General Psychiatry New Patient Assessment

Medication

Commence sertraline (Lustral®) 50 mg PO OD in the morning. Continue propranolol 40 mg PO BID PRN for somatic anxiety.

Care Plan

Mr Vance will commence sertraline and return for a medication review in 4 weeks. He has been signposted to local NHS Talking Therapies for cognitive behavioural therapy (CBT) to address his generalised anxiety and depressive symptoms. He is advised to maintain sleep hygiene and reduce caffeine intake.

We will always do our best to bring appointments forward if our patients are struggling and need support. As Thames Valley Psychiatry Clinic is not an emergency service, if you are in crisis, we recommend calling the Samaritans on 116 123 or NHS 111. The urgent mental health line is 0800 123 4567. Urgent appointments can also be made with the GP. In a severe emergency, use 999 or visit the Accident and Emergency department at your local hospital.

I met with Arthur Vance by video call through Thames Valley Psychiatry Clinic.

Mr Vance presented with a 6-month history of pervasive low mood, anhedonia, and escalating generalised anxiety.

The symptoms began insidiously following a period of restructuring at his workplace in October 2025. Initially, he noticed difficulty initiating sleep and ruminating over work performance. Over the past 3 months, his mood has worsened significantly, accompanied by diurnal mood variation (worse in the mornings), reduced appetite with a 4 kg weight loss, and marked fatigue. He experiences daily palpitations and restlessness, which occasionally culminate in panic attacks lasting 15 minutes. He explicitly denies any suicidal ideation, intent, or self-harm behaviours.

Mr Vance was previously diagnosed with a mild depressive episode by his GP in 2019. He was treated with citalopram 20 mg PO OD for 9 months, which he tolerated well and found effective, alongside 6 sessions of counselling. He has no history of psychiatric admissions or secondary care mental health input.

He has a history of mild asthma and gastro-oesophageal reflux disease (GORD). His current prescribed medications are salbutamol (Ventolin®) 100 mcg INH PRN, omeprazole 20 mg PO OD, and propranolol 40 mg PO BID PRN, which his GP initiated 3 weeks ago.

Allergies

He has a documented allergy to penicillin, which causes a widespread maculopapular rash.

He drinks approximately 10 units of alcohol per week, typically consuming wine at weekends, and denies any history of alcohol dependence. He smokes 5 cigarettes per day and drinks 4 cups of filter coffee daily. He explicitly denies any current or previous recreational drug use.

Family History

His mother has a history of recurrent depressive disorder managed in primary care, and his maternal uncle has bipolar affective disorder. He explicitly states there is no family history of completed suicide or substance misuse. His father has type 2 diabetes mellitus (T2DM) and hypertension.

He lives in a privately rented two-bedroom flat with his long-term partner. There are no financial pressures or housing insecurities reported.

Personal History

He was born at full term via normal vaginal delivery with no neonatal complications and met all developmental milestones on time.

He grew up in Bristol with his parents and one younger sister. His father worked as an engineer and his mother as a primary school teacher. He describes a supportive and stable upbringing and remains close to his family.

He denies any history of childhood trauma, neglect, mistreatment, or physical, emotional, or sexual abuse.

He enjoyed primary and secondary school and maintained a stable group of friends. He was never bullied. He reports no difficulties with concentration, organisation, or classroom behaviour, and explicitly denies any childhood symptoms suggestive of attention deficit hyperactivity disorder (ADHD), such as hyperactivity or impulsivity.

He achieved 9 GCSEs at grades A to B, followed by 3 A-levels in History, English, and Economics. He subsequently attended the University of Leeds, graduating with a 2:1 honours degree in History.

Since graduating, he has worked in logistics and supply chain management. He has been with his current company for 5 years as a senior operations coordinator. He generally gets on well with colleagues and has no history of disciplinary issues, though he currently feels overwhelmed by increased targets and understaffing.

He has been in a stable, supportive relationship with his current partner, a graphic designer, for 4 years. He had one previous significant relationship at university which ended amicably.

Mental State Examination

Mr Vance appeared appropriately dressed and well-groomed on video, appearing his stated age of 31 years. He was cooperative and established good rapport, though he appeared visibly tense and restless at times. His speech was normal in rate, tone, and volume. His mood was subjectively described as "exhausted and low" and objectively appeared dysphoric and anxious, with a reactive affect. His thought form was linear and coherent with no formal thought disorder. Thought content was notable for ruminations regarding occupational failure and health, with no delusions or overvalued ideas; he expressed no thoughts of harming himself or others. There were no abnormal perceptions or hallucinations reported. He was oriented to time, place, and person, with intact attention during the interview. His insight into his condition was good, and his judgement was intact.

Discussion

We discussed that his presentation is consistent with a moderate depressive episode with prominent anxiety symptoms, precipitated by occupational stress. We reviewed treatment options including psychological therapies and pharmacotherapy. Given his previous positive response to an SSRI, we agreed to initiate sertraline 50 mg PO OD. I counselled him on potential initial side effects, including gastrointestinal upset and transient increased anxiety, as well as the expected 2 to 4 week lag before clinical improvement. We discussed the importance of engaging with NHS Talking Therapies alongside medication, and I will write to his GP to request routine baseline blood tests including thyroid function tests (TFTs) and a full blood count (FBC).

Recent observations recorded at his GP surgery last week showed a blood pressure of 124/78 mmHg, a heart rate of 76 bpm, a height of 1.78 m, and a weight of 72 kg.