Comprehensive Psychiatric Intake

Reason for Visit: - Patient presents with worsening depressive symptoms and anxiety over the past three months. History of Present Illness: - The patient reports a gradual onset of depressive symptoms, including persistent sadness, lack of energy, and difficulty concentrating. Anxiety symptoms include restlessness and excessive worry. Past Psychiatric History: - The patient has a history of major depressive disorder, previously hospitalized for suicidal ideation two years ago. Past treatments include cognitive behavioral therapy and sertraline, which was discontinued due to side effects. Past Medical History: - The patient has a history of hypothyroidism, managed with levothyroxine. Medications: - Currently taking fluoxetine 20 mg daily for depression. Allergies: - No known drug allergies. Medication Trials: - Previous trials of sertraline and escitalopram, both discontinued due to gastrointestinal side effects. Access to Weapons: - No access to firearms or other weapons. Social History: - Lives alone in an apartment, has a supportive network of friends. Education: - Completed a bachelor's degree in psychology. Relationships: - Close relationship with parents and one sibling, no current intimate relationship. Work: - Employed as a social worker, reports moderate work-related stress. Supports: - Attends weekly support group meetings and has regular therapy sessions. Protective Factors: - Strong support system, engaged in therapy, and motivated for treatment. Negative Factors: - Occasional alcohol use, reports feeling isolated at times. Suicide Risk Assessment: - Denies current suicidal ideation, intent, or plan. Protective factors include strong family support and engagement in therapy. Forensic History: - No history of legal issues or arrests. Family History: - Family history of depression in mother and substance abuse in father. Mental Status Exam: - Appearance: Well-groomed. Behavior: Cooperative. Speech: Normal rate and volume. Mood: Depressed. Affect: Constricted. Thought Process: Linear. Thought Content: No delusions or hallucinations. Cognition: Intact. Insight/Judgment: Good. Objective Findings: - No significant findings on recent physical exam. Diagnosis: - Major Depressive Disorder, Recurrent, Moderate. Diagnostic Formulation: - Biopsychosocial factors include genetic predisposition, work stress, and social isolation contributing to the current depressive episode. Assessment and Plan: - Continue fluoxetine 20 mg daily. Increase therapy sessions to twice weekly. Encourage participation in social activities. Follow-up in four weeks to assess progress.