HTT 1st visit

HTT 1st Home Visit Present: Patient's mother and sister **Conducted by:** John (CPN) and Lady B (STR) **Diagnosis/Working Diagnosis:** Major Depressive Disorder **Current Medication:** Sertraline 50 mg daily **Reason for the referral**: The patient was referred due to worsening depressive symptoms and increased social withdrawal. **Presenting Situation:** The patient reported feeling persistently low in mood, with a lack of interest in activities they previously enjoyed. They have been experiencing difficulty sleeping, with frequent awakenings throughout the night. The patient expressed feelings of hopelessness and has been isolating themselves from friends and family. They have a history of depression and have been on Sertraline for the past six months. The patient lives with their mother and sister, who are supportive but concerned about the patient's recent decline in mental health. The patient is currently unemployed and has expressed financial concerns, which may be contributing to their stress. They have no current safeguarding concerns but have a history of self-harm, which they have not engaged in for over a year. The patient was advised to contact the Home Treatment Team if feeling overwhelmed and was given the contact information for out-of-hours support. **INTERVENTIONS:** Cognitive Behavioral Therapy (CBT) sessions have been planned to address negative thought patterns and improve coping strategies. **Medications:** Continue Sertraline 50 mg daily, with a review in two weeks. **Carers' views:** The patient's mother expressed concern about the patient's lack of motivation and social withdrawal. She is supportive and willing to assist with any recommended interventions. **MSE** Appearance and Behaviour: The patient appeared disheveled and was slow to respond to questions. **Speech:** Speech was slow, with a low tone and volume, but coherent. **Mood and affect:** The patient reported feeling depressed, and their affect was flat. **Perceptions:** No hallucinations or delusions were reported. **Thought:** Thought process was logical, but content was focused on feelings of worthlessness. **Cognition:** The patient was oriented to time, place, and person. **Insight:** The patient demonstrated good insight into their condition and the need for treatment. **Capacity:** The patient was able to understand and evaluate information during the assessment. **Physical Health Examination:** Sleep: The patient reported disrupted sleep, with frequent awakenings. Dietary and fluid intake: The patient reported a poor appetite and reduced fluid intake. **CURRENT RISK ASSESSMENT:** Risk to self: The patient denied any current thoughts or plans of self-harm or suicide. **Risk to others:** The patient denied any thoughts or plans of harming others. **RISK FORMULATION:** **PRESENTING PROBLEM:** The patient is experiencing a major depressive episode with increased social withdrawal and financial stress. **PREDISPOSING FACTORS:** A history of depression and previous episodes of self-harm. **PRECIPITATING FACTORS:** Recent job loss and financial difficulties. **PERPETUATING FACTORS:** Ongoing financial stress and social isolation. **PROTECTIVE FACTORS:** Supportive family and willingness to engage in therapy. **PROBLEM LIST:** - Major depressive disorder - Social withdrawal - Financial stress **MY SUPPORT NETWORK** Emergency Contacts: Patient's mother and sister **Frequency of visit:** Weekly visits by the Home Treatment Team **Rag:** Amber **PLAN** Continue with weekly CBT sessions and medication review in two weeks. Schedule a follow-up home visit on 8 November 2024. No additional referrals at this time.