General Psychiatry New Patient Assessment (Community Version) (UK)

Medication The patient is currently prescribed Sertraline 50mg once daily for depression. Care Plan The care plan includes weekly cognitive behavioural therapy sessions and a follow-up appointment in four weeks to assess the effectiveness of the medication. We will always do our best to bring appointments forward if our patients are struggling and need support. As the Community Mental Health Clinic is not an emergency service, if you are in crisis, we recommend calling the Samaritans at 116 123. The urgent mental health line is 0800 123 456. Urgent appointments can also be made with the GP. In a severe emergency, use 999 or visit the Accident and Emergency department at your local hospital. I met with John Doe in-person through the Community Mental Health Clinic. Presenting complaint John presented with symptoms of low mood, lack of motivation, and difficulty sleeping, which have persisted for the past six months. History of presenting complaint The symptoms began approximately six months ago following a significant life event, and have gradually worsened over time. Past psychiatric history John has a history of anxiety and was previously treated with cognitive behavioural therapy. Relevant medical history John has a history of hypertension, currently managed with Lisinopril. Allergies No known drug allergies. Current or past recreational drug or alcohol use or dependence John reports occasional alcohol use, approximately 2-3 units per week, with no history of dependence. Family history There is a family history of depression on the maternal side. No known physical health conditions run in the family. Living situation John lives alone in a rented apartment. Personal history John was born full-term with no complications and met all developmental milestones on time. Information about parents, siblings or other family members they grew up with John grew up with both parents and has one younger sister. Childhood experiences John reports a stable childhood with no traumatic experiences or mistreatment. School experiences John had a positive school experience, with no history of bullying and was able to focus well in class. Academic achievement John completed A-levels and graduated from university with a degree in Business Management. Employment history John has worked in various administrative roles and currently works as an office manager. He reports good relationships with colleagues. Relationship experiences John is currently single and has had several long-term relationships in the past. Mental state examination John appeared well-groomed and cooperative. His mood was low, and affect was congruent. Speech was normal in rate and volume. Thought processes were logical and coherent. Discussion The assessment indicates that John is experiencing a major depressive episode. The plan is to continue with the current medication and initiate cognitive behavioural therapy. A follow-up appointment is scheduled in four weeks to monitor progress. Physical health parameters John's blood pressure is well-controlled at 120/80 mmHg.