Psychiatric Assessment Letter

Date of Review: October 24, 2023

Present at review: Eleanor Vance (Patient), David Vance (Husband), Dr. Tarun D. Singh (Specialty Doctor)

Previous medication

• Sertraline 100 mg PO OD, taken for 6 months, ineffective with persistent low mood.
• Citalopram 20 mg PO OD, taken for 8 weeks, discontinued due to GI upset and lack of efficacy.

Medication today onwards

• Venlafaxine XL 37.5 mg PO OD for 7 days, then increase to 75 mg PO OD onwards.
• Promethazine 25 mg PO ON PRN for insomnia, maximum 14 days supply.

Care Plan

1. GP to kindly initiate venlafaxine XL as per the titration schedule above, ensuring sertraline is cross-tapered and stopped over 7 days.
2. Provide short-term promethazine 25 mg PO ON PRN for sleep restoration.
3. Patient advised on sleep hygiene, regular light exercise, and complete avoidance of alcohol and caffeine after 14:00.
4. Psychoeducation provided regarding SNRIs, delayed onset of therapeutic action, and potential discontinuation symptoms.
5. Outpatient psychiatric follow-up scheduled in 4 weeks at the CMHT clinic.
6. Patient and husband made fully aware of the crisis plan, including local Single Point of Access (SPA) contact numbers and 111 option 2.

Impression

• Recurrent depressive disorder, current episode moderate without psychotic symptoms (ICD-11: 6A71.1)
• Generalized anxiety disorder (ICD-11: 6B00)

Physical Health

Mrs. Vance has a history of primary hypothyroidism, which is currently well-managed on levothyroxine 100 mcg PO OD. Recent blood tests performed by her GP on 10/10/2023 showed normal FBC, U&Es, LFTs, and a TSH within the normal reference range (1.8 mU/L). Baseline observations today were stable: BP 124/78 mmHg, HR 72 bpm, and BMI 23.4 kg/m². Baseline ECG was normal with a QTc of 412 ms.

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Thank you for your continued care of Eleanor Vance, a 42-year-old female who attended for assessment regarding a three-month history of worsening low mood, pervasive anxiety, and initial insomnia.

Chief Concerns

Mrs. Vance reports a gradual deterioration in her mood over the past three months, occurring without an identifiable external precipitant. She experiences daily anhedonia, marked diurnal mood variation (worse in the mornings), and reduced energy levels. She describes persistent, free-floating worry regarding her family's finances and health, accompanied by somatic symptoms of restlessness and muscle tension. Sleep is disrupted with initial insomnia taking up to two hours to fall asleep, alongside early morning wakening at 04:00. Her appetite has decreased, resulting in a 3 kg weight loss over two months. Consequently, her occupational functioning has declined, requiring her to take certified sick leave from her role as a primary school teacher three weeks ago.

Past Medical & Psychiatric History

Mrs. Vance was diagnosed with a first episode of moderate depression five years ago, which remitted after a nine-month course of fluoxetine 20 mg PO OD. Over the past year, she has had trials of citalopram and sertraline for recurrent symptoms, neither of which achieved full remission. Her medical history is notable only for hypothyroidism diagnosed four years ago. There is no history of manic or hypomanic episodes, psychotic symptoms, deliberate self-harm, or psychiatric admissions.

Developmental History

Mrs. Vance was born at full term via normal vaginal delivery following an uncomplicated pregnancy. She achieved all developmental milestones within normal limits and reported no early childhood medical complications, head injuries, febrile convulsions, or feeding difficulties. She had a stable upbringing, completed university education without difficulty, and has no history of neurodevelopmental disorders.

Family History

Her maternal aunt was diagnosed with recurrent depressive disorder and responded well to long-term antidepressant therapy and psychotherapy. There is no known family history of bipolar affective disorder, schizophrenia, or completed suicide.

Social History

Mrs. Vance lives in an owner-occupied house with her husband of 12 years, David, and their two children aged 8 and 10. She describes her marriage as supportive and identifies her husband and sister as her primary support network. She is currently signed off work from her teaching position, does not smoke, and consumes approximately 2 units of alcohol per week, though she has abstained entirely for the last month.

Mental State Examination (MSE)

The purpose of the Mental State Examination was explained to Mrs. Vance as a structured way to capture her current emotional and cognitive functioning, providing a baseline to monitor her clinical progress over subsequent appointments.

She presented as a neatly dressed woman who looked her stated age, though appeared visibly fatigued. Eye contact was maintained but intermittently downcast. Her speech was normal in tone and volume, though slightly reduced in rate. She described her mood as "flat and exhausted," and her affect was restricted and congruent with her subjective report, though she managed a brief, appropriate smile when discussing her children. She explicitly denied any current suicidal ideation or intent, and there was no evidence of responding to unseen stimuli.

Her thought form was linear and coherent. Thought content was preoccupied with guilt regarding her inability to work and generalised worries about the future, with no delusions or overvalued ideas elicited. Cognitively, she was fully oriented to time, place, and person; she reported subjective difficulties with short-term concentration, though gross memory was intact during the interview. Her insight and judgment were both good, as she recognised the nature of her depressive relapse and willingly engaged in treatment planning.

Risk assessment

Risk to self: Low. She reports fleeting passive thoughts that life is too overwhelming, but firmly denies active suicidal ideation, intent, or plans. There is no history of self-harm or suicide attempts, and she cites her children as strong protective factors.

Risk to others: Low. There is no history of violence, aggression, or forensics, and she expresses no thoughts or intent to harm others.

Risk of self-neglect: Low. Despite reduced appetite and low energy, she maintains adequate personal hygiene and nutrition, supported closely by her husband at home.

Risk from others: Low. She lives in a safe, supportive domestic environment with no safeguarding concerns or history of domestic abuse identified.

Online: Low. She engages in minimal social media use and reports no online gambling, excessive spending, or engagement with harmful digital content.

Assessment & Formulation

Mrs. Vance is a 42-year-old woman presenting with a relapse of moderate depressive disorder alongside generalised anxiety disorder, significantly impacting her occupational functioning and sleep architecture. Predisposing factors include a family history of affective disorder and a personal history of depression. While no acute precipitating factor was identified, her symptoms are likely perpetuated by chronic sleep deprivation and secondary guilt regarding her occupational absence. Given the inadequate response to two adequate trials of SSRIs (citalopram and sertraline), switching class to a serotonin-norepinephrine reuptake inhibitor (SNRI) is clinically indicated. Protective factors include high insight, strong spousal support, and historical responsiveness to pharmacotherapy.

Management Plan

We agreed to discontinue sertraline via a brief cross-taper and initiate venlafaxine XL 37.5 mg PO OD, titrating to 75 mg PO OD after one week. To address her debilitating insomnia during the transition, a short bridging course of promethazine 25 mg PO ON PRN was recommended. We discussed the importance of routine blood pressure monitoring given the noradrenergic effects of venlafaxine, and she was advised to self-refer to NHS Talking Therapies for Cognitive Behavioural Therapy (CBT). Should her symptoms fail to respond adequately to venlafaxine at 75 mg after four weeks, we will consider further titration up to 150 mg daily.

Capacity Statement: Mrs. Vance demonstrated full mental capacity to consent to the proposed treatment plan, as she was able to understand, retain, and weigh the information regarding the risks and benefits of switching antidepressant medication, and communicated her decision clearly.

Yours sincerely,

Dr. Tarun D. Singh,

Specialty Doctor,