Mental Health Care Plan

Mental Health Care Plan review. 1. Consent Patient provided explicit verbal consent to the review and update of her mental health care plan, acknowledging understanding of its purpose and proposed interventions. 2. Relevant History - Principal Problem/Diagnosis: Major Depressive Disorder, recurrent, moderate severity. - Mental Health History/Treatment: Patient has a 5-year history of MDD, with two previous episodes requiring antidepressant medication (sertraline, fluoxetine) which were partially effective. She also completed 6 months of cognitive behavioural therapy (CBT) two years ago, which she found helpful in developing coping strategies. No hospitalisations. She recently discontinued fluoxetine due to side effects (nausea) and is seeking alternative management. - Language spoken at home: English - How well does the person speak English: Fluent - Family History: Mother diagnosed with anxiety disorder; paternal uncle with history of depression. - Social History: Patient is a 32-year-old single female, living alone in a rented apartment. She works as a primary school teacher, a job she generally enjoys, but has been struggling with motivation recently. She has a close circle of friends and regular contact with her sister, providing a good social support network. No significant relationship changes recently. - Does the person live alone: Yes. Patient lives alone, which occasionally exacerbates feelings of isolation during depressive episodes. - Highest education level completed: Master of Education - Alcohol: Patient reports consuming 3-4 standard drinks per week, primarily on weekends. No concerns or attempts to reduce. - Smoking: Never smoked. - Allergies: Penicillin (rash). - Personal History/Lifestyle Issues: Patient reported significant stress related to recent changes in school curriculum and increased workload. She acknowledges poor sleep hygiene, often staying up late watching TV, leading to 4-5 hours of sleep per night. Diet is generally healthy, but she tends to eat more convenience foods when feeling low. Exercise is irregular, mostly walking on weekends. 3. Presenting Complaint Patient presents with a 3-month history of worsening mood, characterised by persistent sadness, anhedonia (inability to experience joy), and fatigue. She reports significant concentration difficulties at work, impacting her performance, and expresses feelings of worthlessness and guilt, particularly regarding her perceived inability to manage her workload. She denies any thoughts of self-harm or suicide at present, but acknowledges feeling overwhelmed. Her sleep is significantly disturbed, with difficulty falling asleep and early morning waking. Appetite has decreased, leading to a 2kg weight loss over the last month. No panic attacks, but general worry about her job security and future has increased. 4. Mental State Examination (MSE) Findings - Appearance and General Behaviour: Appears tired but well-groomed. Cooperative, with appropriate eye contact. - Speech: Normal volume, rate, and rhythm. Coherent. - Mood: "Flat and sad." - Affect: Restricted range, congruent with reported mood. - Thought Form: No formal thought disorder. - Thought Content: Preoccupation with feelings of guilt and inadequacy related to work. Denies suicidal ideation, self-harm, or homicidal ideation. - Perception: No abnormalities detected. - Cognition: Alert and oriented. Concentration difficulties reported by patient. - Insight: Good insight into her depressive symptoms and the need for treatment, expressing a desire to improve her coping mechanisms. - Judgement: Good. - Orientation: NAD. - Sleep Patterns: Initial insomnia, early morning wakening (around 4 am) with difficulty returning to sleep. - Appetite/Eating Patterns: Decreased appetite, leading to reported weight loss. - Attention/Concentration: Self-reported significant difficulties with attention and concentration, particularly at work. - Motivation/Energy: Markedly reduced motivation and energy (anergia). - Memory: NAD. 5. Risk of Self-Harm or Suicide Patient explicitly denies current suicidal ideation, intent, or plan. Denies any risk to others. Protective factors include a strong social support network and a desire to improve for her job. 6. K10/DASS21 Scores K10 score: 32 (Severe Psychological Distress) DASS21 scores: Depression 28 (Severe), Anxiety 15 (Moderate), Stress 20 (Moderate) 7. Goals of Treatment Principal Problem/Diagnosis: Major Depressive Disorder, recurrent, moderate severity. - Goals: Reduce depressive symptoms (sadness, fatigue, anhedonia) by 50% within 3 months as measured by K10 score; improve sleep quality and duration to 7-8 hours per night within 2 months; enhance coping strategies for work-related stress. - Actions/Tasks: Start new antidepressant medication (e.g., escitalopram 10mg daily); referral to a psychologist for further CBT sessions focusing on stress management and sleep hygiene; patient to aim for 30 minutes of moderate exercise 3 times per week; patient to establish a regular bedtime routine. 8. Next of Kin/Support Person Sister, Sarah Davis (contact number provided to patient for emergencies). 9. Follow-up Plan Review in 2 weeks to assess medication tolerance and initial efficacy. Further review with GP in 4 weeks to discuss progress with therapy and overall mood. Safety netting advice provided regarding worsening mood or suicidal ideation, including emergency contact numbers and instructions to present to the nearest emergency department.