Psychiatric Assessment Report

Introduction

Date: 24/10/2023 at 10:00 SAST. Location: Outpatient Psychology Clinic, Sandton Mediclinic, Johannesburg. Present: Thabo Mokoena (34yo M, ID: 8904125124087, File: JHB-44920) and M. van der Merwe (Counselling Psychologist).

Diagnosis / Problems List

• Major Depressive Disorder (MDD), moderate, recurrent (F33.1)
• Generalised Anxiety Disorder (GAD) (F41.1)
• Occupational burnout

Legal Status

Voluntary outpatient (Mental Health Care Act 17 of 2002).

Prescribed Medications

• escitalopram (Cipralex®) 10 mg PO OD (initiated by GP 2 weeks ago)
• zolpidem (Stilnox®) 10 mg PO PRN nocte

Investigations

• PHQ-9: 16/27 (moderately severe depressive Sx)
• GAD-7: 14/21 (moderate anxiety)
• Recent GP bloods (10/10/2023): FBC, U&E, TFTs, Vit D all NAD.

Current Issues / Situation

Pt referred by GP following 3/12 Hx of worsening low mood, anhedonia, initial and middle insomnia, and daily work-related anxiety. Reports feeling overwhelmed since corporate restructuring 4/12 ago increased his workload. Experiencing impaired concentration, irritability at home, and frequent tension headaches. Decreased appetite with 3 kg weight loss over 2 months.

Background Information

Lives in Randburg with wife and 4yo daughter. Works as a senior financial analyst. Supportive marriage, though recent irritability has caused minor marital friction. No financial or legal stressors.

Past Psychiatric History

One prior depressive episode in 2018 following bereavement; responded well to 6/12 of CBT. No previous psychiatric admissions or DSH.

Medical & Surgical History

• Mild intermittent asthma (uses salbutamol (Ventolin®) 100 mcg INH PRN).
• Appendicectomy (2012).
• NKDA.

Alcohol & Drug History

• Alcohol: 4–6 units/week (social). Slight increase over past month to aid sleep, now ceased since starting escitalopram.
• Tobacco: Non-smoker.
• Illicit drugs: Denies.
• Caffeine: 4 cups coffee/day.

Mental State Examination

• Appearance & Behaviour: Neatly dressed, slight psychomotor slowing, cooperative, good eye contact.
• Speech: Normal rate and volume, slightly monotonous tone.
• Mood & Affect: Subj "exhausted and down"; Obj dysthymic, restricted range, congruent.
• Thought Form: Linear, logical, goal-directed.
• Thought Content: Preoccupied with work performance and fear of failure. Passive fleeting thoughts of "wishing to disappear", nil active SI, nil intent or plan. No delusions.
• Perceptual: Nil hallucinations.
• Cognition: Alert, oriented x3. Attention intact during interview.
• Insight & Judgement: Good; recognises need for psychological intervention and medication adherence.

Risk Assessment

• Suicide/Self-harm: Low acute risk. Passive escapist ideation only; strong protective factors (wife, daughter, future-oriented, treatment-engaged).
• Harm to others: Nil risk identified.
• Vulnerability: Risk of occupational impairment if Sx remain unaddressed.

Formulation / Summary

34yo male presenting with relapse of MDD and comorbid GAD, precipitated by acute occupational stress and excessive workload. Predisposed by prior Hx of depression and perfectionistic traits. Maintained by maladaptive coping (overworking, reduced sleep, withdrawal from leisure activities) and cognitive distortions (catastrophising, all-or-nothing thinking). Good prognosis given strong social support, high insight, and prior positive response to psychotherapy.

Treatment Plan / Recommendations

• Commence weekly individual CBT focusing on cognitive restructuring, behavioural activation, and boundary setting at work.
• Sleep hygiene education and caffeine reduction (cut off after 12:00).
• Continue escitalopram 10 mg PO OD as prescribed by GP; monitor for side effects and efficacy.
• Liaise with GP regarding progress; consider temporary medical certificate for workplace accommodations if Sx do not improve within 2 weeks.
• Next appointment scheduled for 31/10/2023 at 10:00.

Safety Plan

• Triggers identified: Late-night work emails, Sunday evening anticipatory anxiety.
• Internal coping strategies: Deep breathing exercises, progressive muscle relaxation, taking a walk.
• Social support: Discuss feelings openly with wife (Lerato: 082 555 0194).
• Emergency contacts: Contact psychologist during office hours, GP (Dr Naidoo: 011 555 0123), SADAG 24-hour helpline (0800 456 789), or present to Sandton Mediclinic ED if experiencing acute distress or active SI.