Follow-Up: General Adult Psychiatry Clinic

Specialty: Psychiatrist Background and past contacts: Patient, Ms. Jane Doe, a 32-year-old female, has been attending the General Adult Psychiatry Clinic for ongoing management of Generalised Anxiety Disorder (GAD) and co-morbid Major Depressive Disorder (MDD). Previous appointments on 1 August 2024 and 15 September 2024 focused on medication titration and exploring cognitive behavioural therapy (CBT) options. The current visit is a follow-up to assess the effectiveness of medication adjustments and ongoing symptom management. Update on Employment History Ms. Doe reports no change in her employment status. She continues to work full-time as a marketing executive. Update on Social History No update. Ms. Doe continues to live with her partner and reports a supportive home environment. Update on Relationship History No update. Ms. Doe reports her relationship with her partner remains stable and supportive. Update on Drug and Alcohol History No update. Ms. Doe denies any illicit drug use and reports occasional social alcohol consumption, unchanged from previous reports. Update on Past Medical History No update. Relevant past medical history includes well-controlled asthma, for which she uses an inhaler as needed. No known allergies. Update on Medication History Ms. Doe is currently taking Sertraline 100mg once daily (increased from 75mg at the last visit) and Propranolol 20mg twice daily as needed for anxiety symptoms. She reports consistent adherence to her medication regimen. No other changes since the last visit. Update on Past Psychiatric History Brief summary of past psychiatric history includes recurrent episodes of GAD and MDD, with initial diagnosis 5 years ago. No new psychiatric diagnoses or significant changes in presentation since the last review. Update on Forensic History No update. Summary of review: Ms. Doe reports a moderate improvement in her main anxiety symptoms since the Sertraline dosage increase. She notes a reduction in the frequency and intensity of panic attacks, from several times a week to 1-2 episodes in the past month. The duration of anxious episodes has also decreased. Her depressive symptoms, particularly low mood and anhedonia, have shown slight improvement, but she still experiences periods of fatigue and lack of motivation. The impact of symptoms on her daily activities has lessened, allowing her to engage more consistently with work and social activities, a positive change from the previous appointment where her concentration and social withdrawal were significant concerns. She reports mild side effects from Sertraline, specifically occasional mild nausea, which has become less frequent than at the initial titration phase. Ms. Doe assesses the medication as moderately effective for her anxiety and mildly effective for her depression. She expressed concerns about the lingering fatigue and wondered if other medication options might further improve her energy levels. Regarding the treatment plan agreed at the previous appointment, Ms. Doe engaged in online CBT resources as discussed, finding some techniques helpful for managing acute anxiety, particularly breathing exercises. She struggled to consistently apply other techniques due to fluctuating motivation. Psychoeducation was provided on the typical timeline for antidepressant effectiveness and the importance of continued adherence despite some remaining symptoms. Ms. Doe responded positively, acknowledging the gradual nature of recovery. No new symptoms or concerns were raised during the appointment beyond her fatigue. No negative responses to clinical questions were noted. Mental Status Examination: Ms. Doe presented as casually dressed and well-groomed, with good eye contact throughout the session, an improvement from the last appointment where eye contact was often averted. Psychomotor activity was normal. Subjective mood was reported as "better than before, but still a bit flat." Her affect was congruent with her reported mood, showing a restricted range but appropriate reactivity to discussion topics, a slight improvement in amplitude from the previous visit. Speech was of normal rate, volume, and coherence. Thought process was logical and goal-directed. No formal thought disorders were identified. She denied any delusions, overvalued ideas, or obsessive thoughts. No changes from the last appointment in this area. She explicitly denied any hallucinations or perceptual disturbances. Ms. Doe demonstrated good insight into her GAD and MDD, acknowledging the need for ongoing treatment and her role in managing her symptoms. She appears engaged with care, showing a consistent help-seeking stance, unchanged from the last appointment. Risk Assessment: Current risk factors include moderate symptoms of MDD and GAD. Ms. Doe denies any current self-harm ideation, suicidal ideation, or plans. She has no history of self-harm or suicide attempts. She denies any history of violence or aggression towards others or property. Protective factors include a supportive partner, stable employment, and good insight into her condition. No current risk factors for self-harm, suicide, or violence are identified. She has a safety plan in place, which involves contacting her partner or a mental health crisis line if her symptoms significantly worsen. Capacity to consent to care and treatment Ms. Doe demonstrated full capacity to consent to her care and treatment, understanding the information presented, appreciating the implications, reasoning through options, and communicating her choice effectively. Impression Ms. Jane Doe is a 32-year-old female presenting with ongoing GAD and MDD, currently on Sertraline and Propranolol. Biopsychosocial factors contributing to her condition include a genetic predisposition (family history of anxiety) and work-related stress. Her diagnosis remains appropriate given her persistent symptoms and functional impairment. Feedback was given to Ms. Doe regarding the positive impact of the Sertraline dosage increase on her anxiety. She acknowledged the improvements but expressed her desire for further relief from fatigue, a sentiment the clinician validated. Recommendations considered included increasing the Sertraline dose further, switching antidepressants, or adding an adjunct medication. After discussion, Ms. Doe and the clinician mutually agreed to explore the option of increasing the Sertraline to 150mg daily, with a clear understanding of potential benefits and side effects. For additional support, the recommendation for continued CBT engagement was discussed, with a specific focus on strategies for managing fatigue. Ms. Doe agreed to revisit the online CBT modules and try to implement more techniques. Her primary concern about fatigue was addressed by acknowledging its impact and discussing the plan to adjust medication, with an agreement to monitor this closely. Plan: * Increase Sertraline to 150mg daily, to be taken with food. * Continue Propranolol 20mg as needed for anxiety. * Encourage continued engagement with online CBT resources, focusing on energy management techniques. * Follow-up appointment scheduled in 4 weeks to review medication effectiveness and side effects, and to assess fatigue levels.