Biopsychosocial Assessment

Comprehensive Clinical Assessment

Date of Assessment: 24/10/2023

Location of Assessment

[x] Outpatient Clinic [ ] Inpatient Unit [ ] Emergency Department [ ] Telehealth [ ] Home Visit:

Chief Complaint: "I haven't been able to get out of bed or focus on work for the past month."

Presenting Problem: Pt is a 34 y/o male presenting for initial psychiatric evaluation due to worsening depressive sx following a job layoff 3 months ago. Reports persistent low mood, anhedonia, and difficulty functioning daily.

History of Presenting Problem: Sx began insidiously 3 months ago post-layoff and progressively worsened over the last 4 weeks. Initially experienced mild situational anxiety, which transitioned into pervasive sadness, social withdrawal, and severe fatigue.

Current Symptoms: Depressed mood, anhedonia, initial and middle insomnia (sleeping 4–5 hrs/night), decreased appetite with a 4.5 kg weight loss over 2 months, low energy, impaired concentration, and feelings of worthlessness. Denies manic or psychotic sx.

Prior Episodes of Problem: One prior depressive episode at age 22 during university finals; resolved after 6 months of outpatient psychotherapy without pharmacotherapy.

Treatment History: 6 months of CBT at age 22. No prior psychiatric hospitalizations. Naive to psychotropic medications.

Risk Assessment: Low acute risk. Endorses passive SI ("sometimes I wish I'd just go to sleep and not wake up"), but denies active SI, intent, or plan. No Hx of suicide attempts or non-suicidal self-injury. Denies HI. Future-oriented and seeking help.

History of Substance Abuse: EtOH: 2–3 beers on weekends; denies recent increase. Tobacco: Denies. Illicits: Occasional cannabis use in college; none in > 10 years. No Hx of SUD.

Medical History: Mild intermittent asthma. Appendectomy (2015). NKDA. Current meds: salbutamol (albuterol, ProAir HFA®) 90 mcg/actuation INH PRN SOB. Recent PCP lab work (CBC, CMP, TSH) from 10/10/2023 WNL.

Developmental History: Born full-term, NSVD. Met all developmental milestones on time. No childhood learning disabilities or behavioral disorders.

Family Mental Health and Substance Abuse History: Mother has Hx of MDD, responsive to sertraline. Maternal uncle with EtOH use disorder. No family Hx of bipolar disorder, schizophrenia, or completed suicide.

History of Trauma: Denies Hx of physical, sexual, or emotional abuse. No significant trauma Hx.

Supports: Supportive wife of 5 years, close relationship with parents and younger sister who live locally, and two close friends from college.

Living Situation: Lives in a rented townhouse with his wife. Safe and stable environment; finances temporarily strained but manageable with wife's income.

Education: Bachelor of Science in Computer Science.

Employment: Unemployed for 3 months; previously worked as a software engineer for 8 years with strong performance reviews.

Relationship History: Married for 5 years (together for 8 years). Describes marriage as supportive, though recent depressive sx have caused mild strain. No children.

Other Social History: Enjoys cycling and playing guitar, though has not engaged in either for 6 weeks. No military service.

Legal/DCF History: None. No arrests or DCF involvement.

Cultural Beliefs/Identification: Identifies as Caucasian American. Raised Protestant, currently non-practicing. No cultural or religious barriers to psychiatric treatment or pharmacotherapy identified.

Strengths/Protective Factors: Strong spousal and family support, high baseline functioning, good insight, absence of substance abuse, and strong motivation for treatment.

Special Consideration/Needs: None. Speaks English fluently; no sensory or mobility impairments.

Mental Status Exam

Appearance

Well-groomed, casual attire, appears stated age.

Hygiene

Good.

Cooperative

Yes

Psychomotor

Mild psychomotor retardation noted.

Orientation

Oriented to person, place, time, and situation (A&Ox4).

Fund of Knowledge

Average to above average, consistent with educational level.

Attention/Concentration

Mildly impaired on serial 7s; easilyfatigued during cognitive tasks.

Recent Memory

Intact (recalled 3/3 objects at 5 minutes).

Speech/Language

Soft volume, slightly slowed rate, normal prosody, fluent.

Mood

"Depressed and exhausted."

Affect

Constricted, dysphoric, congruent with mood.

Thought Process

Linear, logical, and goal-directed.

Perceptual Disturbances

None; denies AH/VH.

Thought Content

Preoccupied with unemployment and financial adequacy; no delusions, paranoia, or obsessions.

Suicidal Ideation/Plan/Intent

Passive SI without plan or intent.

Homicidal Ideations/Plan/Intent

None.

Judgement

Good.

Insight

Good; recognizes symptoms as part of a treatable depressive episode.

Comments

Pt engaged well in the interview despite visible fatigue.

Stage of Change

Preparation/Action.

Diagnosis: Major Depressive Disorder, recurrent, moderate (F33.1)

Summary: 34 y/o male presenting with a 3-month Hx of worsening depressive sx precipitated by job loss, meeting criteria for recurrent MDD, moderate severity. MSE notable for dysphoric/constricted affect, mild psychomotor retardation, and passive SI without plan or intent. Low acute safety risk given strong protective factors and treatment engagement.

Recommendations:

1. Initiate sertraline (Zoloft®) 50 mg PO daily for depression. Discussed SE profile (GI upset, headache, activation) and black box warning.
2. Refer for individual CBT to address cognitive distortions and behavioral activation.
3. Reviewed safety plan; provided crisis hotline numbers (988) and instructed to go to nearest ED if active SI develops.
4. RTC in 4 weeks for medication management and symptom reassessment.

Treatment Categories

Symptoms of Diagnosis

Problem

Functional Impairment

Problem

Behavioral Concerns

No Problem

Other

No Problem