Mental State Review (Generic)

Clinician's specialty: Psychotherapist **Mental Health Review** Client name: Sarah Jenkins Date of birth: 15/03/1998 Date of review: 01/11/2024 Clinician: Dr. Emily Roberts, Psychotherapist Location: Video **Presenting status** Ms. Jenkins presents for a routine mental health review. She reports feeling generally stable over the past month but notes some recurring challenges with sleep and occasional feelings of anhedonia, particularly related to previously enjoyed hobbies. She reports a slight dip in her overall wellbeing over the past two weeks, attributing it to increased work-related stress and a minor interpersonal conflict. She states that these issues are manageable but wanted to discuss them in therapy. Reason for review: Routine review of mental health progress and therapeutic goals. **Mood and emotional state** Low mood: Denies persistent low mood, describes transient feelings of sadness lasting a few hours, typically triggered by work stress. Severity is mild, managed with coping strategies discussed in therapy. Anxiety: Reports mild generalised anxiety, frequency has reduced. No panic symptoms. Avoidance behaviours are minimal, primarily social media checking when feeling overwhelmed. Irritability or agitation: Denies significant irritability or agitation. Reports occasional frustration which is verbally expressed and quickly resolved. Anhedonia: Reports intermittent loss of interest in painting, a previous highly engaging hobby. Describes it as a 'lack of motivation' rather than complete loss of pleasure. Hopelessness or helplessness: Denies feelings of hopelessness or helplessness. Expresses a strong desire to improve and actively participates in therapeutic interventions. No self-harm, risk to self or others, or suicidality present. **Psychotic symptoms** Hallucinations: Denies hallucinations. Delusions or paranoid thoughts: Denies delusions or paranoid thoughts. Thought disorder: Thought process is coherent, logical, and goal-directed. No evidence of thought disorder. Insight: Intact. **Suicidality and self-harm** Thoughts of death: Denies thoughts of death. Suicidal ideation: Denies suicidal ideation. Suicide attempts: No history of suicide attempts. Self-harm: Denies self-harm behaviours. Protective factors: * Strong family support system * Engaged in therapy and committed to recovery * Has clear future goals related to her career * Finds solace in her pet cat Risk management plan updated: Yes **Functioning** Ms. Jenkins' difficulties have a mild impact on her overall functioning. She maintains her professional responsibilities effectively, but her personal life, particularly her hobbies, has seen some slight disruption due to fluctuating motivation. She is actively working on integrating therapeutic strategies to mitigate this impact. Daily activities: Normal sleep onset, but often wakes up in the middle of the night. Eating habits are regular. Maintains good personal hygiene. Able to complete daily tasks with slight effort on some days. School/work attendance: Consistent. No reduction or absence from work. Social functioning: Actively engaged with friends and family, occasionally experiences social anxiety in new group settings but manages it well. No significant withdrawal. Coping strategies: Utilises healthy coping strategies such as mindfulness, journaling, and regular exercise. Reports occasional reliance on excessive social media use as a distraction, which she is aiming to reduce. CGAS score and justification based on functioning: CGAS 75. Justification: Minor symptoms, but generally functioning well. Some difficulties in one area (hobbies), but overall good functioning. Positive social engagement and professional performance. **Sleep and appetite** Sleep: Fragmented sleep, reports difficulty maintaining sleep with frequent awakenings. Onset is usually normal, but struggles to return to sleep after waking. Appetite: Unchanged appetite. No significant weight changes reported. Energy levels: Reports feeling fatigued most mornings, but energy levels improve as the day progresses. **Medication** Current medication(s): * Sertraline 50mg daily * Propranolol 10mg as needed for anxiety Adherence: Consistent. Side effects: Reports occasional mild gastrointestinal upset with Sertraline, which has lessened over time. No side effects from Propranolol. Effectiveness: Finds Sertraline helpful in stabilising mood, and Propranolol effective for acute anxiety. Tolerability is good. Recent changes: No recent medication changes. **Substance use** Alcohol: Occasional social drinking, 1-2 units per week. No impact on functioning. Drugs: Denies drug use. Smoking/vaping: Denies smoking or vaping. **Physical health** Known conditions: Seasonal allergies. Physical health review: Last physical health review with GP in August 2024, no significant findings. Blood pressure within normal limits. No recent blood tests. Coordination with GP or specialists: Routine coordination with GP for medication monitoring. No other specialist services involved. **Risk assessment** Risk to self: Low. Justification: Denies active suicidal ideation or self-harm. Strong protective factors identified. Risk to others: Denies any risk to others. Safeguarding concerns: No. No active safeguarding concerns. Summary of current risk and protective factors: * Risk factors: Increased work stress, intermittent anhedonia, fragmented sleep. * Protective factors: Strong social support, engagement in therapy, established coping mechanisms, no substance misuse. **Plan and recommendations** Interventions: * Continue weekly psychotherapy sessions focusing on sleep hygiene and re-engagement with hobbies. * Explore cognitive behavioural techniques for managing fragmented sleep. * Encourage structured activities and scheduling for hobbies to combat anhedonia. Safety: * Reinforce current safety plan; no updates required at this time. Liaison: * No immediate liaison with other professionals required. GP to be informed of continued stability and therapeutic progress in next routine letter. Follow-up: Next review in four weeks to assess progress on sleep and anhedonia, and review overall mental state.