Psychiatric Assessment – First Appointment

Patient Name: Arthur Pendelton

Date of Assessment: 14 May 2024

NHS/Clinic Number: 482 910 3847

Seen by: Dr. Eleanor Vance, Consultant Psychiatrist

Setting: Face to face

Duration: 60 minutes

1. Reason for Assessment / Referral

Referred by GP (Dr. S. Patel) for diagnostic clarification and management of treatment-resistant depressive symptoms and escalating generalised anxiety over the past 6 months.

2. History of Presenting Problems

Symptom Onset: Gradual onset 8 months ago following redundancy from long-term employment.

Course and Duration: Progressive worsening over 8 months. Initial low mood evolved into pervasive anhedonia and daily anxiety despite primary care intervention.

Current Symptoms: Pervasive low mood, diurnal variation (worse in mornings), anhedonia, initial insomnia, early morning wakening (04:00), fatigue, poor concentration, and excessive worry regarding finances. Weight loss of 4 kg over 3 months due to reduced appetite.

Impact on Functioning: Unemployed; struggling to apply for jobs due to poor concentration and low drive. Withdrawn from social rugby club. Wife has taken over household financial management. Self-care intact but requires prompting.

Coping and Insight: Recognises symptoms as depressive relapse. Attempts daily dog walking for routine, though motivation is minimal.

Goals and Expectations: Hopes for medication optimisation to improve sleep and energy, enabling a return to employment.

3. Past Psychiatric History

Previous Diagnoses: Moderate depressive episode diagnosed by GP in 2018.

Psychological Therapies: Completed 8 sessions of CBT via NHS Talking Therapies in 2018 with good effect. Re-referred 2 months ago; currently on waiting list.

Medication History: Currently prescribed sertraline (Lustral®) 150 mg PO OD for the past 4 months (increased from 100 mg PO OD with minimal benefit). Previously took citalopram (Cipramil®) 20 mg PO OD in 2018–2019 (good response, tapered off without issue).

Hospital Admissions / Crisis Support: Nil previous psychiatric admissions or Crisis Team involvement.

History of Self-harm or Suicidal Thoughts: Denies history of DSH or suicide attempts. Reports passive suicidal ideation ("wishing I wouldn't wake up") over the past month, but denies active intent or plans.

4. Medical History

Physical Health Problems: Essential hypertension (diagnosed 2020), mild asthma.

Medications: Amlodipine (Istin®) 5 mg PO OD, salbutamol (Ventolin®) 100 mcg/dose INH PRN.

Allergies: Penicillin (maculopapular rash).

Relevant Screening / Investigations: Bloods (10/05/2024): FBC, U&Es, LFTs, TFTs, B12, folate, and ferritin all NAD. ECG (10/05/2024): Normal sinus rhythm, QTc 412 ms.

5. Family History

Psychiatric Conditions in Family: Maternal uncle had recurrent depression and died by suicide aged 55. Mother treated for anxiety in primary care.

Family Dynamics: Supportive relationship with parents and younger sister. No history of intrafamilial conflict.

6. Personal History

Birth and Early Development: Normal vaginal delivery at term; developmental milestones met on time.

Childhood Environment: Raised in a stable, middle-class household by both biological parents. Felt safe and emotionally supported.

Schooling and Peer Relationships: Mainstream schooling; achieved 8 GCSEs and 3 A-Levels. Good peer group; no history of bullying.

Adolescence: Unremarkable transition; active in sports, stable mood.

Trauma History: Denies history of emotional, physical, or sexual abuse or neglect.

Occupational History: BSc in Civil Engineering. Worked as a project manager for a construction firm for 15 years until redundancy 8 months ago.

Relationship History and Sexuality: Heterosexual. Married for 12 years to Sarah (teacher). Describes marriage as supportive, though currently strained by his withdrawal and low libido.

Children / Parenting Role: Two children (aged 9 and 6). Feels guilty about lacking energy to play with them after school; wife currently managing most childcare.

Substance Use: Alcohol: 10–12 units/week (reduced from 25 units/week 2 months ago). Non-smoker. Denies illicit substance use. Caffeine: 2 cups of coffee daily (mornings).

Forensic History: Nil police involvement, arrests, or convictions.

7. Mental State Examination

Appearance and Behaviour: 42-year-old male, dressed casually in clean clothes. Mild psychomotor retardation noted. Slumped posture, intermittent eye contact, cooperative with assessment.

Speech: Spontaneous, slightly reduced rate and volume, monotonous tone. Normal fluency.

Mood and Affect: Mood described as "flat and exhausted". Affect restricted and dysphoric, congruent with reported mood.

Thought Form and Content: Linear and coherent thought form. Content preoccupied with financial ruin, redundancy, and guilt regarding family role. Passive death wishes present; no active suicidal ideation. No delusions or overvalued ideas.

Perception: No hallucinations or dissociative phenomena evident.

Cognition: Alert and oriented to time, place, and person. Attention intact during interview, though subjective memory complaints noted.

Insight and Judgement: Good insight; recognises need for treatment adjustment and engages in collaborative planning. Judgement intact.

8. Risk Assessment

To Self: Low-to-moderate chronic risk, low acute risk. Passive suicidal ideation present without intent or plan. No history of DSH. Risk mitigated by strong family ties, though male gender, family history of suicide, and recent unemployment are noted static/dynamic risk factors.

To Others: Low risk. No history of aggression, violence, or thoughts of harming others.

From Others: Low risk. No evidence of domestic abuse, financial exploitation, or vulnerability.

Safeguarding Concerns: Children (aged 9 and 6) live at home. Wife is a protective factor and primary caregiver currently. No acute child safeguarding concerns identified.

Protective Factors: Supportive spouse, strong attachment to children, good insight, engagement with services, abstinence from illicit substances.

9. Formulation

A biopsychosocial overview that integrates the principal features of the case

Predisposing Factors: Family history of affective disorder and suicide (maternal uncle), previous depressive episode (2018), high conscientiousness/perfectionist traits tied to occupational identity.

Precipitating Factors: Unexpected redundancy after 15 years of service 8 months ago, leading to loss of role and financial stress.

Perpetuating Factors: Ongoing unemployment, disrupted circadian rhythm (early morning wakening), social withdrawal from peer network (rugby club), cognitive ruminations regarding worthlessness, suboptimal response to current SSRI.

Protective Factors: Stable marriage, supportive wider family, absence of personality disorder or substance misuse, previous positive response to CBT and pharmacotherapy.

10. Diagnosis / Provisional Diagnosis

Recurrent depressive disorder, current episode moderate, with somatic syndrome (ICD-10: F33.11).

11. Plan and Recommendations

No further bloods or physical investigations required at present; GP to monitor BP 2 weeks post-SNRI initiation.

Shared decision made to cross-taper from sertraline to venlafaxine (Efexor XL®). Reduce sertraline to 100 mg PO OD for 1 week, then 50 mg PO OD for 1 week, then stop. Simultaneously initiate venlafaxine MR 37.5 mg PO OD during week 2 of taper, increasing to 75 mg PO OD once sertraline is ceased. Discussed potential side effects including nausea, discontinuation syndrome, and transient BP elevation.

Expedite NHS Talking Therapies (CBT) referral via liaison letter, focusing on behavioural activation and cognitive restructuring around occupational loss.

Signposted to Mind UK resources, Samaritans (116 123) for out-of-hours crisis support, and local Citizens Advice Bureau for financial/employment guidance.

Follow-up appointment booked in psychiatric outpatient clinic in 4 weeks to review mental state, medication tolerability, and titration to venlafaxine MR 150 mg PO OD if indicated.

12. Capacity and Consent

The patient demonstrated full capacity to consent to the assessment and proposed treatment plan, being able to understand, retain, weigh up, and communicate the relevant clinical information. Informed consent was obtained for the medication switch and for sharing this assessment letter with his GP. Agreed safety plan in place: patient will contact Crisis Line or attend A&E if suicidal ideation becomes active.