Psychiatric Follow-Up Review Note

Psychiatrist: Psychiatric Follow-Up Review Note Background And Past Contacts: Mrs. Jane Smith was initially assessed on 1 April 2023, presenting with symptoms of persistent low mood, anhedonia, significant fatigue, and difficulty concentrating, suggestive of Major Depressive Disorder. Subsequent follow-up meetings focused on medication titration and exploring coping mechanisms. During her last session, on 18 October 2024, the impression was that her mood had shown slight improvement but still presented with significant anhedonia. The plan was to increase her Sertraline to 100mg daily and schedule a follow-up in two weeks to reassess symptom severity and medication side effects. The current visit is a planned follow-up to review her progress on the increased Sertraline dosage and address ongoing concerns regarding her energy levels and concentration. Update On Employment History: No update. Update On Social History: No update. Update On Relationship History: No update. Update On Drug And Alcohol History: No update. No active and ongoing drug or alcohol use reported. Update On Past Medical History: No update. No known allergies. Update On Medication History: Mrs. Smith is currently taking Sertraline 100mg daily (increased from 75mg daily two weeks prior). She also takes Vitamin D supplements daily. The increase in Sertraline dosage was implemented as per the last treatment plan. Update On Past Psychiatric History: Mrs. Smith has a history of a previous depressive episode five years ago, which was successfully managed with Citalopram and short-term psychotherapy. There have been no other significant psychiatric diagnoses or hospitalisations. Update On Forensic History: No update. Summary Of Review: Mrs. Smith reports a modest improvement in her overall mood since the last clinical review, noting that her 'dark cloud' feels slightly lighter. However, she continues to experience significant anhedonia, particularly in activities she previously enjoyed. Her fatigue remains a prominent symptom, impacting her ability to engage in daily tasks and social interactions. Concentration difficulties persist, affecting her work performance. She reports no changes in the duration, timing, or location of her symptoms, but notes a slight decrease in their overall severity. Mrs. Smith reports that engaging in short walks outdoors provides temporary relief from her low mood, though the effect is transient. She has attempted to self-treat her fatigue with increased caffeine intake, but this has not been effective and sometimes leads to increased anxiety. She has not noticed any new factors that worsen her symptoms. The ongoing symptoms of anhedonia and fatigue continue to significantly impact her daily activities. She finds it challenging to maintain household chores, and her social engagement has further decreased. While she acknowledges the slight improvement in mood, she feels her daily functioning has not significantly improved since the last appointment. Mrs. Smith reports no new side effects from the increased Sertraline dosage. She explicitly denied experiencing nausea, headaches, or increased anxiety, which were discussed as potential side effects at the last appointment. She assesses the medication effectiveness as 'somewhat helpful' but states she was hoping for a more pronounced improvement in her energy levels and ability to feel pleasure. She notes that while the 'edge' has been taken off her depression, she doesn't feel 'like herself' yet. Mrs. Smith expressed concern about the persistent fatigue and questioned if the Sertraline was the right medication given this side effect or if the dosage could be further increased. She also raised concerns about feeling emotionally blunted. Regarding the treatment plan agreed at the previous appointment, the increase in Sertraline dosage proceeded as planned. Mrs. Smith feels it went 'okay' but is disappointed with the lack of significant change in her energy and anhedonia. She believes the medication is only partially addressing her symptoms. The clinician provided psychoeducation on the typical trajectory of antidepressant response, explaining that anhedonia and fatigue often take longer to improve than core mood symptoms. The patient listened attentively and acknowledged the explanation but still expressed a desire for quicker relief. No new symptoms or concerns were raised during the appointment, and Mrs. Smith denied any suicidal ideation or plans when directly asked. Mental State Examination: Mrs. Smith presented as casually dressed and groomed. Her eye contact was maintained intermittently, and her psychomotor activity was slightly reduced but within normal limits. There was no significant change in her overall appearance or behaviour from the last appointment. Her subjective mood was reported as 'a bit better, but still tired and flat.' Objectively, her affect was congruent with her reported mood, constricted in range, and reactive to conversation, though still appearing somewhat blunted. This represents a slight improvement in reactivity compared to the last appointment, where her affect was notably flat. Speech was of normal rate and volume, coherent, and organised. Thought process was linear and goal-directed, with no evidence of formal thought disorder. No changes from the last appointment were noted in speech or thought process. Thought content revealed preoccupation with her persistent fatigue and anhedonia. She denied any delusions, overvalued ideas, obsessive thoughts, or anxious ruminations. These findings are consistent with the last appointment. Perception revealed no evidence of hallucinations or other perceptual disturbances. When explicitly asked, Mrs. Smith denied hearing voices or seeing things that others could not. There were no changes from the last appointment. Mrs. Smith's insight into her difficulties appears good; she acknowledges her depressive symptoms and their impact on her life. She recognises the need for continued treatment and is engaged in the care process, actively participating in treatment discussions. She shows a continued help-seeking stance, similar to the last appointment. Risk Assessment: Current risk factors relevant to Mrs. Smith's presentation include persistent low mood, anhedonia, and significant fatigue. She denies any history of self-harm, suicidal ideation, or attempts, and these were explicitly denied again today. She denies any history of violence or aggression towards others or property. Protective factors include her supportive family, her willingness to engage in therapy, and her capacity for self-reflection. There are no current risk factors for self-harm, suicide, or violence identified. No formal safety plans are currently in place, given the absence of active suicidal ideation. Capacity To Consent To Care And Treatment: Mrs. Smith demonstrates full capacity to consent to care and treatment. She understands the information presented, appreciates the consequences of her choices, reasons about treatment options, and communicates her decisions clearly. Impression: Mrs. Smith continues to experience symptoms consistent with Major Depressive Disorder, though there has been a modest improvement in core mood symptoms following the increase in Sertraline. The biopsychosocial factors contributing to her condition include a history of previous depressive episodes, ongoing work-related stress, and the current challenges of persistent anhedonia and fatigue. The diagnosis remains appropriate given the enduring nature of her symptoms, their impact on her functioning, and her response to antidepressant medication. Feedback was provided to Mrs. Smith regarding her progress. The clinician acknowledged her disappointment with the persistent anhedonia and fatigue, validating her experience. Mrs. Smith expressed appreciation for the validation but reiterated her desire for more significant improvement. Several recommendations were considered, including a further increase in Sertraline, switching to a different antidepressant, or augmenting with a second medication. The discussion with Mrs. Smith focused on the pros and cons of each. She expressed hesitancy about switching medications due to concerns about new side effects but was open to a further dose increase or augmentation if deemed necessary. The clinician advised a plan to try a further increase in Sertraline. A detailed account of the discussion on medication included the clinician explaining the potential for further improvement with a higher dose of Sertraline, while also acknowledging the possibility of exploring augmentation strategies if the current approach proves insufficient. Mrs. Smith agreed to increase the Sertraline dosage, expressing a preference for continuing with the current medication rather than switching. Recommendations for additional support included exploring cognitive behavioural therapy (CBT) specifically tailored for anhedonia and fatigue, and resources for stress management techniques. Mrs. Smith expressed interest in CBT for anhedonia and agreed to a referral. Mrs. Smith's main concern about ADHD management was the ongoing fatigue and 'brain fog'. The clinician explained that while Sertraline can help with mood, other interventions, such as CBT, lifestyle adjustments, and potentially exploring ADHD specific medication, might be necessary to address these residual symptoms effectively. The action steps agreed were to increase Sertraline and pursue a referral for CBT. Plan: * Increase Sertraline to 125mg daily for two weeks, then 150mg daily thereafter, as tolerated. * Referral for Cognitive Behavioural Therapy (CBT) focusing on anhedonia and fatigue. * Follow-up appointment in four weeks to reassess symptom severity, medication side effects, and CBT engagement, conducted via video consultation.