Comprehensive Psychiatric Assessment

SARAH JANE JENKINS, DOB 14/05/1978, NHS 482 910 3847, 42 OAKWOOD AVENUE, BRISTOL, BS8 3TH, SARAH.JENKINS78@EMAIL.CO.UK, 07700 900452

Circumstances Of Referral

Sarah is a 45-year-old woman with a previous diagnosis of generalised anxiety disorder.

She was referred by her oncology team for assessment and management of worsening depressive symptoms following her recent breast cancer treatment.

Cancer History

Sarah noticed a lump in her left breast in 08/2023 and was diagnosed with stage IIA invasive ductal carcinoma on 15/09/2023. She underwent a wide local excision and sentinel lymph node biopsy on 10/10/2023, followed by adjuvant chemotherapy from 11/2023 to 02/2024. She completed a course of radiotherapy on 20/03/2024 and was subsequently commenced on endocrine therapy.

History Of Presenting Symptoms

Sarah presents with pervasive low mood, anhedonia, and severe health anxiety.

Her mood began to deteriorate in 11/2023 shortly after starting chemotherapy, and her symptoms worsened significantly upon completing active hospital treatment in 03/2024.

She links the onset of her depressive episode directly to the physical toll of cancer treatment and the sudden loss of regular medical monitoring after radiotherapy finished.

Sarah describes the impact on her mental health as debilitating, noting that she struggles to get out of bed and has withdrawn from her social circle.

She reports that the cancer diagnosis shattered her sense of physical safety and left her feeling alienated from her own body due to surgical scarring and treatment-induced fatigue.

Emotionally, she feels overwhelmed by guilt for not feeling "grateful" to be in remission and experiences constant dread regarding potential disease recurrence.

She reports early morning wakening at 04:00, diurnal mood variation, poor concentration, and a 4 kg weight loss over the past two months due to reduced appetite.

Reflecting on her past, Sarah notes that her current distress is much more severe than the mild anxiety she experienced in her thirties, feeling that her usual coping mechanisms have failed.

Regarding the future, she feels hopeless about ever returning to her baseline level of functioning and worries she will remain a burden to her family.

Psychiatric History

Sarah was diagnosed with generalised anxiety disorder by her GP in 2015 and was successfully treated with a six-month course of cognitive behavioural therapy (CBT).

She underwent a brief psychological wellbeing assessment via the local IAPT service in 2016 and was discharged back to primary care with full remission of symptoms.

In her recent patient self-assessment statement provided prior to clinic, Sarah noted that the transition from active oncology patient to cancer survivor triggered severe abandonment anxieties.

She has no past history of suicide attempts, although she has experienced fleeting passive thoughts of wishing she would not wake up over the past month.

There is no history of deliberate self-harm.

There is no history of accidental harm or self-neglect.

Medical History

Sarah currently experiences persistent chemotherapy-induced peripheral neuropathy in her fingertips and hot flushes secondary to tamoxifen therapy.

Her past medical history includes mild asthma diagnosed in childhood and an appendicectomy in 2004.

Medications

• Tamoxifen 20 mg PO OD
• Sertraline 50 mg PO OD
• Salbutamol 100 mcg/actuation inhaler PRN

Personal History And Developmental History

Sarah grew up in Bath as the elder of two sisters in a stable, supportive household where her father worked as an engineer and her mother was a primary school teacher.

She describes a happy childhood with no history of emotional, physical, or sexual trauma.

She had no significant childhood illnesses beyond mild asthma and met all early developmental milestones at the expected ages.

Sarah attended a local comprehensive school where she achieved ten GCSEs and three A-Levels before completing a Bachelor of Arts in History at the University of Bristol in 1999.

Social Circumstances

Sarah lives with her husband, Mark, and their two teenage children aged 14 and 16.

Her daily activities are currently limited by profound fatigue and low motivation, preventing her from exercising or managing household chores as she previously did.

Her overall functioning has declined markedly since 11/2023, and she relies heavily on her husband for domestic tasks and meal preparation.

The family lives in a privately ownedfour-bedroom house, and Sarah is currently on long-term sick leave from her role as a secondary school history teacher.

She describes her marriage as very supportive, though she feels guilty about leaning on her husband, and she maintains close contact with her sister.

Financially, the household is stable, though Sarah is anxious about her sick pay reducing to half-pay in 06/2024.

Substance Use

Sarah drinks approximately four units of alcohol per week, has never smoked tobacco, and denies any history of illicit substance or over-the-counter medication misuse.

Family History

Her maternal aunt had a history of recurrent depressive disorder, and her paternal grandmother was diagnosed with ovarian cancer in her seventies.

Mental State Examination

"Appearance and behaviour:" Sarah appeared stated age, casually dressed, with slightly stooped posture; she maintained appropriate eye contact and established a good rapport, though she became tearful when discussing her children.

"Speech and motor:" Mild psychomotor retardation was evident, and her speech was quiet with a slightly reduced rate and normal rhythm.

"Mood and affect:" She described her mood as "empty and exhausted", and her affect was objectively depressed and restricted in range.

"Thought process and content:" Her thought form was linear and coherent, with content dominated by themes of guilt, helplessness, and fear of cancer recurrence, stating "I feel like a ticking time bomb", alongside fleeting passive death wishes without active suicidal intent.

"Perceptions:" She reported no auditory, visual, or other hallucinations.

Standardised Tools

• PHQ-9: 18/27 (Moderately severe depression)
• GAD-7: 14/21 (Moderate anxiety)

Impression And Opinions

Sarah is a 45-year-old woman presenting with her first episode of moderately severe depression.

She reports a six-month history of pervasive low mood, anhedonia, biological depressive symptoms, and severe anxiety regarding cancer recurrence following completion of breast cancer treatment.

The diagnostic impression is a moderate depressive episode (ICD-11: 6A70.1) with prominent anxiety symptoms.

This diagnosis is supported by the presence of core depressive symptoms (low mood, anhedonia, fatigue) alongside neurovegetative features (early morning wakening, weight loss, poor concentration) persisting for over two weeks and causing significant functional impairment.

Differential diagnoses considered include adjustment disorder and chemotherapy-related cognitive and fatigue syndrome, though the severity and pervasiveness of her mood and biological symptoms meet the threshold for a full depressive episode.

In my opinion, her current symptoms were precipitated by the psychological trauma of her cancer diagnosis and the physiological burden of chemotherapy and endocrine therapy, compounded by a predisposition to anxiety.

Her self-reported symptoms are fully corroborated by her oncology clinical nurse specialist's referral letter and her elevated PHQ-9 and GAD-7 scores.

We discussed pharmacological and psychological treatment options, including increasing her current sertraline dose, switching to an alternative antidepressant avoiding CYP2D6 inhibition due to tamoxifen co-administration, and engaging in psycho-oncology CBT; Sarah understood the risks of GI upset and transient anxiety with dose titration and expressed a strong preference to increase sertraline while awaiting therapy, as sertraline has minimal CYP2D6 inhibition compared to paroxetine or fluoxetine.

Risk To Self

Sarah reports fleeting passive thoughts of wishing she would not wake up over the past month, with no history of deliberate self-harm or suicide attempts.

There is no history of self-inflicted injury to assess.

Her current suicide risk is assessed as low, given the absence of active suicidal ideation, intent, or planning, and the presence of strong protective factors including her children and supportive husband.

Future mental health risks include potential worsening of depressive symptoms and emergence of active suicidal ideation if her mood remains untreated or if she receives abnormal oncology surveillance results.

Risk To Others

No risk of harm to others evident.

Recommendations

Increase sertraline from 50 mg PO OD to 100 mg PO OD, to be prescribed by her GP, while continuing tamoxifen 20 mg PO OD.

Refer to the Macmillan Psycho-Oncology Psychology Service for 8 to 12 sessions of individual CBT focused on depression and fear of cancer recurrence.

Follow-up appointment scheduled for 18/06/2024 at 10:30 at the Liaison Psychiatry Outpatient Clinic, Bristol Royal Infirmary.

If you feel overwhelmed or have thoughts of suicide, 24-hour crisis counselling is available from the Samaritans on 116 123, and NHS 111 can provide advice through option 2. If you feel unsafe, mental health assistance is available at any UK emergency department or through an ambulance on 999.

Copy To

Dr A. Patel, Clifton Medical Practice, 15 Whiteladies Road, Bristol, BS8 1PB

Dr R. Evans, Consultant Medical Oncologist, Bristol Haematology and Oncology Centre; Ms L. Davies, Macmillan Breast Care Clinical Nurse Specialist, Bristol Haematology and Oncology Centre