Mental Health Care Plan COMPLETE NOTE

MENTAL HEALTH CARE PLAN COMPLETE NOTE Consult Summary: Patient presents with escalating anxiety and low mood impacting daily functioning. Plan involves MHCP development, lifestyle adjustments, and referral for psychological support. Likely stress-induced adjustment disorder with anxious and depressed mood. MENTAL HEALTH CARE PLAN Reason for Presentation Patient attending for development of a Mental Health Care Plan due to persistent symptoms of anxiety and low mood. History of Presenting Problem and Impact: * Onset approximately 6 months ago, gradually worsening after a significant work restructure. * Symptoms include daily feelings of worry, restlessness, difficulty concentrating, and occasional panic attacks (last one 2 weeks ago). * Low mood characterised by anhedonia and reduced motivation. * Severity: Patient rates anxiety as 7/10 and mood as 6/10 on average. "I just can't seem to switch off my brain, it's exhausting." * Exacerbating factors: Work pressure, social gatherings. Relieving factors: Solitary walks, listening to music. * Impact on daily activities: Struggles to complete household chores, has missed social events. * Work/Study: Reduced productivity at work, difficulty focusing on tasks. * Relationships: Increased irritability with partner, withdrawing from friends. * Self-care: Neglecting personal hygiene sometimes, eating less regularly. * Sleep: Difficulty falling asleep and frequent nocturnal awakenings. Appetite: Reduced appetite. Past Medical History: * No formal psychiatric diagnoses previously. * Brief period of counselling for stress 5 years ago, found it mildly helpful. * Medical comorbidities: Mild hypertension, well-controlled with medication. * No significant medical issues. Medications: * Currently: Ramipril 5mg OD for hypertension. * No psychotropic medications currently or in the past. Family History: * Mother has history of anxiety, managed with medication and therapy. * Paternal uncle experienced depression. Social History: * Developmental history: Unremarkable. Childhood history: Stable home environment. * Past traumas: No significant reported trauma. * Living arrangements: Lives with partner in a rented flat. * Relationships: Long-term stable relationship, supportive but concerned partner. * Work/Study: Works full-time as an accountant, recently experienced a demanding restructure. * Psychosocial stressors: High work pressure, financial concerns related to recent car repair. Substance Use: * Alcohol: Occasional social drinker, 2-3 standard drinks per week. Denies binge drinking. * Smoking: Never smoked. Vaping: Never vaped. * Recreational drug use: Denies any illicit drug use. Mental State Examination: Appearance: Appears well-groomed, but somewhat tired. Maintains eye contact. Behaviour: Psychomotor activity is normal. No abnormal movements. Speech: Normal rate, volume, and rhythm. Coherent. Mood: "Anxious and fed up." Affect: Restricted, congruent with mood. Thought Form: Linear and goal-directed. Thought Content: Preoccupied with work stressors and future uncertainties. No suicidal ideation, homicidal ideation, or delusions reported. Perception: No hallucinations or perceptual disturbances. Cognition: Appears alert and oriented. Concentration slightly impaired. Insight: Good insight into the impact of her symptoms on her life. Judgement: Intact. Outcome Measures: * GAD-7: 1 November 2024, Score: 16 (Severe anxiety) * PHQ-9: 1 November 2024, Score: 14 (Moderately severe depression) Diagnosis: F43.2 Adjustment disorder with mixed anxiety and depressed mood (DSM-5). Formulation: * Predisposing factors: Family history of anxiety, potentially perfectionistic personality traits. * Precipitating factors: Recent significant work restructure and increased job demands, financial strain. * Perpetuating factors: Avoidance behaviours (social withdrawal), poor sleep, rumination, lack of effective coping strategies. * Protective factors: Supportive partner, good insight, willingness to engage in treatment. * Risk assessment: Low risk of self-harm or harm to others. No current suicidal ideation. Goals of Treatment: * Patient goal: "I want to feel less worried all the time and enjoy my weekends again." * Clinician goal: Reduce GAD-7 and PHQ-9 scores by 50% within 3 months. * Improve coping mechanisms for stress. * Re-engage in previously enjoyed social activities. Management Plan: Psychoeducation: * Discussed nature of anxiety and depression, stress response cycle. Provided resources on sleep hygiene. * Lifestyle modifications: Encouraged regular exercise (e.g., 30 mins brisk walking daily), balanced diet, limiting caffeine. * Strategies: Explained mindfulness techniques and progressive muscle relaxation. Medication Management: * No new psychotropic medication initiated at this stage, will review at next appointment. Psychological Strategies: * Recommended Cognitive Behavioural Therapy (CBT) techniques for challenging negative thought patterns. * Discussed benefits of relaxation techniques. Referrals: * Referral to Psychologist, "Ms. Sarah Jones" at "MindPath Psychology" for CBT and further psychological support. Safety Plan: * No immediate safety concerns identified. Patient understands to contact GP, partner, or Lifeline (13 11 14) if distress escalates. Crisis Plan: * Patient to contact local mental health crisis line (1800 011 511) or present to emergency department if experiencing acute crisis or suicidal thoughts. Planned Review In: * 4 weeks Consent Patient provided informed consent for the plan and referrals.