FULL PSYCHIATRIC ASSESSMENT

**JANE DOE, DOB 01/01/1980, 123 Example Street, Anytown, AB1 2CD, jane.doe@email.com, 01234 567890** **CIRCUMSTANCES OF REFERRAL** Jane Doe, a 44-year-old woman, with a history of major depressive disorder, was referred by her GP due to worsening symptoms of depression and anxiety. **HISTORY OF PRESENTING SYMPTOMS** Jane reports a significant worsening of her depressive symptoms over the past three months, including persistent low mood, loss of interest in activities, and feelings of hopelessness. She describes feeling overwhelmed by her current situation. She reports that her sleep has been disrupted, with difficulty falling asleep and early morning awakenings. She also reports increased anxiety, particularly related to her health and finances. She states that she has been experiencing panic attacks. She reports that she has been feeling increasingly isolated and withdrawn from social activities. She reports that she has been experiencing suicidal ideation, but denies any active plans or intent. She reports that she has been feeling increasingly fatigued and has difficulty concentrating. She reports that she has been experiencing a loss of appetite and has lost weight. She reports that she has been feeling increasingly irritable and easily frustrated. She reports that she has been experiencing a sense of worthlessness and guilt. She states that she has been feeling increasingly anxious about her health and finances. She reports that she has been feeling increasingly hopeless about the future. She reports that she has been feeling increasingly isolated and withdrawn from social activities. She reports that she has been experiencing suicidal ideation, but denies any active plans or intent. She reports that she has been feeling increasingly fatigued and has difficulty concentrating. She reports that she has been experiencing a loss of appetite and has lost weight. She reports that she has been feeling increasingly irritable and easily frustrated. She reports that she has been experiencing a sense of worthlessness and guilt. She reports that she has been feeling increasingly anxious about her health and finances. She reports that she has been feeling increasingly hopeless about the future. **PSYCHIATRIC HISTORY** Jane has a history of major depressive disorder, diagnosed five years ago. She has previously been treated with sertraline, which was effective in managing her symptoms. She has also attended several sessions of Cognitive Behavioural Therapy (CBT). **MEDICAL HISTORY** Jane reports no significant current physical health concerns. She has a history of seasonal allergies. **MEDICATIONS** - Sertraline 100mg daily **PERSONAL HISTORY AND DEVELOPMENTAL HISTORY** Jane grew up in a stable family environment. She reports a happy childhood. She completed her education and has been working as a teacher for the past 20 years. **SOCIAL CIRCUMSTANCES** Jane is married and lives with her husband. She has a good relationship with her family and friends. She is currently employed as a teacher. She reports that she has been feeling increasingly isolated and withdrawn from social activities. She reports that she has been experiencing a loss of appetite and has lost weight. She reports that she has been feeling increasingly irritable and easily frustrated. She reports that she has been experiencing a sense of worthlessness and guilt. She states that she has been feeling increasingly anxious about her health and finances. She reports that she has been feeling increasingly hopeless about the future. She reports that she has been feeling increasingly isolated and withdrawn from social activities. She reports that she has been experiencing suicidal ideation, but denies any active plans or intent. She reports that she has been feeling increasingly fatigued and has difficulty concentrating. She reports that she has been experiencing a loss of appetite and has lost weight. She reports that she has been feeling increasingly irritable and easily frustrated. She reports that she has been experiencing a sense of worthlessness and guilt. She states that she has been feeling increasingly anxious about her health and finances. She reports that she has been feeling increasingly hopeless about the future. **SUBSTANCE USE** Jane reports occasional alcohol use, but denies any substance abuse. **FAMILY HISTORY** Jane's mother has a history of anxiety. **MENTAL STATE EXAMINATION** "Appearance and behaviour:" Appears her stated age, well-groomed, and cooperative. "Speech and motor:" Normal rate and rhythm, no abnormalities. "Mood and affect:" Reports low mood, affect congruent. "Thought process and content:" No evidence of psychosis. **IMPRESSION AND OPINIONS** Jane Doe, a 44-year-old woman, presents with worsening symptoms of major depressive disorder and anxiety. She reports a significant worsening of her depressive symptoms over the past three months, including persistent low mood, loss of interest in activities, and feelings of hopelessness. She reports that she has been experiencing suicidal ideation, but denies any active plans or intent. The diagnostic impression is major depressive disorder, recurrent, moderate severity, and generalized anxiety disorder. The rationale for diagnosis is based on the patient's reported symptoms, history, and mental state examination findings. Differential diagnoses considered include bipolar disorder and adjustment disorder. The cause of current symptoms is likely a combination of biological and psychological factors. The patient's reports are corroborated by her history and presentation. Treatment options discussed include medication adjustment and psychotherapy. The patient is agreeable to both. **RISK TO SELF** History of suicidal ideation. Assessment of current suicide risk: Moderate. Future mental health risks: High. **RISK TO OTHERS** No risk of harm to others evident. **RECOMMENDATIONS** - Increase sertraline to 150mg daily. - Referral to a therapist for CBT. - Follow up appointment 01/12/2024 at 10:00 AM. If you are feeling overwhelmed or suicidal, 24h crisis counselling is available from the Samaritans on 116 123 or advice from NHS 111 (option 2). If you are feeling unsafe, mental health support is available in every UK emergency department or via ambulance (999). **COPY TO:** Dr. John Smith, 1 Example Street, Anytown, AB1 2CD Other CCs: Dr. Jane Brown (GP)