Psychiatric Assessment Report

**Introduction:** 1 November 2024, Outpatient Psychiatry Clinic, attended by Dr. Eleanor Vance and patient, John Smith. **Diagnosis / Problems List:** Major Depressive Disorder, Recurrent, Severe; Generalized Anxiety Disorder. **Legal Status:** Voluntary admission. **Prescribed Medications:** Sertraline 100mg daily; Clonazepam 0.5mg as needed for anxiety. **Investigations:** Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) within normal limits. Thyroid Stimulating Hormone (TSH) level: 2.1 mIU/L. **Current Issues / Situation:** Patient reports persistent low mood, anhedonia, and significant anxiety. Difficulty sleeping and loss of appetite. Reports feeling overwhelmed by work and social obligations. Suicidal ideation present, but no active plans or intent. **Background Information:** Patient is a 35-year-old male, employed as a software engineer. Lives alone. Reports a supportive family but limited social network. **Past Psychiatric History:** Previous episode of major depression approximately 3 years ago, treated with Sertraline. No prior hospitalizations. History of childhood anxiety. **Medical & Surgical History:** No significant medical or surgical history. Reports seasonal allergies. **Alcohol & Drug History:** Patient reports occasional alcohol use (2-3 drinks per week). Denies illicit drug use. **Mental State Examination:** Appearance: Well-groomed, appropriate for age. Affect: Depressed, constricted. Mood: Subjectively reports low mood. Speech: Normal rate and rhythm. Thought Process: Linear and goal-directed. Thought Content: Preoccupied with negative thoughts. Denies psychosis. Cognition: Intact. Insight and Judgement: Good. **Risk Assessment:** Suicide risk: Moderate. Patient reports passive suicidal ideation. No current plans or intent. No history of suicide attempts. Protective factors include supportive family and good insight. **Formulation / Summary:** Mr. Smith presents with a recurrent episode of major depressive disorder and generalized anxiety disorder. Symptoms are impacting his daily functioning. Risk of self-harm is present but currently moderate. The patient is aware of his condition and is seeking help. **Treatment Plan / Recommendations:** Continue Sertraline 100mg daily. Increase Clonazepam to 0.5mg twice daily for anxiety. Schedule weekly psychotherapy sessions with a therapist. Encourage regular exercise and healthy lifestyle habits. Follow-up appointment in two weeks. **Safety Plan:** Patient agrees to contact the crisis line or present to the emergency department if suicidal ideation worsens or if he develops active plans or intent. Contact information for crisis services provided.