Adult Intake

Presenting Problems

Pt is a 34 yo M presenting with a 4-month hx of worsening low mood, anhedonia, initial insomnia, and impaired concentration following a corporate restructuring at work. Reports persistent worry regarding job security, daily fatigue, and a 4 kg weight loss due to decreased appetite. Denies SI/HI, manic sx, or psychotic features.

Relationships

Married for 6 years; describes spouse as supportive, though notes recent marital friction secondary to his social withdrawal and irritability. No children. Close relationship with younger sister in Ottawa. Has a small circle of friends but has been avoiding social gatherings for the past 2 months.

Living Arrangements

Resides in a mortgaged 2-bedroom condominium in Toronto with his wife. Housing is stable and financially secure at present.

Education/Employment

Holds a Bachelor of Commerce degree. Employed full-time as a senior financial analyst for 8 years. High work-related stress over the past 6 months due to team downsizing, increased workload, and a change in management. Considering taking short-term disability leave if sx do not improve.

Physical Health

Hx of mild intermittent asthma; uses salbutamol (Ventolin®) 100 mcg INH PRN. Recent routine blood work by PCP on 02/03/2026 (CBC, electrolytes, TSH, ferritin, vitamin B12) was WNL. Non-smoker; consumes 2–3 caffeinated beverages daily and 2 standard alcoholic drinks per week. Minimal physical exercise recently.

Mental Health History

Previous depressive episode at age 24 during university; completed 8 sessions of CBT via campus health services with good response. No prior psychotropic medication trials. Denies hx of psychiatric hospitalizations, self-harm, or suicide attempts. FHx significant for maternal MDD.

Treatment Goals

Improve sleep continuity and daytime energy levels, develop coping strategies to manage workplace stressors, and restore engagement in recreational and social activities. Open to both pharmacotherapy and psychotherapy.

Additional Notes

Pt expressed concern about potential weight gain and daytime sedation with antidepressant medications. Provided psychoeducation on SSRI side-effect profiles and expected timeline for clinical response.

Initial Impressions

Alert, oriented x3, neatly groomed. Psychomotor activity mildly slowed. Speech normal in rate, rhythm, and volume. Mood described as "exhausted and down"; affect constricted and mood-congruent. Thought process linear and goal-directed; thought content notable for occupational ruminations, no delusions or SI/HI. Insight and judgment intact. Presentation consistent with Major Depressive Disorder, recurrent, moderate, with anxious distress.

Plan for Next Session

Initiate escitalopram (Cipralex®) 5 mg PO QAM for 7 days, then increase to 10 mg PO QAM. Pt instructed to maintain a daily sleep and mood log and implement basic sleep hygiene measures (eliminating caffeine after 12:00, no screens 1 hr prior to bedtime). Follow-up appointment scheduled in 2 weeks to assess medication tolerability, review sleep log, and initiate structured CBT interventions for workplace anxiety.