Psychiatry Medication Initial Titration

Psychiatrist Note: Psychiatry Medication Initial Titration Background & Purpose of Appointment This titration appointment focuses on initiating pharmacological treatment for the patient's Attention Deficit Hyperactivity Disorder (ADHD), confirmed by previous diagnostic assessments. Despite consistent engagement in non-pharmacological strategies, including cognitive behavioural therapy and lifestyle modifications, the patient continues to experience significant functional impairments in academic performance, emotional regulation, and interpersonal relationships. The session aims to establish a safe and effective titration plan for stimulant medication, review medical safety, and ensure patient readiness for treatment. The patient expresses a strong desire to improve their ability to focus and complete tasks. Treatment Goals The patient's stated goals for treatment include improving their ability to sustain attention during lectures, reducing impulsivity in social interactions, and enhancing their capacity for task completion, particularly with academic assignments. They specifically mentioned a desire to "finally finish my degree without constantly feeling overwhelmed" and to "stop interrupting people mid-sentence." Capacity & Consent Capacity was assessed in accordance with legal and clinical standards under the South African Mental Health Care Act. The patient demonstrated a clear understanding of their ADHD diagnosis, the proposed stimulant medication as a treatment option, and the potential benefits (e.g., improved focus, reduced impulsivity) and risks (e.g., side effects like increased heart rate, insomnia, appetite suppression). They were able to weigh this information rationally and consistently expressed a desire to proceed with medication. Formal written consent was obtained prior to the discussion. Mental State Examination The patient presented as well-groomed and appropriately dressed for their age, engaging actively throughout the assessment. They maintained good eye contact and appeared cooperative. While generally calm, they exhibited mild restlessness, occasionally shifting in their seat. Their speech was spontaneous, of normal volume, and coherent, though at times rapid. Mood was subjectively reported as "anxious but hopeful." Affect was observed to be congruent with their stated mood, with periods of appropriate emotional expression. Thought process was logical and goal-directed, though slightly tangential on occasion when discussing the impact of ADHD on their life. Thought content revealed no evidence of delusions, obsessions, or intrusive thoughts. Perceptions were normal; the patient denied any hallucinations or perceptual disturbances. Cognition appeared largely intact; they were oriented to person, place, and time. Attention was variable, consistent with their ADHD, but they remained engaged with redirection. Insight into their condition and the need for medication management was good, and they expressed a clear understanding of the treatment plan and the importance of monitoring. Judgment appeared sound, demonstrating a clear ability to reason about the risks and benefits of the proposed treatment. • Appearance: Well-groomed, appropriately dressed for age. • Behaviour: Mild restlessness, engaged, cooperative. • Speech: Spontaneous, normal volume, coherent, occasionally rapid. • Mood (subjective): "Anxious but hopeful." • Affect (objective): Congruent with mood, appropriate range. • Thought Process: Logical, goal-directed, mild tangentiality. • Thought Content: No delusions, obsessions, or intrusive thoughts. • Perceptions: Denied hallucinations or perceptual disturbances. • Cognition: Oriented x3, attention variable but maintained with redirection. Discussed impact of ADHD on cognitive function. • Insight: Good understanding of condition, treatment plan, and monitoring. • Judgment: Sound, able to reason about treatment risks and decisions. Physical Health Review The patient denies any personal history of cardiac disease, arrhythmias, hypertension, or syncope. They also deny any seizure history. Family history is negative for sudden cardiac death or congenital heart disease. They have no current cardiovascular symptoms, including chest pain, palpitations, shortness of breath, or dizziness. Their BMI is 24, and they engage in moderate exercise three times a week. They report a generally healthy diet. There are no noted contraindications to stimulant medication. • Blood Pressure: 120/78 mmHg • Pulse: 72 bpm • ECG (obtained pre-assessment as per protocol): Normal sinus rhythm, no abnormalities noted. Risk Assessment & Formulation No disclosures of past or current self-harm, suicidal ideation, intent to harm others, aggression, or engagement in risky behaviour were made during the assessment. • Predisposing factors: Family history of ADHD (paternal uncle), neurodevelopmental traits consistent with ADHD since childhood, temperament described as easily distracted and restless from a young age. • Precipitating factors: Increased academic demands in final year of university, leading to significant stress and exacerbation of inattentive and impulsive symptoms, impacting deadlines and social interactions. • Perpetuating factors: Unresolved ADHD symptoms leading to poor academic performance, social frustration, and a sense of overwhelm, contributing to avoidance behaviours. • Protective factors: Strong family support, good insight into their condition, high motivation to improve academic and social functioning, stable relationship with a long-term partner, and engagement in regular exercise. Discussion of Pharmacological Options Discussion focused on stimulant medication (methylphenidate) and non-stimulant options (atomoxetine). The mechanism of action for stimulants (increasing dopamine and norepinephrine in the brain) and non-stimulants (selective norepinephrine reuptake inhibition) was explained. Expected benefits, such as improved focus and reduced impulsivity, were detailed, along with the typical time course of action. Potential side effects, including insomnia, decreased appetite, and cardiovascular effects, were discussed. Risks such as misuse potential and the importance of adherence were also addressed. Written information regarding methylphenidate was provided. The patient expressed a preference for methylphenidate due to its quicker onset of action, hoping for more immediate symptom relief, and agreed to all monitoring requirements. Medication Plan The chosen medication is Methylphenidate Modified Release (Concerta) 18mg, to be taken once daily in the morning. The rationale for this choice is the patient's preference for a stimulant due to its expected rapid onset and the modified release formulation for sustained effect throughout the day. Expected onset of action is within 30-60 minutes, with effects lasting approximately 10-12 hours. The titration plan involves starting at 18mg for one week, followed by an increase to 36mg if tolerated and symptoms persist, after review. Instructions were given to track symptom improvement and any adverse effects daily using a provided symptom diary. Criteria for dose adjustment will be based on symptom response and tolerability, aiming for optimal symptom control with minimal side effects. Safety Advice Comprehensive safety counselling was provided. The patient was advised on common side effects such as insomnia (take early in the day), appetite suppression (ensure adequate nutrition), and potential for mild anxiety or irritability. Warning signs requiring urgent attention, such as chest pain, severe palpitations, or significant changes in mood, were highlighted. Lifestyle advice included avoiding excessive caffeine, refraining from illicit stimulant use, and being cautious with over-the-counter decongestants. The patient was instructed on how to monitor their heart rate and blood pressure at home and to report any significant changes. Prescription & Monitoring A private prescription for Methylphenidate Modified Release (Concerta) 18mg (28 tablets) was issued, to be collected from a private pharmacy. Monitoring materials, including a symptom and side-effect diary, were provided. Reminders were given regarding the secure storage of medication, the strict prohibition against sharing medication with others, and the expectation for regular tracking of symptoms and physical health parameters (heart rate, blood pressure). Next Steps Follow-up is planned for two weeks, with an interim phone call in one week to assess initial tolerability and symptom response. The focus of the next appointment will be to reassess ADHD symptoms, review the symptom diary, evaluate for side effects, and determine if a dose adjustment to 36mg is appropriate. Patient agreement with this plan was confirmed.