Psychiatric Assessment Letter

**Date of Review**: November 1, 2024 **Present at review**: Patient, Dr. Tarun D. Singh **Previous medication**: * Sertraline 100mg daily, for 6 months, efficacy: partial response **Medication today onwards:** * Sertraline 150mg daily, Titration: Increase by 50mg every 2 weeks. **Care Plan:** 1. Continue Sertraline at increased dosage. 2. Schedule follow-up appointment in 4 weeks. 3. Encourage regular exercise and healthy diet. 4. Review crisis plan and ensure patient has contact information for support. **Impression:** * Major Depressive Disorder (6A70) * Generalized Anxiety Disorder (6B00) **Physical Health:** Patient reports no significant physical health concerns. Reports being up to date with all routine health checks. --- "Thank you for your continued care of" Jane Doe, "a" 32-year-old female "who attended for assessment regarding" persistent low mood, anxiety, and difficulty sleeping. **Chief Concerns:** Patient reports feeling persistently sad and hopeless for the past 6 months. She experiences significant anxiety, particularly in social situations, and has difficulty falling asleep. She reports feeling overwhelmed by daily tasks and has withdrawn from social activities. She also reports a loss of interest in activities she used to enjoy. **Past Medical & Psychiatric History** Patient has a history of Major Depressive Disorder, diagnosed 6 months ago. She was previously prescribed Sertraline, which provided partial relief. She denies any history of self-harm or suicidal attempts. No other significant medical history. **Developmental History:** Patient reports a normal developmental history. No complications during pregnancy or birth. Early childhood was unremarkable. **Family History** Mother has a history of depression. No other significant family psychiatric history. **Social History** Patient is single and lives alone. She has a supportive network of friends. She is employed full-time. **Mental State Examination (MSE):** The MSE was explained to the patient as a way to track her progress and understand her current mental state. Patient is well-groomed and appropriately dressed. Eye contact is good. Mood is reported as low, affect is constricted. No reported humor. Denies suicidal ideation or intent. No response to unseen stimuli. Thought content is preoccupied with feelings of sadness and worthlessness. No evidence of psychosis. Cognitive assessment reveals intact memory and orientation. Insight and judgment are fair. **Risk assessment:** _Risk to self_: Low. No current suicidal ideation or intent. _Risk to others_: Low. No intent or plan to harm others. _Risk of self-neglect:_ Low. Patient maintains good hygiene and living environment. _Risk from others:_ Low. No identified immediate risks. _Online:_ Low. No concerning online activity. **Assessment & Formulation** Jane Doe presents with symptoms consistent with Major Depressive Disorder and Generalized Anxiety Disorder. Her symptoms significantly impact her daily functioning. The previous treatment with Sertraline provided partial relief, and an increase in dosage is warranted. **Management Plan** Increase Sertraline to 150mg daily. Schedule a follow-up appointment in 4 weeks to assess response to medication and provide supportive psychotherapy. Encourage regular exercise and a healthy diet. Review the crisis plan and ensure the patient has contact information for support. Consider referral to a therapist for CBT if symptoms persist. **Capacity Statement**: The patient demonstrates the capacity to understand the nature of her illness and the proposed treatment plan. She is able to make informed decisions about her care. Yours sincerely, Dr. Tarun D. Singh, Specialty Doctor,