Psychiatric Assessment Update for GP

Thank you for referring Thabo for review.

Thabo is a 34-year-old male residing in Johannesburg with his wife and two children. He is employed full-time as a financial analyst.

Thabo presented with a six-month history of pervasive low mood, anhedonia, and insomnia triggered by corporate restructuring and increased occupational stress. He reports no prior psychiatric admissions, though he attended three brief employee wellness counselling sessions two months ago with minimal relief.

He describes his mood as consistently flat and exhausted, noting significant diurnal variation with symptoms worse in the mornings.

He experiences concurrent generalised anxiety characterised by excessive rumination regarding job security, muscle tension, and intermittent palpitations.

He reports a longstanding history of inattentive symptoms since childhood, including chronic disorganisation, distractibility, and difficulty completing administrative tasks, which now severely impact his work performance.

His father was treated for major depressive disorder, and his paternal uncle has a history of alcohol use disorder.

Thabo began consuming alcohol socially at age 19, previously averaging four units per week. Over the past four months, his intake escalated to three glasses of wine nightly to aid sleep, with no history of withdrawal seizures, delirium tremens, or rehabilitation admissions.

He smokes 10 cigarettes daily and denies illicit substance use or gambling behaviours.

His past medical history includes mild asthma and a laparoscopic appendectomy in 2015.

A maternal family history of narrow-angle glaucoma is noted as a potential contraindication to specific psychotropics.

He has a documented allergy to penicillin, which causes a generalised maculopapular rash.

Thabo is currently taking the following medication:

• escitalopram (Cipralex®) 10 mg PO OD
• salbutamol (Ventolin®) 100 mcg INH PRN
• magnesium glycinate 400 mg PO nocte

Raised in Pretoria as the eldest of three siblings, Thabo describes a supportive upbringing despite his father's depressive episodes, with no history of childhood trauma or abuse. He matriculated with university exemption, though school reports frequently noted daydreaming and unfulfilled potential, before completing a Bachelor of Commerce degree at the University of the Witwatersrand. He has worked in the financial sector for ten years, changing employers three times due to boredom and struggles with routine deadlines. He has been married for six years and describes his partner as supportive, though his current irritability and emotional withdrawal are placing strain on their relationship.

On mental state examination, Thabo appeared neatly groomed and cooperative, with normal psychomotor activity and fluent, normovolaemic speech. His mood was dysphoric with a restricted, congruent affect, while his thought form was linear without delusions or perceptual disturbances, and his cognition, insight, and judgement remained intact.

In summary, my impression is that Thabo has Major Depressive Disorder with Generalised Anxiety Disorder and suspected Adult Attention-Deficit/Hyperactivity Disorder.

My management plan for Thabo: I will commence weekly Cognitive Behavioural Therapy (CBT) focusing on stress management, sleep hygiene, and alcohol reduction. For diagnostic clarification regarding ADHD, I have administered the DASS-21 today and scheduled the DIVA-5 assessment for our next session, alongside requesting his primary school reports and collateral history from his wife and mother. I recommend discussing a titration of his escitalopram to 20 mg PO OD with you, and suggest baseline blood investigations (FBC, U&E, LFTs, and TSH) to exclude organic contributors.

Thank you again for referring Thabo for review. I will keep you updated on his progress.