Outpatient Mental Health Referral Form

Outpatient Mental Health Form Patient Name: John Doe Date of Birth: 15/03/1990 Date of Visit: 1 November 2024 **Chief Complaint:** "Feeling overwhelmed and unable to cope with daily stressors. Difficulty sleeping and concentrating at work." **History of Present Illness (HPI):** Mr. Doe presents today reporting a significant increase in feelings of anxiety and low mood over the past six months, exacerbated in the last two months following a demanding project at work. He describes experiencing persistent worry, racing thoughts, and a sense of impending doom. He reports crying spells occurring 3-4 times per week, often without a clear trigger. His sleep has been severely affected, reporting difficulty falling asleep (taking over an hour) and waking frequently throughout the night, leading to daytime fatigue and poor concentration. He denies any suicidal ideation, homicidal ideation, or psychotic symptoms. He reports a loss of interest in hobbies he once enjoyed, such as hiking and playing guitar. Appetite has decreased, resulting in a reported weight loss of approximately 5kg over the past three months. He endorses increased irritability. **Past Psychiatric History:** * **Previous Diagnoses:** Generalised Anxiety Disorder (GAD) diagnosed in 2018. * **Previous Treatments:** Cognitive Behavioural Therapy (CBT) in 2019 for GAD, which he found moderately helpful. Previously prescribed Sertraline 50mg daily from 2019-2021, which was discontinued due to perceived lack of efficacy and sexual side effects. * **Hospitalisations:** None. **Medical History:** * **General Medical Conditions:** Hypertension, well-controlled with medication. * **Current Medications:** Lisinopril 10mg daily. * **Allergies:** Penicillin (rash). **Social History:** * **Marital Status:** Married. * **Occupation:** Software Engineer. * **Living Situation:** Lives with wife in a flat. * **Substance Use:** Occasional alcohol use (2-3 units per week), denies illicit drug use or tobacco use. * **Support System:** Reports good support from his wife, but hesitant to discuss his current struggles with friends. **Family History:** Mother has a history of depression and anxiety. Father has a history of hypertension. **Mental Status Examination (MSE):** * **Appearance:** Well-groomed male, dressed casually, appearing fatigued. * **Behaviour:** Cooperative, made good eye contact, somewhat restless (fidgeting with hands). * **Speech:** Normal rate and rhythm, soft in volume. * **Mood:** "Overwhelmed, stressed, down." * **Affect:** Constricted, congruent with mood. * **Thought Process:** Linear, goal-directed. * **Thought Content:** Preoccupied with work stressors and feelings of inadequacy. Denies suicidal/homicidal ideation, delusions, or hallucinations. * **Perceptions:** Denies hallucinations. * **Cognition:** Alert and oriented to person, place, and time. Concentration appears impaired, as reported. Memory intact (remote and recent). * **Insight:** Good insight into his difficulties and impact on his life. * **Judgment:** Good. **Diagnosis:** * F41.1 Generalised Anxiety Disorder (recurrent episode, severe) * F32.1 Major Depressive Disorder, single episode, moderate **Formulation:** Mr. Doe is a 34-year-old married software engineer presenting with a significant exacerbation of anxiety symptoms and new onset depressive symptoms. His history suggests a vulnerability to anxiety, with a previous diagnosis of GAD and a family history of mood disorders. Current stressors, particularly a demanding work project, appear to have precipitated the current episode. Lack of effective coping mechanisms and reluctance to seek social support are contributing factors. His symptoms are impacting his occupational functioning and quality of life. **Treatment Plan:** 1. **Medication Management:** Discuss initiation of a Selective Serotonin Reuptake Inhibitor (SSRI) such as Escitalopram, starting at a low dose and titrating as tolerated, given previous negative experience with Sertraline. 2. **Psychotherapy:** Recommend referral for Cognitive Behavioural Therapy (CBT) focused on anxiety management, stress reduction techniques, and cognitive restructuring. 3. **Lifestyle Modifications:** Encourage regular exercise, improved sleep hygiene (with non-pharmacological interventions initially), and mindfulness techniques. 4. **Follow-up:** Schedule follow-up appointment in two weeks to review medication efficacy and side effects, and monitor symptom progression. **Prognosis:** Guarded, given the chronicity of anxiety and current severity of symptoms, but good with adherence to treatment recommendations and engagement in therapy. **Reviewed By:** Dr. Evelyn Reed **Date of Review:** 1 November 2024