Initial Psychiatric Assessment

**Initial Psychiatric Assessment** **Background:** Mr. John Smith, a 35-year-old male, identifies as heterosexual. He is married with two children and works as a software engineer. **Reason for Assessment / Referral:** Mr. Smith was referred for a psychiatric assessment by his GP due to increasing symptoms of low mood, anxiety, and difficulty sleeping. The purpose of the assessment is to evaluate his symptoms and determine an appropriate course of treatment. **History of Presenting Illness:** Mr. Smith reports that his symptoms began approximately six months ago, gradually worsening over time. He initially experienced mild feelings of sadness and worry, which have escalated to the point where they significantly impact his daily functioning. He reports that the symptoms are worse in the mornings and improve slightly in the evenings. He has not sought any treatment for these symptoms previously. Current Symptoms: Low mood, anhedonia, anxiety, insomnia, fatigue, poor concentration. Impact on Functioning: Difficulty at work, withdrawal from social activities, strained relationship with his wife, neglecting self-care. Coping and Insight: Mr. Smith reports that he has tried to cope by increasing his exercise, but this has not been effective. He acknowledges that his symptoms are impacting his life and is seeking help. **Past Psychiatric History:** Mr. Smith denies any previous psychiatric diagnoses, hospitalisations, or psychological therapies. History of Self-harm or Suicidal Thoughts: Denies any history of self-harm or suicidal ideation. **Family Psychiatric History:** His mother has a history of depression, and his maternal grandmother died by suicide. **Family Dynamics:** Mr. Smith describes his childhood as generally positive, although he reports feeling pressure to succeed from his parents. **Drug and Alcohol History:** Mr. Smith reports drinking alcohol socially, approximately once or twice a week. He denies any recreational drug use. He is a non-smoker. **Forensic History:** Denies any history of legal trouble. **Medical History:** Mr. Smith has no significant medical history. **Meds/Allergies:** * None **Developmental, Personal & Social History:** Mr. Smith reports a normal developmental history. He had a happy childhood and did well in school. He has always been a high achiever. He reports being bullied at school. Adolescence: Mr. Smith reports that he struggled with low mood and anxiety during adolescence, but these symptoms resolved without intervention. Trauma History: Denies any history of trauma. Social Circumstances and Support Network: Mr. Smith is married and lives with his wife and two children. He has a supportive network of friends and family. **Mental State Examination:** Mr. Smith is a well-groomed, cooperative male who makes good eye contact. His speech is normal in rate and rhythm. His mood is low, and his affect is constricted. His thought process is linear and goal-directed. He denies any hallucinations or delusions. His cognition is intact. He demonstrates good insight and judgment. **Risk Assessment:** Mr. Smith denies any current risk to self or others. He has protective factors including a supportive family and a strong desire to get better. **Formulation** Predisposing * Family history of depression. * Personality traits of perfectionism and high achievement. Precipitating * Work-related stress. * Relationship difficulties. Perpetuating * Negative thought patterns. * Social isolation. Protective * Strong social support. * Good insight. * Motivation to seek treatment. **Impression / Summary:** Mr. Smith presents with symptoms consistent with a major depressive episode. He is experiencing significant distress and impairment in multiple areas of his life. He is motivated to engage in treatment. **Diagnosis / Provisional Diagnosis:** Major Depressive Disorder, single episode (F32.9) **Plan and Recommendations:** * Initiate antidepressant medication (e.g., sertraline). * Recommend cognitive behavioural therapy (CBT). * Schedule follow-up appointment in four weeks. * Provide psychoeducation about depression and treatment options.