Ketamine clinic intake report
Chief complaint
"I've tried everything and nothing has really lifted the depression."
History of present illness
Current depressive episode for about 2 years. Reports low mood most days, poor sleep and loss of interest in work and hobbies. Took 3 weeks off work this fall. No periods of unusually elevated mood reported.
Antidepressant trials in this episode
- Escitalopram 20 mg for about 4 months. Little change.
- Venlafaxine XR 225 mg for about 5 months. Some improvement, stopped because of sweating.
- Bupropion XL 300 mg added for about 3 months. No change reported.
- Current: sertraline 150 mg daily for 6 months.
Other treatment
Weekly CBT for about 4 months in 2025. No ECT or rTMS.
Rating scales
- PHQ-9: 19, completed at home
- GAD-7: 12, completed at home
Medical history
- High blood pressure, on amlodipine 5 mg. Home readings "around 135 over 85".
- Snores loudly. Partner has noticed pauses in his breathing at night. No sleep study.
- No heart disease, stroke or brain bleed reported.
- Allergies: none reported.
Substance use
Alcohol: 1 to 2 beers most evenings. No cannabis in the past year. No other substances reported.
Psychosis and mania
No history of psychosis or mania reported. No family history of bipolar disorder reported.
Safety
Denies current suicidal ideation. No past suicide attempts reported.
Getting to sessions
His partner can drive him to and from each session. Prefers morning appointments.
Flagged for review
Contains only what the patient reported. For clinician review.