| CLINICAL INFORMATION |
| Part a). Comprehensive Mental Health Assessment |
| Introduction: Mark is a 35 yr old man partnered with his girlfriend Jude for 2 years. Both live together in a house they are renting in Mile End. Mark is employed full time as a tradesman carpenter. Jude is presently away interstate for work. |
| Situation: * Reason for Referral * Presenting Issue * Recent Significant Events or Stressors * Symptoms * Change in Frequency, Intensity, Duration of Symptoms * Collateral Mark presented to the Emergency Department alone at approximately 10am, encouraged by his mother (Sue) who was concerned about his safety. At triage he described thoughts of suicide without a clear plan. He denies self-harm and denies overdose of medications. Mark states he has a history of depression and anxiety which has worsened over the past 4 weeks. His symptoms are characterised by negative thinking with thoughts of suicide, poor sleep, anxiety with physical symptoms of psychomotor agitation, SOB, increased heart rate and thoughts of a fear of dying. Marks mother Sue concurs that his symptoms have worsened over the past month as she has noticed his mood is low, he appears sad, tired and talks about wanting to quit his job which is unusual since he has moved to a job he has wanted to be in for the past year. Sue believes his mental state has been affected by news that his close friend Luke has been diagnosed with a medical condition, possibly leukemia. She has known Mark to be suicidal in the past (approx. 4 years ago) but that since engaging with a psychologist, his mental state has been much improved until recently. |
| Background: * Current Living Situation * Significant Relationships * Developmental History * Psychiatric History * Current Medication * Drug and Alcohol and Gambing History * Family History * Previous Treatment / Medication * Relevant Health / Medical Problems * Domestic Violence * Psychosocial * Allergies Mark lives in secure rental accommodation in Mile End with supportive girlfriend Jude. They have been partnered for 2 years in a supportive relationship. Jude is currently away interstate on business and intends on returning home tomorrow. No dependants. Supports: Jude partner of 2 years Mother Sue and Father David- very supportive and aware of Marks situation Psychologist Amber Davies GP Dr Raj Developmental hx: Mark grew up in the family home with his mother Sue, his father David and younger brother Sam. Achieved expected developmental milestones. Described as a happy child with many friends at school. Enjoyed surfing and other outdoor activities such as playing soccer. During high school, a close friend of Marks struggled with mental health problems and their friendship impacted Marks mental state also. During this time, Mark began to struggle with his own anxiety which was supported with school counselling and GP. His self esteem was impacted negatively until adulthood. Mark completed high school at the local public PS and high school, successfully completing year 12 and enrolling into a trade apprenticeship with a local carpentry company. Mark has worked hard with this team and was successfully promoted to new position in the past 2 weeks. Currently Mark feels he is not well enough to work in this promotional position and does not want to let his employer down given he is struggling and has difficulty focusing on learning the new role. Psychiatric hx: History of depression and anxiety for the past 4 years managed in the community with supports including GP and psychologist. No hospital admissions for mental health. Suicidal ideation 4 years ago during an episode of depression. No self-harm or suicide attempt at this time. Medication: Prescribed Escitalopram 10 mg daily. Adherent to treatment since being commenced by GP 6 months ago. No other medications prescribed. Family psychiatric hx: David (Marks father) suffers from depression and his grandfather who is in a supported residential facility. No family history of suicide. Drug and alcohol use: Alcohol use includes x2 standard drinks of beer after work each day. Recently increased to 6 beers per night in the past 4 weeks. Drug use includes THC each weekend approx. 2-3 joints across the weekend. Usually this is less regular. No gambling behaviours. Medical history: No major health problems. Presents today with tachycardia which needs further investigation with regular observations, ECG and medical review. Back pain commenced 6 months ago and treated with physiotherapy and paracetamol. Back pain worsened in the past 2 weeks causing headaches and difficulty sleeping. Possible development of withdrawal symptoms (alcohol and THC) which need monitoring and treatment. No history of alcohol withdrawal seizures. Denies allergies. |
| Mental State Examination: * Appearance 35-year-old Caucasian male, casually dressed wearing clean clothing, blue tee shirt, jeans and casual lace up shoes. Within a healthy weight range. Short hair, blonde ends. Unshaven facial hair. Nose ring. Small tattoos on both hands. No visible scars. * Behaviour Sitting in a chair. Cooperative with mental health review. Answering questions and engaging in conversation. No obvious psychomotor agitation or retardation. Very good eye contact. Gesturing appropriately with his hands. No self harm. * Mood Describes mood as “really low at the moment”. Admits that he is feeling anxious and depressed. * Speech Normal volume, rate and flow to conversation. Speech is clear and coherent. Australian accent. * Affect Affect is anxious and reactive and congruent to stated mood. * Thought (form and content). Normal thought form- nil formal thought disorder. Thoughts are clear. Thought content relates to negative thinking with guilt and thoughts of suicide without a clear plan, themes of feeling anxious with physical symptoms, and feeling supported by family and partner, wanting to access help for mental health. * Perception Nil perceptual abnormalities described or observed. * Cognition function Cognition is intact. Consumer is oriented to person, place and time. Memory is intact as consumer is able to recall recent events and historical events accurately. No cognitive deficits noted. * Insight Consumer presents with a good insight into his mental health as evidenced by his ability to identify unhelpful thinking patterns which are impacting his mood. He is able to recognise that his mental illness has relapsed and understands health promotion activities to support recovery. * Judgement Consumer demonstrates good judgement related to accessing health care and treatment for mental illness. Judgement related to suicidal thoughts remains intact as he does not wish to act on his thoughts and is following his Safety plan to ensure his own safety. * Rapport Rapport is established as consumer is trusting and engaging with health professionals in a collaborative manner and discussing the best treatment approach for his recovery. “Strengths and skills” * Please identify the consumer’s strengths and coping skills when they are well. * Please include the perspective of the consumer’s family/carer. Mark is a hard-working, successful carpenter recently promoted to a senior level position. He enjoys surfing and uses exercise as a coping mechanism along with psychological approaches such as ACT and mindfulness to manage his mental health and back pain. Mark engages well with his supports and has good insight into his mental health and when he requires additional support. He is usually bright in his mood and has hope for the future but currently he is struggling with strong negative thoughts which impair his ability to rationalise. Mark has a supportive network of family, friends, work colleagues and health professionals around him which he actively engages with when feeling unable to cope with symptoms of his mental illness. |
| Risk Categories: Assessed Level: Suicide/Self-Harm Level: Low/Medium/High* (indicate which level applies) Evidence to support assessed level: Marks risk of suicide is moderate as he has thoughts of suicide which have escalated recently. He does not have a certain plan to end his life but remains a moderate risk as his negative thoughts could worsen and cause him to act on these thoughts. Mark has no access to means as he is in hospital and seeking help. His negative thoughts need monitoring by his nurse and daily mental state examination and risk assessment. Mark has no history of suicide attempts or self-harm and this reduces his risk. No family history of suicide. Mark has a current Safety Plan which he will forward on to the mental health team and add to his file. Violence/Aggression/Criminal Activity Level: Low/Medium/High* (indicate which level applies) Evidence to support assessed level: Mark is a low risk of violence and aggression. He does not express any thoughts of wanting to harm others and is cooperative with nursing direction. He is not agitated but will need to be monitored for signs of withdrawal given recent increase in substance use and abrupt withdrawal in hospital. Absconding Level: Low/Medium/High* (indicate which level applies) Evidence to support assessed level: Mark is a low risk of absconding as he voluntarily sought help from the hospital for this admission. He is cooperative and engaged with health professionals to manage his mental health. He will need to be monitored for any change to his decision to stay in hospital which may be prompted by withdrawal symptoms or increasing thoughts of suicide. Self-Neglect/Exploitation/Vulnerability Level: Low/Medium/High* (indicate which level applies) Evidence to support assessed level: Mark is a medium risk of self-neglect or vulnerability as evidenced by his deteriorated mood, negative thinking and suicidal thoughts. He has considered quitting his job which is an unusual decision for him. He will *L = Low (mild, limited frequency and intensity) M = Medium – (frequent but with limited intensity) and H = High (frequent, intense) N = No Risk Risk Summary See template PDF for prompts Mark presents as a 35 yr old man with a relapse of depression and anxiety characterised by thoughts of suicide with no clear plan or self harm behaviours. Marks static risk factors relate to his being a male gender, history of depression and thoughts of suicide. Recent stressor relates to news of his close friend’s illness which has triggered a decline in Mark’s mental health. Further static risk factors relate to Marks family history of depression in his paternal side (Father and Grandfather). Mark’s dynamic risk factors relate to a relapse of symptoms of depression and anxiety with suicidal ideation. He has no access to means while in hospital and he remains a voluntary patient. Further dynamic risk factors include active substance use with possible withdrawal symptoms while hospitalised which may contribute to a deterioration in his mood and level of agitation. Currently Mark does not present with agitation or irritability and so is assessed as a low risk of harm to others. Further dynamic risk factors relate to physical comorbidity including back pain which is currently causing physical discomfort and impacting sleep and mood. Mitigating factors or protective factors relate to Marks ability to seek out support from social networks and health care services. Mark has good insight into his mental health and has a safety plan which he follows when his mental health deteriorates. Mark has a strong family support unit but currently his partner is away interstate and due to return tomorrow. Mark has given consent for the health care team to speak with his partner Jude and his mother Sue about his health care. Voluntary admission for mental health. |
| Setting: Inpatient √ Community □ (tick whichever applies) |
| Care plan: Monitor and document mental state and risk assessment on a daily basis and respond to any changes in a therapeutic manner. Review progress, reviewing strategies which are helpful to Marks recovery. Provide regular support to Mark and maintain 15 minutely observations during first 2 hours and reduce to hourly observations thereafter. Regularly review thoughts of suicide and self harm with Mark, communicate with compassion and ensure safety of consumer if thoughts of suicide/self harm escalate. Provide a safe environment, any potential dangerous objects should be removed from the immediate environment.Monitor for signs and symptoms of withdrawal related to cessation of alcohol and THC and treat with antianxiety medication. Review back pain and provide pain relief as required. Review from physiotherapy on exercises to treat injury. Review tachycardia with medical team. ECG scheduled for later today. Regular psychiatric review by the Mental Health team psychiatrist and medication review. Therapeutic counselling skills will enhance communication by using open ended questions allowing Mark to feel he is being listened to without judgement, building trust and promoting a therapeutic relationship while building rapport. Collaborative care- openly discuss treatment options with Mark and explore his therapeutic goals. This conversation should include psychotherapy and medication review. Share health information with Marks GP. Exploration of Marks willingness and attitude towards medication as well as his concerns should be listened to and responded. Encourage engagement with existing supports during hospitalisation such as family and partner and invite collaboration with care planning. Maintain regular communication between treating team and supports.Promote resilience and problem-solving skills through a strengths-based approach to identify strengths and abilities and improve self-esteem. Explore personal interests and encourage Mark to slowly reintroduce pleasurable activities at his own pace, such as exercise. Provide psychoeducation/information related to Marks questions and encourage his input into the decisions related to his care and treatment Challenging of core beliefs and reframing of negative cognitions will assist in identifying more positive perspectives to Marks thinking. CBT principles can be used in this strategy. Promote hope and support future planning activities which enhance self-worth and achievement. Discharge planning- consider supports in the community to maintain Marks recovery and design a discharge plan with Mark such as GP, psychology, regular exercise, cutting down alcohol and THC. |
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