New Psychiatric Assessment

History of Presenting Complaints: - Patient, Ms. Clara Davies, a 34-year-old female, presents with a 6-month history of persistent low mood, anhedonia, significant weight loss (7kg), and severe insomnia. She reports feeling overwhelmed, tearful daily, and has lost interest in her previously enjoyed hobbies, such as painting and hiking. She states her symptoms began shortly after being made redundant from her marketing executive position. - Associated symptoms include chronic fatigue, difficulty concentrating, feelings of worthlessness, and occasional passive suicidal ideation, though she denies any specific plans or intent. Past Medical & Psychiatric History: - Past psychiatric history includes a single episode of moderate depression 5 years ago, treated with Sertraline 50mg daily for 12 months, with full remission. No prior psychiatric hospitalizations. Denies history of mania or hypomania. - Chronic medical conditions: Well-controlled hypothyroidism, diagnosed 2 years ago, managed with Levothyroxine 75mcg daily. Medications: - Current medications: Levothyroxine 75mcg daily. No known drug allergies. Family History: - Maternal aunt diagnosed with bipolar disorder. Paternal grandfather had a history of recurrent depression. Social History: - Occupation: Currently unemployed; previously a marketing executive. Level of education: Master's degree in Marketing. - Substance use: Denies smoking or recreational drug use. Reports occasional alcohol consumption (1-2 units per week), but states this has decreased recently due to low mood. - Social support: Lives alone but has a close relationship with her sister and a few friends, though she has been isolating herself recently. Mental Status Examination: - Appearance: Ms. Davies is neatly dressed in casual attire, with fair hygiene. She appears visibly tired with slightly dishevelled hair. - Behaviour: Psychomotor slowing observed; she speaks softly and maintains limited eye contact. She fidgets with her hands throughout the interview. - Speech: Speech is soft, slow in tempo, and reduced in volume. Coherent, but with prolonged latencies. - Mood: "Miserable, hopeless, utterly drained." - Affect: Restricted and congruent with reported mood. Reactivity is blunted. - Thoughts: Thought process is linear, but content is preoccupied with feelings of failure and self-blame. No evidence of delusions, paranoia, or obsessions. - Perceptions: Denies any hallucinations or perceptual disturbances. - Cognition: Oriented to time, place, and person. Concentration is mildly impaired, reporting difficulty focusing on tasks. Memory appears intact. - Insight: Partial insight into her condition, acknowledging she feels depressed but attributes it primarily to her unemployment rather than an illness. - Judgment: Impaired judgment, evidenced by recent financial decisions (e.g., impulsive online purchases) and difficulty making everyday decisions. Risk Assessment: - Endorses passive suicidal ideation (wishes she wouldn't wake up) but denies active plans, intent, or access to means. No history of self-harm. Denies homicidal ideation or aggressive impulses. Assessed as moderate risk for self-harm given chronic low mood and passive ideation; protective factors include supportive family and no intent/plan. Discussion: - Patient was engaged in a discussion regarding treatment options, including antidepressant medication and psychotherapy. She expressed reservations about restarting medication due to past side effects (nausea) but was open to exploring therapeutic approaches. She inquired about Cognitive Behavioural Therapy (CBT). Patient acknowledged the importance of social support and agreed to try to reconnect with her sister more frequently. Summary: - 34-year-old female presenting with a major depressive episode, severe, without psychotic features (DSM-5 criteria met for 5 of 9 symptoms for over 2 weeks, causing significant distress and functional impairment). Relevant psychological scales (e.g., PHQ-9, GAD-7) were not administered during this initial assessment but are planned for follow-up. Treatment Plan: - Investigations: Baseline blood tests (FBC, U&Es, LFTs, TFTs, B12, Folate) to rule out organic causes. - Medication plans: Discussed initiating Sertraline at 25mg daily, titrating up to 50mg after 1 week, with close monitoring for side effects and efficacy. Provided prescription and explained potential side effects. - Psychotherapy plans and strategies: Referral to a psychologist for CBT. Encouraged daily light exercise and structured routine. - Planned family meetings & collateral information, psychosocial interventions: Encourage reconnecting with social support network. Consider collateral information from sister if patient consents. - Follow-up appointments and referrals: Follow-up psychiatric review in 2 weeks (1 November 2024) to assess medication response and side effects. Referral to local employment support services. Safety Plan: - Detailed safety plan developed. Patient to contact her sister or attend A&E if suicidal ideation escalates or becomes active. Provided crisis helpline numbers. Agreed to remove access to excessive funds for impulsive spending. Regular check-ins with her sister were arranged.