Psychiatrist to GP Letter

Thank you for referring John to see me. John is a 35-year-old male. He is single and lives in a rented flat. He is currently employed as a software engineer. John presented with symptoms of low mood, anhedonia, and fatigue for the past six months. He reports feeling overwhelmed and struggling to concentrate at work. He has a history of similar episodes, with the last one occurring two years ago. He has previously been prescribed sertraline by his GP, which provided some relief. He reports that he has not been taking any medication for the past 6 months. He reports that he has been feeling increasingly isolated and withdrawn from social activities. He denies any suicidal ideation or self-harming behaviours. John's mood appeared low during the consultation. He reported feeling sad and hopeless. John denies any symptoms or history of psychosis. John reports experiencing frequent feelings of anxiety, particularly in social situations. He describes physical symptoms such as a racing heart and sweating. He has been avoiding social gatherings due to his anxiety. John denies any symptoms or history of eating disorders. John denies any symptoms or history of ADHD. John denies any symptoms or history of Autism Spectrum Disorder (ASD). John's past psychiatric history includes a diagnosis of recurrent depressive disorder. He has previously been treated with sertraline and CBT. There is no family history of psychiatric conditions. John reports that he drinks alcohol socially, consuming approximately 2-3 units once or twice a week. He denies any history of alcohol dependence or withdrawal symptoms. John denies any history of drug use, cigarette use, or gambling disorder. John's past medical history is unremarkable. He reports no significant medical conditions or surgeries. John has no known contraindications for medications. John has no relevant forensic history. John has no known allergies. John is currently prescribed the following medication: Sertraline 50mg daily. John grew up in a supportive family environment. He had a positive relationship with his parents and siblings. He excelled in school and went on to obtain a degree in computer science. He has been working as a software engineer for the past 10 years. He has had several long-term relationships, but is currently single. He reports feeling lonely and isolated, and is struggling to form new relationships. John appeared well-groomed and appropriately dressed. His behaviour was cooperative and engaged. His speech was normal in rate and rhythm. His mood was low, and his affect was congruent. His thought form was linear, and his thought content was negative. He denied any delusions or hallucinations. He demonstrated good insight and judgement. So, in summary, my impression is John suffers from recurrent depressive disorder associated with generalised anxiety disorder. My management for John: I plan to restart John on sertraline 50mg daily and monitor his response. I will also refer him to a therapist for CBT. I will schedule a follow-up appointment in four weeks to assess his progress and adjust his treatment plan as needed. Thank you once again for referring John to see me. I will keep you informed of his progress.