Mental Health Care Plan

Consult Summary

34yo F presenting with 3/12 Hx of worsening low mood, anhedonia, and anxiety, precipitated by recent workplace redundancy and relationship breakdown on a background of maternal depression. Plan: Commence escitalopram 10 mg PO OD, refer to clinical psychologist under MHCP for CBT, and review in 2/52.

Mental Health Care Plan

Reason for Presentation

Requesting mental health support and MHCP for worsening low mood and anxiety over the past 3 months.

History of Presenting Problem and Impact

• Persistent low mood, tearfulness, and anhedonia for 3/12, stating she feels "completely empty and overwhelmed".

• Associated with generalized anxiety, excessive worry regarding finances, and subjective palpitations.

• Symptoms aggravated by job-seeking rejections and social isolation; mildly alleviated by walking her dog.

• Denies suicidal ideation (SI), deliberate self-harm (DSH), or psychotic features.

• Sleep: Initial insomnia (takes > 2 hrs to fall asleep) and early morning wakening (04:00).

• Appetite: Decreased with 4 kg unintentional weight loss over 2/12.

• Function: Struggling with motivation for daily chores and job applications; withdrawing from friends.

• Self-care: Maintained, though requires significant effort.

Past Medical History

• Episode of mild reactive depression in 2018 (managed with 6 sessions of counselling; no pharmacotherapy; full remission).
• No previous psychiatric admissions or history of DSH.
• Mild asthma (well controlled).
• Iron deficiency anaemia (resolved 2022).

Medications

• Current: salbutamol (Ventolin®) 100 mcg INH PRN.
• Current: levonorgestrel/ethinylestradiol (Levlen ED®) 150 mcg/30 mcg PO OD.
• Previous: Naive to psychotropic medications.

Family History

• Mother: Major Depressive Disorder (MDD), responsive to SSRIs.
• Maternal Aunt: Generalised Anxiety Disorder (GAD).

Social History

• Lives alone in a rented apartment; previously lived with ex-partner of 4 years (separated 2/12 ago).
• Unemployed for 3/12 following corporate redundancy (previously worked in marketing).
• Experiencing financial stress due to ongoing rental payments.
• Good relationship with sister who lives locally.
• Uneventful childhood; denies history of developmental trauma or abuse.

Substance Use

• Alcohol: 2–3 standard drinks on weekends (reduced recently due to low socialising).
• Smoking/Vaping: Ex-smoker (ceased 2020), denies vaping.
• Recreational drugs: Denies any illicit substance use.

Mental State Examination

• Appearance: Well-groomed 34yo female, dressed casually, appears stated age.
• Behaviour: Cooperative, psychomotor retardation noted, intermittent tearfulness, reduced eye contact.
• Speech: Soft volume, mildly reduced rate and tone.
• Mood: "Exhausted and hopeless."
• Affect: Dysphoric, restricted range, congruent with mood.
• Thought Form: Linear, logical, no formal thought disorder.
• Thought Content: Preoccupied with financial security and self-worth; negative cognitions re: future; nil SI, homicidal ideation, or delusions.
• Perception: Normal; no auditory or visual hallucinations.
• Cognition: Alert and oriented to time, place, and person; attention intact during consult.
• Insight: Good; recognises symptoms as depression and actively seeking treatment.
• Judgement: Intact.

Outcome Measures

• Kessler Psychological Distress Scale (K10) administered on 15/05/2024: Score 32/50 (Very high psychological distress).
• Depression Anxiety Stress Scales (DASS-21) administered on 15/05/2024: Depression 24 (Severe), Anxiety 16 (Severe), Stress 22 (Moderate).

Diagnosis

Major Depressive Disorder, moderate-to-severe, recurrent episode, with anxious distress (DSM-5).

Formulation

• Predisposing: Family history of MDD and GAD; previous depressive episode in 2018.
• Precipitating: Workplace redundancy (3/12 ago) and breakdown of 4-year relationship (2/12 ago).
• Perpetuating: Ongoing unemployment, financial stress, social withdrawal, poor sleep hygiene, and negative cognitive distortions.
• Protective: Good insight, strong help-seeking behaviour, supportive local sister, pet ownership (dog), no substance misuse.
• Risk Assessment: Low acute risk of suicide, self-harm, or harm to others.

Goals of Treatment

• "Get back into a normal sleeping routine and feel less exhausted."
• Reduce severity of depressive and anxious symptoms to enable effective job-seeking.
• Re-engage with social network (aim to meet one friend per week).
• Develop healthy cognitive coping strategies for financial and relationship stressors.

Management Plan

Psychoeducation

• Provided education regarding the neurobiological and psychosocial model of depression and anxiety.
• Discussed sleep hygiene principles (strict wake times, avoiding screens before bed, limiting caffeine after 12:00).
• Encouraged daily behavioural activation, specifically maintaining daily dog walks and scheduling small, achievable tasks.

Medication Management

• Commence escitalopram (Lexapro®) 10 mg PO OD in the morning for MDD and anxious distress (advised to take 5 mg PO OD for the first 4 days, then increase to 10 mg PO OD).
• Discussed mechanism of action, expected delayed onset of efficacy (2–4 weeks), and potential side effects (transient GI upset, headache, initial increased anxiety, sexual dysfunction).
• Advised on red flags including emerging SI or agitation upon initiation.

Psychological Strategies

• Recommended Cognitive Behavioural Therapy (CBT) focusing on cognitive restructuring of negative automatic thoughts and structured behavioural activation.
• Discussed mindfulness and progressive muscle relaxation techniques for acute anxiety symptoms.

Referrals

• Referred to Ms Sarah Jenkins (Clinical Psychologist) at Melbourne Mind Clinic for 6 initial sessions of CBT under MBS Better Access initiative.

Safety Plan

• Recognise early warning signs: Increasing withdrawal, skipping meals, persistent crying.
• Internal coping strategies: Take dog for a walk, listen to calming podcasts, practice deep breathing.
• Social contacts for distraction/support: Call sister (Emma - 0412 345 678).
• Emergency contacts: Lifeline (13 11 14), Beyond Blue (1300 22 4636).

Crisis Plan

• If experiencing acute suicidal thoughts or inability to keep safe:
• Contact sister Emma immediately to stay over.
• Call local Area Mental Health Triage (1300 874 243) or Lifeline (13 11 14).
• Present to nearest Emergency Department (Royal Melbourne Hospital ED) or call 000.

Planned Review In

2 weeks (29/05/2024 at 10:30 AEST) to assess medication tolerability, side effects, and mood/risk status, or earlier PRN.

Consent

"Patient provided informed consent for the plan and referrals."