Psychiatric Follow-Up Letter

For a Psychiatrist: JOHN DOE, DOB 01/01/1985, MRN 1234567, 123 HIGH STREET, LONDON, W1A 1AB, JOHN.DOE@EMAIL.COM, 07700 900000 Diagnosis: • Major Depressive Disorder, recurrent, moderate • Generalised Anxiety Disorder Current Medications: • Sertraline 100mg once daily • Diazepam 5mg as needed (max 1 tablet per day) Update on psychiatric issues: John reports a slight improvement in his mood since his last appointment, with fewer episodes of low energy and anhedonia. He acknowledges still struggling with persistent feelings of worry and restlessness, particularly in social situations. He has been engaging with the mindfulness exercises recommended previously, finding them moderately helpful in managing acute anxiety symptoms. Update on medical issues: John's blood pressure remains stable, and he reports no new physical health concerns. He has been more consistent with his exercise routine, which he finds positively impacts his overall well-being. Update on medications: John finds Sertraline 100mg tolerable with no significant side effects. He uses Diazepam sparingly for severe anxiety episodes, approximately once or twice a week, and reports it helps to quickly alleviate his symptoms without causing excessive drowsiness. He has no concerns about his current medication regimen. RISK: John denies any current suicidal ideation, self-harm, or passive thoughts of death. He reports feeling hopeful about his progress and has good social supports. There is no history of self-harm. He is managing well with his current coping strategies. John denies any thoughts or intent to harm others. He has no history of aggression or violence. RECOMMENDATIONS: 1. Continue Sertraline 100mg once daily. 2. Continue Diazepam 5mg as needed for anxiety, with a maximum of one tablet per day. 3. Consider an increase in Sertraline to 150mg daily at the next review if anxiety symptoms persist at current levels. 4. Continue with CBT sessions as planned with the community mental health team. 5. Explore group therapy options for anxiety management within the local area. 6. Can I ask GP to please arrange routine blood tests (FBC, U&Es, LFTs, TFTs, Lipids, Glucose) prior to John's next appointment? 7. Follow-up appointment booked for 1 November 2024 at 10:00 AM, in Clinic B at St. Jude's Hospital. If you are feeling overwhelmed or suicidal, 24h crisis counselling is available from the Samaritans on 116 123 or advice from NHS 111 (option 2). If you are feeling unsafe, mental health support is available in every UK emergency department or via ambulance (999). COPY TO: Dr. Sarah Jenkins Evergreen Medical Practice 45 Oak Lane London SW1A 2BC sarah.jenkins@evergreenmp.com Community Mental Health Team Coordinator