Psychiatric assessment (1st appointment)

Patient Name: John Smith Date of Assessment: 1 November 2024 NHS/Clinic Number: 1234567 Seen by: Dr. Emily Carter, Consultant Psychiatrist Setting: Video consultation Duration: 60 minutes 1. Reason for Assessment / Referral Referred by GP due to low mood, anxiety, and social withdrawal. 2. History of Presenting Problems Symptom Onset: Symptoms began approximately 6 months ago, following a job loss. Course and Duration: Symptoms have been persistent, with fluctuating intensity. Current Symptoms: Low mood, anhedonia, anxiety, difficulty sleeping, poor appetite, and social isolation. Impact on Functioning: Significant impact on work, social life, and self-care. Coping and Insight: Patient acknowledges difficulties but struggles to identify coping strategies. Goals and Expectations: Patient hopes to improve mood, reduce anxiety, and regain social functioning. 3. Past Psychiatric History Previous Diagnoses: None. Psychological Therapies: None. Medication History: None. Hospital Admissions / Crisis Support: None. History of Self-harm or Suicidal Thoughts: Reports passive suicidal ideation, but no active plans or intent. 4. Medical History Physical Health Problems: Reports occasional headaches. Medications: None. Allergies: No known allergies. 5. Family History Psychiatric Conditions in Family: Mother has a history of depression. 6. Personal History Childhood Environment: Stable childhood, supportive parents. Schooling and Peer Relationships: Good academic performance, some social difficulties. Adolescence: No significant issues. Occupational History: Previously employed as an accountant, currently unemployed. Relationship History and Sexuality: Single, no current romantic relationships. Substance Use: Occasional alcohol use, no illicit drug use. 7. Mental State Examination Appearance and Behaviour: Appears his stated age, slightly dishevelled, poor eye contact, and psychomotor slowing. Speech: Slow rate, quiet volume, coherent. Mood and Affect: Subjective mood is low, affect constricted. Thought Form and Content: No evidence of formal thought disorder. Perception: No hallucinations. Cognition: Oriented to time, place, and person. Memory intact. Insight and Judgement: Limited insight into the severity of his condition. 8. Risk Assessment To Self: Passive suicidal ideation, low risk. 9. Formulation Predisposing Factors: Family history of depression, personality traits. Precipitating Factors: Job loss. Perpetuating Factors: Social isolation, negative thought patterns. Protective Factors: Supportive family. 10. Diagnosis / Provisional Diagnosis Major Depressive Disorder, moderate severity (ICD-10: F32.1). 11. Plan and Recommendations Medication advice: Discussed the option of starting an antidepressant medication. Psychological therapy recommendations: Recommend Cognitive Behavioural Therapy (CBT). Signposting to services or self-help resources: Provided information on local mental health support groups. Next steps – follow-up plans or referrals: Schedule a follow-up appointment in 4 weeks. 12. Capacity and Consent The patient has the capacity to consent to assessment and treatment. Consent was obtained. I have no concerns regarding risk at this stage.