Thorough Mental Health Assessment Template

Reason for Visit:
- Patient presents with exacerbating depressive symptoms and anxiety over the last three months.
History of Present Illness:
- The patient describes a gradual onset of depressive symptoms, such as persistent sadness, low energy, and trouble concentrating. Anxiety symptoms include restlessness and excessive worry.
Past Psychiatric History:
- The patient has a history of major depressive disorder, with a previous hospitalization for suicidal thoughts two years ago. Past treatments included cognitive behavioral therapy and sertraline, which was stopped due to side effects.
Past Medical History:
- The patient has a history of hypothyroidism, managed with levothyroxine.
Medications:
- Currently taking fluoxetine 20 mg daily for depression.
Allergies:
- No known drug allergies.
Medication Trials:
- Previous trials of sertraline and escitalopram, both discontinued due to gastrointestinal side effects.
Access to Weapons:
- No access to firearms or other weapons.
Social History:
- Lives alone in an apartment, has a supportive network of friends.
Education:
- Completed a bachelor's degree in psychology.
Relationships:
- Close relationship with parents and one sibling, no current intimate relationship.
Work:
- Employed as a social worker, reports moderate work-related stress.
Supports:
- Attends weekly support group meetings and has regular therapy sessions.
Protective Factors:
- Strong support system, engaged in therapy, and motivated for treatment.
Negative Factors:
- Occasional alcohol use, reports feeling isolated at times.
Suicide Risk Assessment:
- Denies current suicidal ideation, intent, or plan. Protective factors include strong family support and engagement in therapy.
Forensic History:
- No history of legal issues or arrests.
Family History:
- Family history of depression in mother and substance abuse in father.
Mental Status Exam:
- Appearance: Well-groomed. Behavior: Cooperative. Speech: Normal rate and volume. Mood: Depressed. Affect: Constricted. Thought Process: Linear. Thought Content: No delusions or hallucinations. Cognition: Intact. Insight/Judgment: Good.
Objective Findings:
- No significant findings on recent physical exam.
Diagnosis:
- Major Depressive Disorder, Recurrent, Moderate.
Diagnostic Formulation:
- Biopsychosocial factors include genetic predisposition, work stress, and social isolation contributing to the current depressive episode.
Assessment and Plan:
- Continue fluoxetine 20 mg daily. Increase therapy sessions to twice weekly. Encourage participation in social activities. Follow-up in four weeks to assess progress.