Depression Assessment

Chief Complaint

Persistent low mood and fatigue x 6 weeks.

History of Present Illness

38yo F (PHN: 9123 456 789) presents with a 6-week Hx of worsening depressed mood, anhedonia, and severe fatigue following a job layoff on 01/02/2026. Sx have progressively impaired her daily functioning, resulting in difficulty getting out of bed and neglect of household chores. Associated Sx include terminal insomnia, 4 kg weight loss due to poor appetite, and impaired concentration. She reports one prior depressive episode in 2019 which resolved after 6 months of pharmacotherapy.

Past Psychiatric History

Dx with MDD in 2019 by her previous GP. No Hx of psychiatric admissions, manic episodes, or suicide attempts.

Medications

• • escitalopram (Cipralex®) 10 mg PO daily (restarted 3 days ago using leftover medication)
• sertraline (Zoloft®) 50 mg PO daily in 2019; discontinued due to GI upset. escitalopram (Cipralex®) 10 mg PO daily in 2019; good clinical response with full remission.

Family History

Mother has a Hx of MDD and GAD. Father has no known psychiatric Hx.

Social History

Unemployed graphic designer, lives in an apartment with her supportive common-law partner. Denies tobacco or recreational drug use; drinks 1–2 standard alcoholic beverages on weekends. Good social support from partner and local friends.

Mental Status Examination

• Appearance – The patient appears stated age, is casually dressed, and exhibits fair grooming.
• Behavior – She is cooperative with mild psychomotor retardation and intermittent eye contact.
• Speech – Speech is soft, slightly slowed in rate, and monotone.
• Mood and Affect – Mood is described as "empty" and affect is dysphoric and constricted.
• Thought Process and Content – Thought process is linear and goal-directed without delusions, hallucinations, or obsessions.
• Cognition – She is alert and oriented x 3 with intact memory, though mild distractibility is noted during the interview.
• Insight and Judgment – Insight into her current condition is good, and judgment remains intact.

PHQ-9 Score

16/27 (Moderately severe depression).

Risk Assessment

Patient endorses fleeting passive thoughts that she would be "better off asleep" over the past 2 weeks, but explicitly denies active SI, intent, or plan. Denies HI or Hx of NSSI. Protective factors include strong partner support and future orientation regarding job interviews.

Diagnosis

Major Depressive Disorder, recurrent, moderate.

Treatment Plan

• Continue escitalopram (Cipralex®) 10 mg PO daily; reassess for titration to 20 mg PO daily in 2–4 weeks if partial response. Advised weekly CBT sessions. Recommended sleep hygiene measures and 30 minutes of daily outdoor walking.
• RTC in 2 weeks (02/04/2026 at 10:30) to monitor SSRI tolerability and mood Sx.

Patient Education

Discussed etiology of MDD and expected 4–6 week timeline for full SSRI efficacy, as well as potential transient side effects (nausea, headache). Reviewed non-pharmacological strategies. Collaboratively established a safety plan: patient agreed to contact the BC Mental Health Support Line (310-6789) or present to the nearest ED if active SI develops.

Referrals

• BounceBack BC program for guided CBT.
• Community mental health counselling services.