Initial Clinical Interview

Clinical Interview

Presenting Problem(s)

• The Client presents with persistent low mood, anhedonia, and pervasive anxiety regarding work performance and financial stability.
• Associated stressors include a recent company restructuring and increased caregiving responsibilities for an ageing parent.

History of Presenting Problem(s)

• Onset approximately 6 months ago following redundancy of several colleagues and a subsequent doubling of the Client's workload.
• Symptoms began as initial insomnia and irritability, progressing over 3 months to daily depressed mood and frequent worry.
• Course has been steadily worsening, with severity escalating over the past 4 weeks following a critical performance review.

Current Functioning

Sleep

• Initial insomnia, taking 2–3 hours to fall asleep due to racing thoughts.
• Frequent middle-of-the-night awakenings, averaging 5 hours of fragmented, non-restorative sleep per night.

Employment/Education

• Employed full-time as a senior project manager.
• Experiencing impaired concentration, procrastination, and missed deadlines, resulting in heightened occupational stress.

Family

• Resides with partner, Sarah (34), and daughter, Chloe (4).
• Reports increased irritability and emotional withdrawal at home, causing strain in the relationship with Sarah.

Social

• Withdrawn from regular social activities over the past 3 months, declining invitations from close friends.
• Maintains a small support network but feels too exhausted to engage.

Exercise/Physical Activity

• Previously ran 5 km three times weekly; ceased all structured exercise 2 months ago due to lethargy.

Eating Regime/Appetite

• Reduced appetite with a 4 kg unintentional weight loss over 2 months.
• Skips breakfast and relies on convenience foods or takeaway in the evenings.

Energy Levels

• Persistent fatigue throughout the day, with a marked slump in the mid-afternoon.
• Wakes feeling unrefreshed regardless of sleep duration.

Recreational/Interests

• Loss of interest in previously enjoyed hobbies, including guitar playing and gardening.

Current Medications

• Escitalopram (Lexapro®) 10 mg PO mane (commenced by GP 3 weeks ago).
• Melatonin 2 mg PO nocte PRN.

Psychiatric History

• One prior episode of mild depressive symptoms 8 years ago following a relationship breakdown; resolved with 6 sessions of supportive counselling.
• No history of psychiatric hospitalisations or psychiatrist involvement.
• No prior psychotropic medication trials before current escitalopram prescription.

Other Interventions

• Utilised a mindfulness smartphone application intermittently over the past month with minimal reported benefit.

Medical History

• Personal: Mild asthma (well-controlled), no history of head injury, seizures, or thyroid dysfunction. Recent blood panel (FBC, TFTs, B12, iron studies) ordered by GP on 02/03/2026 was NAD.
• Family: Maternal history of Major Depressive Disorder; father has T2DM and HTN.

Developmental, Social and Family History

Family of Origin

• Raised in Sydney by parents David (68, retired accountant) and Helen (65, retired teacher).
• Parents remain married; relationship described as stable but emotionally reserved, with high academic expectations placed on the Client.
• One younger sister, Emma (31, physiotherapist), with whom the Client has a supportive relationship.

Developmental History

• Born full-term via normal vaginal delivery; met all developmental milestones WNL.
• Experienced mild separation anxiety upon starting primary school, which resolved without intervention.

Educational History

• Completed HSC with high academic achievement.
• Completed a Bachelor of Commerce at university; maintained stable peer relationships and denied history of bullying or learning difficulties.

Employment History

• Consistent employment history in corporate project management for 12 years.
• Promoted to senior management 2 years ago; no prior history of performance issues or workplace disputes.

Relationship History

• In a committed de facto relationship with Sarah for 7 years; generally supportive dynamic despite current symptom-related strain.
• One previous significant relationship lasting 3 years in early twenties.

Forensic/Legal History

• Nil forensic or legal history.

Substance Use

• Alcohol: Consumes 2–3 standard drinks (wine) on 4–5 nights per week to assist with sleep onset, increased from social weekend drinking 6 months ago.
• Caffeine: 3–4 cups of espresso coffee daily to combat fatigue.
• Tobacco/Illicit substances: Denies current or past use.

Relevant Cultural/Religious/Spiritual Issues

• Anglo-Australian background; identifies as non-religious.
• Strong familial cultural emphasis on self-reliance and stoicism, contributing to reluctance in seeking help earlier.

Risk Assessment

Suicidal Ideation

Passive ideation reported ("wishing I could just go to sleep and not wake up" approximately twice weekly), but denies active suicidal intent, plan, or history of attempts. Identifies daughter and partner as strong protective factors.

Homicidal Ideation

Nil reported.

Self-harm

Nil current or historical deliberate self-harm.

Violence & Aggression

Nil history of violence or aggression.

Risk-taking/Impulsivity

Nil current risk-taking or impulsive behaviours noted.

Mental State Exam

Appearance

Well-groomed, dressed in neat casual attire, appearing stated age. Mild dark circles noted under eyes.

Behaviour

Cooperative and polite; psychomotor retardation evident with slowed movements and slumped posture. Intermittent eye contact.

Speech

Normal volume, slightly reduced rate and prosody, monotone at times.

Mood

Described as "exhausted and flat".

Affect

Dysphoric and restricted in range, congruent with stated mood.

Perception

Nil hallucinations, illusions, or dissociative phenomena reported or observed.

Thought Process

Logical, coherent, and goal-directed, though mildly slowed.

Thought Form

No formal thought disorder. Thought content notable for themes of inadequacy, guilt regarding family, and occupational failure.

Orientation

Oriented to time, place, and person.

Memory

Remote and recent memory grossly intact during clinical interview.

Concentration

Mildly impaired; requested repetition of two complex questions during the session.

Attention

Sustained attention adequate for the 50-minute interview, though easily fatigued toward the end.

Judgement

Intact; recognises the need for professional intervention and the unhelpful nature of increased alcohol use.

Insight

Good; attributes physical and cognitive symptoms to underlying depression and occupational stress.

Test Results

Summary of Findings

Depression Anxiety Stress Scales (DASS-21) administered on 18/03/2026: Depression = 24 (Severe), Anxiety = 12 (Moderate), Stress = 28 (Severe). K10 score = 32 (Very High psychological distress).

Diagnosis

Major Depressive Disorder, single episode, moderate, with anxious distress (DSM-5-TR).

Clinical Formulation

Presenting Problem

• Severe depressive symptoms, moderate anxiety, and high occupational stress characterised by low mood, anhedonia, insomnia, and cognitive fatigue.

Predisposing Factors

• Maternal family history of Major Depressive Disorder.
• Upbringing characterised by high parental expectations and emotional stoicism, fostering perfectionistic schemas.

Precipitating Factors

• Workplace restructuring 6 months ago resulting in a doubled workload and reduced job security.
• Recent critical performance review and increased caregiving demands for ageing parents.

Perpetuating Factors

• Maladaptive coping strategies including social withdrawal, cessation of physical activity, and increased evening alcohol and daytime caffeine consumption.
• Unhelpful cognitive patterns including catastrophising and self-criticism.
• Chronic sleep deprivation exacerbating daytime fatigue and cognitive inefficiency.

Protective Factors

• Supportive partner and strong attachment to young daughter.
• High baseline functioning, stable housing, and good insight into mental health needs.
• Engagement with GP and willingness to participate in psychological therapy.

Case Formulation

The Client presents with a moderate episode of Major Depressive Disorder with anxious distress, triggered by acute occupational overload and a critical performance review against a background of increased familial caregiving demands. A genetic vulnerability to mood disorders, coupled with early developmental experiences that fostered perfectionism and reluctance to express vulnerability, predisposed the Client to decompensate when faced with perceived professional failure. The presentation is currently maintained by a cycle of behavioural withdrawal, cessation of exercise, disrupted sleep architecture worsened by excess caffeine and evening alcohol use, and pervasive ruminative self-criticism. Nevertheless, the Client possesses significant protective factors, including a supportive partner, strong motivation driven by a young daughter, good clinical insight, and active engagement with medical and psychological treatment, which bode well for prognosis with targeted Cognitive Behavioural Therapy.