Psychiatric Consultation

Name: Arthur Pendelton

Age: 34

Gender: Male

ID Number: OHIP 8492-301-742-AB

History of Presenting Illness

Pt presents for urgent psychiatric consultation referred by GP for 6-week history of worsening depressed mood, severe anhedonia, and terminal insomnia (waking at 03:00 daily). Symptoms began following a job layoff on 01/02/2026 and have progressively worsened in severity, occurring daily with no relieving factors. He reports low energy, poor concentration, 4 kg unintentional weight loss, and feelings of worthlessness. Functioning is significantly impaired; he has stopped looking for work, rarely leaves his apartment, and has isolated himself from his partner. He endorses passive suicidal ideation ("better off dead") without active intent, plan, or access to means. Denies manic/hypomanic or psychotic symptoms.

Past Psychiatric History

Diagnosed with Major Depressive Disorder (MDD) in 2019 by GP; treated with escitalopram 10 mg PO daily for 12 months with full remission, then self-discontinued. Completed 8 sessions of Cognitive Behavioural Therapy (CBT) in 2019 with good effect. Denies history of psychiatric hospitalizations, suicide attempts, or self-harm behaviours.

Past Medical History

Primary hypothyroidism diagnosed in 2021, currently stable. Appendectomy in 2012. No history of head trauma, seizures, or other chronic medical conditions.

Medications

• Levothyroxine (Synthroid®) 75 mcg PO daily for hypothyroidism • Melatonin 5 mg PO QHS PRN for insomnia

Substance Use History

Alcohol use consists of 2–3 standard drinks on weekends; denies recent escalation, blackouts, or withdrawal symptoms. Ex-smoker, quit tobacco 4 years ago after a 5 pack-year history. Denies recreational cannabis, illicit drug use, or prescription medication misuse.

Family Psychiatric History

Mother has a history of MDD, successfully treated with sertraline. Maternal uncle died by suicide at age 45; suspected history of Bipolar I Disorder. No other known family history of psychiatric hospitalizations.

Legal History

No history of arrests, convictions, incarceration, or pending legal issues. Never placed on an involuntary psychiatric hold (Form 1).

Mental Status Examination

Appearance – The patient appears stated age, casually dressed in clean clothes, with slightly dishevelled hair and slumped posture.

Behavior – He is cooperative with the assessment, exhibiting mild psychomotor retardation and Intermittent, downcast eye contact.

Speech – Speech is soft in volume, slow in rate, and monotonous in tone, with increased latency of response but normal fluency.

Mood – The patient describes his mood as "empty and hopeless."

Affect – Affect is dysphoric, constricted in range, and congruent with his reported mood.

Thought Process – Thought process is linear, logical, and goal-directed, though slowed.

Thought Content – Thought content is notable for themes of guilt, worthlessness, and passive suicidal ideation without intent or plan; no delusions, hallucinations, or obsessions are elicited.

Cognition – The patient is fully oriented to person, place, and time, with intact recent and remote memory, though mild deficits in sustained attention are noted during conversation.

Insight – Insight is good, as he recognizes his symptoms as a relapse of depression and acknowledges the need for clinical intervention.

Judgment – Judgment is intact, evidenced by his willingness to seek help, engage in safety planning, and adhere to treatment recommendations.

Impression and Recommendations

34yo male presenting with a moderate-to-severe relapse of Major Depressive Disorder (MDD), recurrent episode, without psychotic features, triggered by recent unemployment. Meets DSM-5-TR criteria including depressed mood, anhedonia, weight loss, insomnia, psychomotor retardation, fatigue, worthlessness, and impaired concentration for > 2 weeks. Differential includes depressive episode secondary to hypothyroidism, though less likely given prior euthyroid labs; repeat TSH is warranted to rule out organic contribution. Acute safety risk is low-to-moderate given passive SI and family history of suicide, mitigated by strong insight, supportive partner, and absence of intent/plan, making outpatient management appropriate.

• Restart escitalopram (Cipralex®) 10 mg PO daily for 1 week, then increase to 20 mg PO daily as tolerated for depression. • Provided psychoeducation regarding SSRI mechanism, delayed onset of action (2–4 weeks), potential transient side effects (GI upset, activation), and importance of daily adherence. • Order baseline bloodwork: CBC, electrolytes, creatinine, ALT, and TSH to rule out underlying medical contributors. • Refer to structured outpatient CBT program for depression and behavioural activation. • Reviewed sleep hygiene strategies and advised discontinuing melatonin if daytime grogginess occurs. • Completed crisis safety plan: patient to contact partner, call 988 Suicide Crisis Helpline, or present to nearest ED if suicidal ideation becomes active. • Follow up in psychiatry clinic in 2 weeks (02/04/2026 at 10:00) to assess medication tolerability and monitor mood/safety.