Psychiatric Follow-Up Letter

Clinician Specialty: Psychiatrist JOHN SMITH, DOB 01/01/1985, MRN 12345, 123 HIGH STREET, LONDON, W1A 1AA, JOHN.SMITH@EXAMPLE.COM, 07700 900123 Diagnosis: * Major Depressive Disorder, Recurrent, Severe, without Psychotic Features * Generalised Anxiety Disorder Current Medications: * Sertraline 100mg once daily * Lorazepam 0.5mg as needed (max twice daily) Update on psychiatric issues John reports a slight improvement in his mood over the past month, with fewer days of feeling utterly hopeless. He has been engaging in more social activities, including a weekly walking group, which he finds beneficial. His anxiety remains a significant issue, particularly in crowded places, leading to occasional panic attacks, though these are less frequent than previously reported. He describes ongoing sleep disturbances, often waking early and struggling to fall back asleep. Update on medical issues John continues to manage his controlled hypertension with previously prescribed medication from his GP. No new medical concerns were raised during this session. He reports good adherence to his antihypertensive regimen and regular blood pressure monitoring at home. Update on medications John states he is tolerating Sertraline 100mg well, with no new side effects. He uses Lorazepam occasionally for acute anxiety, approximately 2-3 times per week, and finds it effective. He expressed some concern about potential dependence on Lorazepam but feels he is using it responsibly. He denies any issues with medication adherence. RISK John denies any current suicidal ideation or plans. He reports no self-harm behaviours since the last review. His historical risk of self-harm remains but is currently mitigated by his improved mood and engagement in therapy. He acknowledges occasional fleeting thoughts of not wanting to wake up, but these are not accompanied by intent or plan. John denies any current thoughts or plans to harm others. He has no history of violence or aggression towards others. RECOMMENDATIONS 1. Continue Sertraline 100mg daily. 2. Continue Lorazepam 0.5mg as needed for anxiety, with review at next appointment. 3. Consider increasing Sertraline to 150mg if anxiety symptoms do not improve significantly over the next month. This will be discussed further at the next appointment. 4. Continue with CBT for anxiety, focusing on exposure therapy for crowded places. 5. Explore mindfulness techniques to aid sleep and anxiety management. 6. **Can I ask "Dr. Emily White" to please monitor John's blood pressure regularly and inform us of any significant changes.** 7. Follow-up appointment scheduled for 1 December 2024, 10:00 AM at the clinic. "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. Emily White, The Family Practice, 456 Oak Lane, London, W1B 2BC, emily.white@familypractice.com Mr. David Green (Patient's Referrer)