Psychiatry intake report
Chief complaint
"I've been feeling low for months and I can't switch my brain off at night."
History of present illness
Low mood for about 4 months, worse since a job change in the spring. Reports anhedonia, early morning awakening (around 4 a.m. most nights) and poor concentration at work. Describes worry as "constant", mostly about work and money. No periods of unusually elevated mood reported.
Psychiatric history
One prior episode of low mood at age 22, managed by her family physician. No hospitalizations reported.
Past treatment and medications
- Sertraline 50 mg for about 8 months at age 22. Stopped on her own when she felt better.
- Counselling, 6 sessions in 2023. "Somewhat helpful."
- Current: no psychiatric medications. Oral contraceptive. No known drug allergies.
Substance use
Alcohol: 2 to 3 drinks on weekends. Cannabis: about twice a week, "to help me sleep". No other substances reported.
Family history
Mother treated for depression. No family history of bipolar disorder reported.
Social situation
Lives with partner. Works full time in accounting. Good support from her sister.
Safety
Denies current suicidal ideation. No past suicide attempts reported.
Screening results
- PHQ-9: 16 (moderately severe)
- GAD-7: 12 (moderate)
- MDQ: negative
- AUDIT-C: 3
- DAST-10: 2
Flagged for review
Contains only what the patient reported. For clinician review.