Psychiatric Ongoing Care Review Note

Background And Past Contacts

Mr Thomas Vance (DOB: 14/05/1991, NHS Number: 482 910 3847) was initially assessed on 12/01/2026 presenting with lifelong difficulties in sustained attention, chronic disorganisation, and restlessness, alongside secondary moderate depressive symptoms. Following a comprehensive diagnostic evaluation, he was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), combined presentation, and commenced on a titration regimen of lisdexamfetamine (Elvanse®). At his first follow-up on 16/02/2026, his dose was increased from 30 mg to 50 mg daily due to partial symptom response and good initial tolerability.

At the previous session on 16/02/2026, the clinical impression was of partially treated ADHD with resolving reactive low mood. The agreed plan was to trial lisdexamfetamine 50 mg PO mane for four weeks, monitor home blood pressure and pulse weekly, and implement structured daily planner use.

Thomas attends today, 16/03/2026, for a planned four-week titration review to evaluate the efficacy and tolerability of the 50 mg dose and consider treatment stabilisation.

Update On Employment History

Thomas continues his role as a software developer, noting that while his employment status is unchanged, he has recently transitioned from a performance support plan back to standard duties due to improved output over the past month.

Update On Social History

No update.

Update On Relationship History

Thomas reports reduced friction with his partner at home, attributing this to better shared management of household chores compared to the baseline assessment.

Update On Drug And Alcohol History

Thomas has reduced his caffeine intake from four cups of coffee daily to one decaffeinated coffee in the morning as advised at the previous review.

He continues to consume approximately 4 units of alcohol on weekends and denies any illicit substance use.

Update On Past Medical History

Thomas has no new medical diagnoses, and his mild asthma remains well-controlled. Home monitoring over the past week shows a mean BP of 122/78 mmHg and HR of 76 bpm (compared to 118/74 mmHg and 72 bpm at baseline), with weight stable at 78.5 kg.

He has no known drug allergies (NKDA).

Update On Medication History

Thomas currently takes lisdexamfetamine (Elvanse®) 50 mg PO OM and salbutamol 100 mcg/dose inhaler 1–2 puffs PRN.

He is currently undergoing stimulant titration, having commenced lisdexamfetamine 30 mg PO OM on 13/01/2026 before increasing to 50 mg PO OM on 17/02/2026.

Update On Past Psychiatric History

Thomas has a history of mild-to-moderate depressive episodes treated in primary care with sertraline 50 mg PO OD in 2022, with no new psychiatric admissions or secondary care contacts since the last review.

Update On Forensic History

No update.

Summary Of Review

Since increasing lisdexamfetamine to 50 mg daily, Thomas reports a marked improvement in sustained attention and task initiation. His distractibility during complex coding tasks has decreased significantly in severity, and he now sustains focus for 3 to 4 hours at a time compared to 20 minutes prior to treatment. However, he experiences a noticeable wearing-off effect around 16:00, accompanied by mild rebound lethargy lasting approximately 90 minutes.

He identified that skipping lunch exacerbates the late-afternoon lethargy. He attempted setting smartphone alarms to prompt midday meals and taking a 15-minute walk at 16:00, which has moderately alleviated the afternoon dip.

His daily functioning has improved substantially compared to the February review; he is meeting work deadlines consistently and keeping up with domestic administration without previously reported procrastination.

Regarding side effects, Thomas reports mild xerostomia and a slight reduction in midday appetite. He explicitly denies palpitations, chest pain, syncope, insomnia, tics, or increased anxiety.

Thomas views the current medication as highly effective, describing the past month as transformative for his workplace productivity and emotional regulation.

His only concern with the current regimen is the 16:00 wear-off, as he occasionally needs to work until 18:00 and struggles with focus during those final two hours.

He made good progress with the non-pharmacological plan agreed at the last visit, successfully using a digital kanban board daily, though he still struggles with prioritising tasks when multiple urgent requests arrive simultaneously.

Psychoeducation was provided regarding the pharmacokinetics of lisdexamfetamine, the importance of high-protein breakfasts, and adequate hydration; Thomas was receptive and agreed to adjust his morning nutrition.

No new psychiatric or physical symptoms were raised, and he explicitly denied any emergence of mood elevation, manic symptoms, or paranoia.

Mental State Examination

Thomas presented as casually dressed and well-groomed. His behaviour was cooperative and engaged, with normal eye contact. Psychomotor restlessness, specifically the persistent leg-bouncing observed at the initial assessment, was notably reduced today.

He described his subjective mood as "much more level and optimistic," which was objectively interpreted as euthymic. His affect was reactive, congruent, and of normal amplitude, showing improvement from the mildly constricted affect noted in January.

Speech was normal in rate, rhythm, and volume. Thought process was linear, logical, and goal-directed, with less tangentiality than observed at baseline and no evidence of formal thought disorder.

Thought content was appropriate to the clinical context. He explicitly denied any delusional beliefs, overvalued ideas, obsessive thoughts, or suicidal ideation, and noted a significant reduction in anxious ruminations regarding work failure compared to his last visit.

There was no evidence of hallucinations or other perceptual disturbances in any modality, consistent with previous assessments.

Insight remains good; Thomas clearly recognises the impact of ADHD on his executive functioning, understands the role of both pharmacological and behavioural interventions, and remains actively engaged in treatment planning.

Risk Assessment

Current risk factors are minimal, as previously noted occupational stress has largely resolved.

There is a distant history of transient passive suicidal ideation during a depressive episode in 2022, with no history of actual self-harm or suicide attempts.

There is no history of violence or aggression towards people or property.

Protective factors include a supportive partner, stable employment, secure housing, and strong engagement with clinical services.

Current risks of self-harm, suicide, and violence to others are assessed as low.

Standard outpatient safety-netting remains in place, with Thomas aware of how to contact the duty team or crisis services if acute distress arises.

Capacity To Consent To Care And Treatment

Thomas demonstrated full capacity to consent to his ongoing care and treatment plan, as evidenced by his ability to understand, retain, and weigh the risks and benefits of stimulant dose adjustments and communicate his decision clearly.

Impression

Thomas presents with ADHD, combined presentation, showing a robust clinical response to lisdexamfetamine 50 mg daily, alongside resolution of secondary depressive symptoms linked to previous occupational underperformance.

Feedback was given regarding his positive objective and subjective progress; the clinician highlighted his stable cardiovascular parameters and improved MSE, and Thomas agreed that his baseline functioning is substantially better.

Options to address the late-afternoon wear-off were discussed, including increasing lisdexamfetamine to 60 mg OM, adding a small afternoon top-up of immediate-release dexamfetamine, or maintaining the 50 mg dose while optimising nutrition and behavioural pacing. The clinician advised trialling conservative nutritional adjustments first before escalating stimulant exposure, and Thomas agreed this was a sensible, cautious approach.

Regarding medication, both the clinician and Thomas agreed that the benefits of lisdexamfetamine 50 mg clearly outweigh the mild appetite suppression and afternoon dip, concluding with the joint decision to maintain the 50 mg dose for a further month.

Recommendations for targeted ADHD coaching via the Access to Work scheme were discussed to address residual task-prioritisation difficulties; Thomas was keen on this option and elected to submit an application this week.

Thomas asked when his prescribing could be transferred to his GP under a Shared Care Agreement; the clinician explained that one further review confirming stability on the 50 mg dose is required before initiating the handover, and it was agreed to review this in four weeks.

Plan

• Continue lisdexamfetamine (Elvanse®) 50 mg PO OM for 28 days (prescription issued today).

• Thomas to self-refer to the Access to Work scheme for workplace ADHD coaching support.

• Follow-up appointment booked in 4 weeks (13/04/2026 at 10:00) via video consultation for final titration review and consideration of GP Shared Care handover.

• Thomas to continue fortnightly home BP, HR, and weight monitoring and submit readings via the patient portal prior to the next review.