Psychiatric Intake Brief
DOB: 05/16/2005 (Age 21 y/o)
Date: 6/3/2026
Lifelong depression, crippling anxiety, and intense difficulty managing interpersonal relationships.
Patient reports chronic, lifelong depressive tendencies and severe anxiety, recently exacerbated by a breakup and housing instability. He describes a lifelong 'horrific' sleep disturbance and a 2.5-year history of daily cannabis use. Recently attempted to quit cannabis 'cold turkey,' experiencing two weeks of severe psychological withdrawal symptoms.
Moderately severe depression
Severe anxiety
Physical health rated as 'Good'; recommended workup includes TSH, CBC, and Metabolic panel to rule out organic causes for fatigue and chronic insomnia.
Received psychotherapy from Aug 2022 to Aug 2023 for depression and interpersonal issues with limited benefit; no prior psychiatric hospitalizations documented.
Single; adequate housing; currently employed and satisfied. History of daily cannabis use (2.5 years, recent quit), alcohol use (1-2 drinks/day for 3 years), and past hallucinogen use in high school.
Father has history of cancer, diabetes, and emotional problems; brother has active suicidal ideation; reports significant parental conflict during childhood.
No known allergies
What is your current status of suicidal ideation and do you have access to lethal means?
Can you provide specific details regarding the hallucinations you reported in your screening?
What is the exact nature and dosage of your 'melatonin overdose'?
What are your specific reservations regarding 'contemporary medicine' and pharmacological treatment?
Can you provide specific examples of how your symptoms currently impair your professional performance?
Major Depressive Disorder, Recurrent, Moderate F33.1
The patient reports lifelong depressive tendencies with a current PHQ-9 score of 16, indicating moderately severe depression. His symptoms have been exacerbated by recent stressors including a breakup and housing instability, and he presents with chronic insomnia and a history of suicidal ideation.
Generalized Anxiety Disorder F41.1
The patient describes his anxiety as 'crippling' and lifelong. His GAD-7 score of 19 falls into the severe range, reflecting persistent and excessive worry that likely impairs his daily functioning and interpersonal relationships.
Cannabis Withdrawal F12.93
Following 2.5 years of daily cannabis use, the patient attempted to quit 'cold turkey' and experienced two weeks of severe psychological withdrawal symptoms. This history must be differentiated from his primary mood and anxiety disorders as it may exacerbate depressive and anxious symptoms.
Borderline Personality Disorder F60.3
The patient's clinical picture includes lifelong interpersonal relationship difficulties, chronic feelings of depression, and a report of hallucinations. These factors, combined with intense reactions to a recent breakup and a history of suicidal ideation, warrant consideration of a personality disorder characterized by emotional instability and relational conflict.
Safety and Crisis Intervention
Conduct an immediate comprehensive suicide risk assessment and develop a formal safety plan including lethal means restriction.
The patient is flagged as 'Acute Risk Detected' with a family history of suicidal ideation and active reports of hallucinations.
Diagnostic Workup
Order a comprehensive metabolic panel (CMP), complete blood count (CBC), TSH with reflex T4, and Vitamin D/B12 levels.
Necessary to rule out thyroid dysfunction, anemia, or metabolic imbalances contributing to chronic fatigue and lifelong sleep disturbances.
Substance Use Management
Provide psychoeducation on Cannabis Withdrawal Syndrome and offer support for cessation of 'melatonin overdosing' and alcohol use.
The patient is currently in a withdrawal state from daily cannabis use and is using melatonin and alcohol in a non-therapeutic, potentially harmful manner.
Psychotherapy
Refer for Dialectical Behavior Therapy (DBT) or Cognitive Behavioral Therapy (CBT) focusing on emotional regulation and interpersonal effectiveness.
The patient reports significant difficulty managing interpersonal relationships and has high scores for both anxiety and depression.
Pharmacological Intervention
Discuss the initiation of a low-dose SSRI or SNRI once the patient's reservations regarding contemporary medicine are addressed.
Severe GAD-7 (19) and moderately severe PHQ-9 (16) scores suggest that therapy alone may be insufficient for symptom stabilization.
Sleep Medicine Referral
Refer for a formal sleep study (polysomnography) to investigate the etiology of 'lifelong horrific sleep disturbance'.
Chronic insomnia since childhood warrants investigation into primary sleep disorders such as sleep apnea or restless leg syndrome before attributing it solely to psychiatric causes.
Specialty Psychiatric Evaluation
Perform a diagnostic interview focusing on the reported hallucinations to differentiate between primary psychosis, substance-induced psychosis, or mood-congruent features.
A positive screen for hallucinations requires specific characterization to determine the appropriate level of care and diagnostic accuracy.
Subject: A warm welcome and support for your journey, Satchel
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Melatonin and Alcohol
Counsel the patient on the additive CNS depressant effects of combining alcohol with high-dose melatonin, which can increase sedation and further disrupt sleep architecture.
High-dose Melatonin ('Overdosing') and Cannabis Withdrawal Syndrome
Address the patient's self-reported melatonin 'overdose'; educate on appropriate sleep hygiene and the physiological limits of melatonin efficacy to prevent potential adverse effects like daytime somnolence or nightmares during withdrawal.
Alcohol and Psychiatric Symptom Burden (Depression/Anxiety)
Discuss the role of daily alcohol use in exacerbating moderate-to-severe depression and anxiety; monitor for substance-induced mood fluctuations that may interfere with future pharmacotherapy.
C-SSRS Columbia-Suicide Severity Rating Scale
Given the patient's history of suicidal ideation, family history of SI, and acute risk detection, this scale is critical for tracking lethal intent and monitoring safety across sessions.
PSYRATS Psychotic Symptoms Rating Scales
This scale provides a multidimensional assessment of the patient's reported hallucinations, allowing for monitoring of frequency, duration, and the distress levels associated with these symptoms.
ISI Insomnia Severity Index
To quantify the severity of the patient's lifelong sleep disturbances and track the effectiveness of interventions as he navigates cannabis withdrawal and attempts to normalize his sleep hygiene.
Why You Feel This Way
You have been feeling very sad and very worried for a long time. These feelings are called depression and anxiety. They can make it hard to sleep and hard to get along with others. It is important to know that these are real health problems, and you do not have to face them alone.
Checking Your Physical Health
Because you have had trouble sleeping your whole life, we want to check your body. We will do some simple blood tests. This helps us see if your thyroid or other parts of your body are making you feel tired or stressed.
Stopping Cannabis Use
You recently stopped using cannabis after using it every day for a long time. When you stop suddenly, your brain and body can feel very sick or upset. This is called withdrawal. It explains why you have felt worse lately, and it should get better with time.
Seeing and Hearing Things
You mentioned seeing or hearing things that other people do not. We want to talk more about this so we can keep you safe. If you ever feel like hurting yourself or if those things become scary, please tell a doctor or a trusted person right away.
Next Steps Together
We want to help you find a way to feel better that you feel good about. We will talk about your sleep, the vitamins you take, and how to help you feel more steady in your life and work.
Clarification of Hallucinations
"I noticed you mentioned seeing or hearing things that others don't. Could you describe those experiences for me? For instance, do they happen more often when you're using cannabis, when you're trying to fall asleep, or do they happen even when you are completely sober and wide awake?"
Note: The screening indicates positive hallucinations, but the HPI lacks detail on timing, frequency, and whether these occur exclusively during substance use, withdrawal, or periods of sobriety.
History of Suicidal Behavior
"You've shared that you've struggled with thoughts of suicide in the past. To better understand your safety, have you ever made an actual attempt to end your life, or have you ever engaged in behaviors to intentionally hurt yourself without the intent to die?"
Note: While history of ideation is noted and risk is flagged as acute, specific details regarding past suicide attempts or self-harming behaviors are missing and critical for risk stratification.
Screening for Mania/Hypomania
"With your history of chronic depression, have you ever had a period of several days where you felt the exact opposite—where your mood was unusually high, your thoughts were racing, and you felt like you didn't need any sleep at all?"
Note: Given the 'lifelong' nature of the depression and sleep disturbances, it is necessary to rule out Bipolar Disorder by screening for history of elevated mood or decreased need for sleep.
Developmental and Educational History
"You mentioned that these struggles with anxiety and relationships have been lifelong. Looking back at your school years, did you ever require special education services, or were there concerns from teachers about your social development or your ability to focus?"
Note: The patient reports lifelong social difficulties and anxiety; exploring childhood milestones and school performance can help identify potential undiagnosed neurodevelopmental issues.
Extended Family Psychiatric History
"Beyond your brother and father, do any other blood relatives, like grandparents, aunts, or uncles, have a history of psychiatric diagnoses like bipolar disorder or schizophrenia, or has anyone in the family ever died by suicide?"
Note: While the brother and father are mentioned, a broader history of specific diagnoses like Bipolar, Schizophrenia, or completed suicides in the extended family is missing.