Initial Assessment Template - General Adult Psychiatry

Initial Assessment Template - General Adult Psychiatry Patient ID Presented: Yes Consent to Record via AI Transcribing Tools: Yes Location at Time of Appointment: Home address Family History: Mr. David Smith, 45, the patient's father, is a retired engineer with a history of anxiety. He has a good relationship with the patient, described as supportive, though sometimes overprotective. Mrs. Sarah Smith, 43, the patient's mother, is a teacher with no significant past medical or psychiatric history; their relationship is close and open. The patient has one sibling, a 32-year-old sister named Emily, who is a marketing executive and has recently been diagnosed with depression. The patient describes their relationship as generally positive, with occasional disagreements. There is no family history of heart problems or other relevant physical conditions that the patient is aware of, and no other mental health problems aside from those mentioned. Significant family events include the patient's parents' divorce when he was 15, which he describes as a difficult period, but ultimately resolved amicably. Personal History: The patient's mother reported a healthy pregnancy with no maternal smoking or drinking. Perinatal and postnatal periods were unremarkable. Developmental milestones were met within expected ranges, with no reported concerns regarding early development. Childhood was generally stable, though the patient experienced some bullying in primary school for being 'bookish,' which led to periods of social withdrawal. There were no reported traumatic events, mistreatment, or abuse during childhood. School experiences were largely positive academically; he was able to focus well and organised his studies effectively, achieving good results in his GCSEs and A-Levels. He completed a degree in Computer Science at university. He denies any history of sexual, physical, or emotional abuse. Employment History: The patient has a consistent employment history as a software developer, holding a position at 'Tech Innovations Ltd.' for the past seven years. Prior to this, he worked at 'Software Solutions Inc.' for three years. He reports generally good relationships with colleagues and no history of dismissals or impulsive resignations. He is currently employed full-time, though has recently experienced some difficulties with concentration and motivation at work, impacting his productivity. Social History: The patient enjoys hiking, playing board games with friends, and reading science fiction novels. He is part of a local hiking club and regularly attends their outings. He finds these activities to be a good source of stress relief and social interaction. Relationships and Children: The patient is currently single and has been for the past three years since the end of a five-year relationship. He reports that the relationship ended amicably due to differing life goals. He has had two significant past relationships, both lasting approximately two to three years, which he describes as generally healthy but eventually faded. He denies any history of domestic violence or abuse in any of his relationships. The patient does not have any children. Substance Use History: The patient reports occasional social alcohol consumption, typically 2-3 units once or twice a week, denying any history of alcohol dependence. He denies any current or past recreational drug use. He quit smoking five years ago after smoking 10 cigarettes a day for ten years; he sought support from his GP at the time and used nicotine patches to aid cessation. Past Medical History: The patient's past medical history is largely unremarkable. He reports no current physical health problems or diagnoses. He had an appendectomy at age 12, with no complications. He explicitly denies any history of cardiovascular disease or symptoms, glaucoma, or epilepsy. Medication: No current medications. Allergies: Denied all medication and other allergies. Forensic History: Denied any forensic history. Past Psychiatric History: The patient reports a previous episode of low mood and anhedonia approximately eight years ago, following a significant relationship breakup. At that time, he consulted his GP who diagnosed him with a mild depressive episode and prescribed a short course of sertraline, which he took for six months and found to be effective. He attended six sessions of cognitive behavioural therapy (CBT) through a local service, which he also found helpful. He reports no history of psychiatric admissions or other past psychotherapeutic treatments. He explicitly denies any history of mania, hypomania, psychosis, or significant anxiety disorders in the past. History of Present Concerns: Mr. John Doe is a 35-year-old single male who uses he/him pronouns. He is a software developer, originally from Manchester, and currently resides in a rented flat in London, living alone. He does not have any children. Mr. Doe presents with a several-month history of worsening low mood, anhedonia, and significant fatigue, which he believes started insidiously around six months ago after a period of increased work-related stress. He describes his mood as consistently low, often feeling flat and unmotivated. He has lost interest in his usual hobbies, such as hiking and board games, which he previously enjoyed. He notes difficulty concentrating at work, leading to decreased productivity and increased self-criticism. He reports significant fatigue, feeling constantly tired despite sleeping 8-9 hours per night, and struggles to get out of bed in the mornings. His appetite has decreased, and he has lost approximately 5kg over the past three months without intentional dieting. He describes a sense of hopelessness about the future and frequently engages in ruminative thoughts about past mistakes and perceived failures. He states that he is seeking treatment because he is finding it increasingly difficult to function and wants to regain his previous level of enjoyment and productivity. He has not tried any recent treatments for these specific symptoms. He denies any recent major life stressors beyond work pressure. Personality: Mr. Doe presents as a conscientious and somewhat introverted individual, meticulous in his work and organised in his personal life. He tends to be self-critical and can be prone to overthinking, which may contribute to his current ruminative state. He demonstrates a strong sense of responsibility, particularly towards his work commitments. Mental State Examination: On examination, Mr. Doe is a casually dressed male who appears tired, with somewhat dishevelled hair and clothes. He maintains good eye contact throughout the interview, though his facial expression is often flat, and he rarely smiles. His psychomotor activity is reduced, with slowed movements and occasional sighs. Speech is of normal volume and rate but lacks spontaneity and prosody. Thought content is preoccupied with feelings of inadequacy and hopelessness, with occasional self-critical rumination. There is no evidence of delusional thinking. Mood is reported as 'low' and 'flat,' with an affect that is congruent and restricted. He denies any perceptual disturbances, including auditory or visual hallucinations. Cognition appears intact, with good attention and concentration during the interview. Insight into his current difficulties is good, acknowledging that his symptoms are indicative of a depressive episode and expressing a desire for help. He denies any current suicidal ideation or intent. Risk Assessment: Mr. Doe denies any current suicidal ideation, intent, or plans. He reports a past history of passive thoughts of not wanting to wake up during his previous depressive episode, but explicitly denies any active suicidal thoughts. He states he has no current thoughts of self-harm. His protective factors include his supportive family and his engagement with hobbies, though his enjoyment of these is currently diminished. There are no other identified risk factors relating to risk to self. Mr. Doe explicitly denies any thoughts of harm to others or a history of violence or aggression. He reports no history of engaging in any behaviours that would pose a risk to others. No other risks identified. Overall, Mr. Doe's current risk is considered low due to the explicit denial of suicidal ideation or intent, and the presence of protective factors, including family support and good insight. A safety plan was briefly discussed, focusing on maintaining routine and engaging with his therapist, should his mood worsen significantly. Capacity Assessment: No formal capacity assessment was conducted as there were no grounds to doubt Mr. Doe's capacity to understand the information presented, retain it, use it in making a decision, or communicate his decision. He actively participated in the discussion about his care and treatment options. Diagnosis, Impression and Discussion on Treatment Plan: Diagnosis: 6A70.0 - Single episode of moderate depressive disorder without psychotic symptoms Mr. Doe's presentation is consistent with a single episode of moderate depressive disorder without psychotic symptoms, given his pervasive low mood, anhedonia, fatigue, appetite changes, and feelings of hopelessness that have persisted for several months. This aligns with his self-reported symptoms and the findings of the Mental State Examination. The discussion with Mr. Doe included explaining the diagnosis in lay terms, validating his experiences, and emphasising that depression is a treatable condition. He verbalised understanding of the diagnosis. The discussion around treatment options explored both pharmacological and psychotherapeutic approaches. Given his positive past response to sertraline and CBT, these were presented as viable options. Mr. Doe expressed a preference to initially try psychotherapy, specifically individual CBT, as he felt it provided him with good coping strategies in the past. He was open to considering medication if psychotherapy alone proved insufficient. The rationale for starting with CBT was his past success and current preference, whilst acknowledging that medication could be added if needed. Other options, such as alternative psychotherapies or different antidepressant classes, were briefly mentioned but not pursued at this stage given his clear preference. Suggestions and Plans Discussed: 1. Referral for individual Cognitive Behavioural Therapy (CBT). 2. Review appointment in 4 weeks to assess progress and re-evaluate treatment plan. 3. Recommend maintaining a regular sleep schedule and engaging in light physical activity. 4. Provide psychoeducational materials on depression and self-management strategies. Helpful Resources: * Mind.org.uk - Information on depression and mental health support. * NHS Every Mind Matters - Self-care resources for mental well-being.