Mental Health Note (custom)

Clinician Specialty: Mental Health and Behavioural Specialist History of Presenting Complaints: - Patient presents with persistent low mood, anhedonia, and significant fatigue over the past 6 months, worsened by recent job loss. Expresses feelings of hopelessness and worthlessness. - Associated symptoms include difficulty concentrating, changes in appetite (decreased), and sleep disturbance (insomnia with early morning waking). Reports increased social withdrawal and lack of motivation. Past Medical & Psychiatric History: - Previous diagnosis of Major Depressive Disorder (MDD) 5 years ago, treated with Sertraline and CBT, with good response. One prior psychiatric hospitalisation for severe depression with suicidal ideation 3 years ago. - Current medications: None. Patient discontinued Sertraline 8 months ago due to perceived improvement and side effects. - Chronic medical conditions: None reported. Family History: - Mother has a history of depression and anxiety. Paternal uncle committed suicide. Social History: Patient is a 32-year-old male, previously employed as a marketing executive. Holds a Bachelor's degree in Business Administration. Currently unemployed due to recent redundancy. Patient reports smoking 10 cigarettes daily for 12 years. Consumes alcohol socially (2-3 units per week) but denies binge drinking. Denies use of recreational drugs. Lives alone but has regular contact with his sister. Reports feeling isolated since losing his job and finds it difficult to connect with friends. Mental Status Examination: -Appearance: Patient is casually dressed in clean but somewhat dishevelled clothing. Maintains fair eye contact. Appears fatigued and apathetic. -Behaviour: Psychomotor activity is mildly slowed. Patient is cooperative but withdrawn. No abnormal movements or tics observed. -Speech: Speech is soft, slow in rate, and of low volume. Articulation is clear, and thought processes are coherent. -Mood: Patient reports his mood as "terrible" and "empty." -Affect: Affect is constricted and flat, congruent with reported mood. Limited emotional reactivity observed. -Thoughts: Thought process is linear and goal-directed. Thought content is preoccupied with feelings of failure and self-blame. Denies suicidal ideation, homicidal ideation, or paranoid thoughts. Expresses a sense of hopelessness for the future. -Perceptions: Denies hallucinations (auditory, visual, tactile, olfactory, or gustatory) or other sensory misinterpretations. -Cognition: Orientation to person, place, and time is intact. Memory appears adequate for recent and remote events. Attention and concentration are fair but patient reports difficulty focusing. Comprehension is intact. -Insight: Has fair insight into his current struggles, acknowledging his low mood and difficulty coping, but attributes it solely to his unemployment rather than underlying depression. -Judgement: Judgement appears intact. Patient understands the need for treatment but initially hesitated due to stigma. Risk Assessment: - Patient denies current suicidal or homicidal ideation. Reports passive thoughts of not wanting to wake up but no specific plan or intent. No history of violence. No current safety concerns identified, but will monitor closely given history. Diagnosis: - Major Depressive Disorder, recurrent episode, severe without psychotic features (F33.2) Treatment Plan: - Investigations or assessments conducted: Beck Depression Inventory (BDI-II) administered, score of 35 (severe depression). PHQ-9 score of 22 (severe depression). - Medications prescribed or adjusted: Re-initiated Sertraline 50mg daily, titrating to 100mg after one week if tolerated. Provided detailed instructions on medication use and potential side effects. - Psychotherapy approaches or sessions delivered: Commenced Cognitive Behavioural Therapy (CBT) with focus on behavioural activation, cognitive restructuring, and problem-solving skills. Scheduled weekly individual therapy sessions. - Psychosocial interventions, family meetings, or collateral information: Recommended patient attend a local support group for individuals experiencing job loss. Encouraged patient to inform his sister about treatment plan. - Referrals made and follow-up arrangements: Referral to employment counselling services. Follow-up appointment scheduled for 15 November 2024 to review medication efficacy and therapeutic progress. Safety Plan: Patient has agreed to notify his sister or attend the local crisis walk-in clinic if suicidal thoughts intensify or if he feels unable to keep himself safe. He will also contact the clinic directly via phone if experiencing significant distress between appointments.