception would be if I was seriously concerned for your safety — and even then I would always try to speak to you about it first."
Clinical Management: Cannabis Withdrawal
Management has four components: psychoeducation, non-pharmacological symptom support, harm reduction, and referral.
Psychoeducation — Reframing the Patient's Belief:
- ●Leo believes cannabis is his medicine and that his symptoms represent depression. The candidate must correct this belief clearly, accessibly, and without condescension.
- ●The reframe: the brain has become dependent on THC to regulate mood and sleep. Without it, the system is dysregulated. The anger, insomnia, and low mood are not signs of underlying depression — they are signs that the brain is readjusting. The cannabis has been creating the problem it appeared to solve.
- ●After delivering this explanation, check understanding and give Leo space to respond — this is the pivotal moment of the consultation.
Withdrawal Timeline — Setting Expectations:
- ●Symptoms typically peak at days 2–6 and largely resolve within 1–2 weeks of cessation.
- ●Giving Leo a realistic timeline is essential: without it, he will interpret continued symptoms as evidence that he must return to cannabis, making relapse almost inevitable.
Non-Pharmacological Symptom Support:
- ●Regular physical exercise — reduces irritability and promotes natural sleep
- ●Strict sleep hygiene: consistent bedtime, no screens in the hour before sleep, cool room, avoid caffeine after midday
- ●Regular small meals and adequate hydration despite reduced appetite
- ●Acknowledging that the first 5–7 days are the hardest and that this is time-limited
Harm Reduction (If Full Cessation Is Not the Immediate Goal):
- ●If Leo expresses ambivalence about stopping, a harm reduction approach is clinically appropriate and more likely to produce engagement than demanding immediate abstinence.
- ●This includes: reducing frequency, avoiding daytime use, avoiding use before revision sessions, and avoiding mixing cannabis with tobacco.
- ●Motivational Interviewing (OARS: open questions, affirmations, reflective listening, summaries) is the evidence-based framework for exploring ambivalence in adolescent substance use.
Referral Pathways: CYP Drug and Alcohol Services vs CAMHS
Two distinct pathways apply to this case, and candidates must understand the distinction.
CYP Drug and Alcohol Services (primary referral):
- ●Adolescents with cannabis dependency are referred first to Local Authority-commissioned Children and Young People's Drug and Alcohol Services — not to CAMHS. These services (often delivered by organisations such as Change Grow Live or We Are With You) provide youth-specific workers, motivational enhancement therapy, CBT for substance use, and harm reduction counselling.
- ●Referring to adult drug and alcohol services is inappropriate for a 17-year-old.
CAMHS (conditional referral):
- ●CAMHS referral becomes appropriate if: (1) Leo meets threshold for psychosis or severe mental illness, (2) there is active suicidality or self-harm risk, or (3) a formal depressive disorder is confirmed after sustained abstinence.
- ●In this consultation, CAMHS referral is not yet indicated — but the candidate should document a clear plan for reassessing mood at 2–4 weeks post-withdrawal and for referring if depression is confirmed at that point.
School and Pastoral Support:
- ●Given Leo's immediate risk to his A-Level results and conditional university offer, the candidate should explore whether school pastoral support, adjusted workload expectations, or a GP letter to the school would be helpful — this is part of holistic management.
Cannabis-Associated Psychosis and Red Flags
Heavy adolescent cannabis use carries a specific and significant risk of psychotic illness that must be screened for in this consultation.
- ●Cannabis-associated psychosis: Regular heavy use of high-potency cannabis (skunk/sinsemilla) in adolescence is associated with a substantially elevated risk of psychotic illness, including early-onset schizophrenia. The risk is higher with earlier age of initiation and greater frequency of use.
- ●The candidate must screen explicitly for: paranoia, auditory hallucinations, unusual perceptual experiences, and thought disorganisation.
- ●Leo denies all of these — but the screen must be documented.
- ●Red flags requiring same-day action: any features of acute psychosis; active suicidal ideation with intent or plan; inability to care for self; risk of harm to others.
- ●Red flags requiring urgent (within days) review: emerging or worsening paranoia without full psychotic features; marked functional deterioration not explained by withdrawal; sustained suicidal ideation without immediate plan.
Safety Netting and Follow-Up
Safety netting in this case must be specific — not generic reassurance.
- ●Advise Leo to contact the surgery same-day or attend A&E if he develops: paranoia, hearing voices, thoughts of self-harm or suicide, or inability to care for himself.
- ●Advise him to call 999 or go to A&E if he is in immediate danger.
- ●Give Leo a named route back to care — not "come back if you're worried." He should know that his GP is the point of contact and that he can call the same day if needed.
- ●Follow-up appointment: arrange a specific review at 2 weeks to reassess mood formally once the acute withdrawal period has resolved, and to determine whether a CAMHS referral for depression assessment is indicated at that point. Document the rationale for deferring the depression diagnosis explicitly.
Common Candidate Mistakes in This Case
- ●Prescribing SSRIs over video to a 17-year-old is the most significant error in this case. It represents a failure of safe prescribing, a failure to identify the withdrawal syndrome, and an inappropriate response to an adolescent presenting with a substance dependency. It is a critical fail.
- ●Missing the cannabis use entirely — by failing to ask about substance use, drugs, or coping mechanisms — means the withdrawal syndrome is never identified and the entire consultation is built on a false premise.
- ●Accepting "a bit of weed" at face value without quantifying frequency, duration, and escalation. 2–3 joints every evening for 6 months represents physiological dependence, not recreational use. The escalation pattern and the abrupt cessation must be established.
- ●Lecturing Leo about cannabis harms without first acknowledging his distress causes him to shut down. The consultation must start with validation of his academic pressure, not a cannabis warning.
- ●Providing no withdrawal timeline — leaving Leo without a framework for what to expect makes relapse highly likely.
- ●Referring to CAMHS immediately without first screening for the clinical features that would determine priority, or without explaining why the depression diagnosis must be deferred.
The HEADSS Framework in Adolescent Consultations
This case tests the candidate's ability to use a structured adolescent psychosocial assessment framework rather than a purely biomedical history.
- ●HEADSS (Home, Education/Employment, Activities, Drugs/Alcohol, Suicidality/Self-harm/Sex) is the validated framework for adolescent psychosocial review. It is the adolescent equivalent of a systems review.
- ●Using HEADSS in this case systematically uncovers: the home situation (parental separation, guilt about mum), education pressure (A-Levels, university offer), the cannabis use (only disclosed if directly asked), and the risk screen (self-harm, suicidality).
- ●A purely biomedical approach — symptom review, examination, diagnosis, management — will miss the cannabis disclosure and therefore misdiagnose the case entirely.
- ●Begin with open questions and build rapport before the sensitive domains (drugs, suicidality) — but do not avoid these domains because the patient is a teenager.
Mapped to the RCGP curriculum topic: Smoking, Alcohol and Substance Misuse.
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