Dr Raeik Kang

Patrick St Medical Centre

8 Patrick st

Blacktown

NSW 2148

16.03.2024

Re: Rebecca Valades (DOB: 20/06/1983) GP MHCP mental health assessment and review

Dear Dr Raeik,

Thank you for referring Rebecca Valades for a GP MHCP and following Wentworth Healthcare (NBM PHN) PTS plan for ‘chronic depression and anxiety’ on the 23rd of August, 2023. I write to provide you with feedback at the end of this plan, and to request another referral/plan.

Rebecca attended the first consultation on this plan on the 23rd of August, 2023. She has attended fortnightly to monthly consultations and engages well, however when her mental health deteriorates, she tends to cancel appointments, which unfortunately is when she needs the most support.

Initial Presentation

At the time of her initial consultation, Rebecca reported a deterioration in her mental health following “workplace bullying by my boss”. She has since been out of the workforce and on Centrelink benefits. In the middle of 2023, Rebecca’s daughter was badly bullied at school, an incident in she lost consciousness and an ambulance had to be called. In trying to address the incident with her daughter’s school, and feeling they weren’t taking appropriate action, Rebecca lost control of her emotions. She swore at staff and made physical contact with a staff member when they put their arm out to block her (according to Rebecca), and she was charged with common assault. Rebecca received fines from the court, which she was unable to pay, which caused financial strain. I was able to set up a Work Development Order (WDO) for her, and her fines have now been fully paid. For a person with no previous history of legal issues, the legal proceedings were very distressing for her, particularly on the back of feeling of injustice for the lack of action and support from the school. This is out of character for her and Rebecca felt embarrassed and regretted her actions.

Rebecca focussed on getting her daughter settled into a new school, which had been going well. Unfortunately, her daughter was the victim of “inappropriate touch” by a student at the new school. Rebecca reported struggling with the balance between being a caring parent and an over protective, hypervigilant parent. This internal conflict was causing some distress, with dwelling on best course of action for her daughter. I provided her with the contact number for 1800 RESPECT and Springfield Cottage. Rebecca considered that the school handled the matter well, and this issue seemed to have become less of a focus.

At the time of her initial session, Rebecca reported increased anxiety, with constant rumination about these distressing events. She stated that she felt overwhelmed and was “not coping”. Tears were close to the surface when talking about the incidents and had anguish about consequences of her actions. She described her mood as “sombre”. She stated “I feel burnt out, tired and exhausted. There are a lot of things I haven’t faced. I have no energy for life.”

23.08.2023 K10 score: 39/50

Mental health history

2006: Post natal depression after birth of her son. “I had high expectations of a natural birth, but it was caesarean and I couldn’t breastfeed.”

2010: Diagnosed with Major depression, following death of close aunty. Rebecca stated “it was a shock; I took it badly.”

2015: anxiety attack whilst driving with 2yo in the car. Stated “vision left me; vertigo; room spinning.” Had to pull over and call her mother. After that, had anxiety with “every event”

Has TMS 2 to 3 times per week.

Jan 2022: shoulder injury at work time off work. Boss not happy workplace bullying depression stress leave end of July 2023 for one week. “I was in shock”.

Family history

2014: MGF died of pulmonary disease. “I was with him when he died. It took a toll on me.”

Mother: panic attack at age 30, but she overcame it.

Aunty suicided (history of sexual assault by family member).

Sister sexual abuse by family member over a long period of time.

Mother diagnosed with breast cancer in 2023.

Physical health

2022: shoulder injury

Ectopic heart beats

Migraine

Gastro-oesophageal reflux disease (GORD)

Ongoing pain in Cervical spine – C4, C5, C6 and C7 – saw neurosurgeon 01.02.2024 – wants to do further investigations and rule out other conditions. Goes to gym and has physiotherapy and massage.

Noticed butterfly rash across nose and cheeks. Requested that Rebecca follow up with you.

Medication

Was on Zoloft, however had side effects of weight gain.

Currently on Brintellix 10mg daily (anti-depressant)

Prazozin 1mg daily

Ivermectin 1mg topical cream daily

Developmental history

Parent separated when I was 8. Mother is Spanish.

Age 7, Mum tried to live in Spain. Father was absent a lot due to financial stress. Mum wanted to move back to Australia, but he didn’t, so she returned on her own.

“I grew up in a loving single parent home; we had a good life”.

Moved to Central Coast and Sydney.

Schooling unstable – changed a lot; struggled with ESL.

Age 5: recalls inappropriate contact by 17yo male. Doesn’t remember details, but knew it wasn’t right and had no hymen with first sexual intercourse as an adult.

2006: separated from husband, but on and off relationship until after third child.

2006: son born

2008: daughter born

2012: daughter born

AOD

TBC Has not mentioned any substance use, but need to confirm alcohol use.

Supports

Rebecca is a single parent on Centrelink Job Seeker payments.

She has three children living with her, age 11, 15 and 17.

Separated from her husband 10 year ago; divorced 1 year ago. They co-parent, however Rebecca is the children’s primary carer

She feels better when she is organised and the house is clean and tidy.

Yoga is helpful.

Estranged from her sister for 10 years, which she stated “was like my heart was breaking.” (when her sister ceased contact).

Formulation

40 year old unemployed single parent of Spanish descent, living with her three teenage children, presenting with anxiety and depression, in background of multiple biopsychosocial stressors.

Impression

Situational crisis due to recent stressful life events

Anxiety

Depression

Not responding to treatment

Update

Rebecca continued to struggle over the past six months, with other life events triggering anxiety and low mood, including:

In October, Rebecca’s sister started proceedings for childhood sexual assault (CSA) and Rebecca was subpoenaed to court, which caused distress. She had had no contact with her sister for 15 years, following a breakdown in relationship in relation to CSA, and would be seeing her in court in November 2023.

Flashbacks of daughter’s incident and emotional about it; anger and injustice; “I can’t keep them safe. Lost in my thoughts a lot.”

Ruminating about her mental health and feeling like a failure.

Anxiety triggered by minor things.

TMS program coming to an end.

Poor sleep.

Chronic pain

Ongoing worker’s compensation claim.

At the time of her review, Rebecca stated “I have gone downhill. I’m tired, not sleeping and dwelling on things.” She continued struggle to manage emotions of anger and sadness. She has intrusive thoughts and suicidal thoughts, however stated “I wouldn’t act on the them.” Her children are her protective factor.

Over the course of the plan, a range of psychotherapeutic interventions have been utilised to support her recovery, including:

Discussed transgenerational trauma. Rebecca aware of sense of “disgust; that we are not safe and can’t trust anyone,” which she associates with past traumatic events.

Discussed DBT program at SJOG

We have explored the opportunity to upskill and develop a new sense of meaning and purpose in her life now that the children are getting older.

Underlying causes of distress

Psychodynamic processes exploring the inner experience of distress

Coping strategies

Self-care, including diet/nutrition, sleep hygiene and exercise

Rebecca does not feel that medication or TMS were working. Despite that, at the time of her review, Rebecca felt anxious about the TMS treatment stopping. She acknowledges that the 2 – 3 weekly sessions had been therapeutically supportive. She stated that her psychiatrist was considering changing her medication.

Rebecca saw her psychiatrist in October, 2023. She was prescribed Melatonin to help with sleep.

Her sister’s court case had been delayed to 2025, which she felt relief about.

At the commencement of the plan, Rebecca showed signs of improvement, however has since deteriorated. She continues to say that the sessions are helpful, as we have begun to explore underlying causes of distress in a psychodynamic way. She would like to continue to see me.

Plan

Continue fortnightly to monthly sessions.

When Rebecca next comes in to see you, could you please discuss with her how she would like to proceed. Should she continue to want to see me, could you please contact Wentworth Healthcare intake line on: 1800 223 365 and request another referral for her? Possibly and ‘extended’ PTS plan.

Regards,

Michelle Hookham