Dr de Silva

Hawkesbury Family Practice

86 Lennox St

Richmond

NSW 2753

06.07.2024

Re: Allister Claasz (DOB: 21.02.00) Review PTS SOS plan

Dear Dr De Silva,

Thank you for re-referring Allister for psychological therapeutic (SOS) for depression and suicidal ideation in April, 2024. I write to provide you with a review at the end of this plan.

Allister had his first session of this plan on the 18th of April, 2024. He had weekly appointments, with his review being held on the 17th of June, 2024. At the time of his review, he had made a significant recovery; was emotionally stable and no longer suicidal – see update below. He has since been referred for counselling with a work cover psychological service provider.

Allister has had previous referrals. He was first referred to me by yourself, Dr de Silva in March 2019. He has had several referrals since then and has made steady progress since this time. Previous correspondence outlines the history of these presentations.

Presentation

At the time of Allister’s initial presentation on this plan, he phoned me requesting an urgent appointment under the SOS referral. He had sustained a back injury at work in November 2023 and subsequently lost his job. He reported a deterioration in mental health since then, including low mood, hopelessness about his future and suicidal ideation, with “multiple plans”. He stated “I’ve given up; I’m staying in bed most of the day; I’m not socialising; I’ve lost interest in things.” Financial stressors were a contributing factor and he was unsure how to pay rent in 2 weeks’ time. He was able to give a guarantee of his safety until his money runs out - so at least 2 weeks. Protective factors included reaching out for help and his dog, Reggie.

During the initial session, Allister was able to consider different choices for moving forward with his life. He expressed passion about conservationism and was able to consider other pathways to channel his energy and direction. This showed me that there was some hope and not complete hopelessness, which was also a protective factor. By the end of the first consultation, Allister stated that he felt somewhat better.

MSE - initial

Dishevelled; covered in dog hair; unclean.

Engaged well; good eye contact and rapport (established therapeutic relationship)

Speech - normal rate tone and volume

Thought form: logical and sequential; no FTD Alteration in perception - not discussed

Insight and judgement - seeking help; is aware of impact of stressors on wellbeing

Impression

Relapse in mood: major depression; suicidal ideation.

Formulation

24-year-old male of Phillipino/Sri Lankan descent, living alone in private rental accommodation, presenting with relapse in depression with suicidal ideation, in background of psychosocial stressors, including loss of employment and financial stressors.

Update

Over the course of this plan, a diverse range of psychotherapeutic interventions were utilised to support Allister’s recovery. These included bush walking, interview practice, lifestyle coaching, career planning, counselling and psychotherapy, with good effect.

At the time of his review on the 17th of June, Allister was working 4 days per week on a rural property and enjoying the work and flexibility of the role, though he was concerned about needing to get his career path on track, including having a stable income, with tax, super and sick leave in place. His financial stressors had eased with the employment, and he had withdrawn his Centrelink application.

Allister reported an improvement in his mental health, and he developed a six-month plan for getting his life back on track in the final session. He looked visibly better in himself; was engaging well, with good eye contact and rapport. Affect was bright and reactive and he described his mood as "ok; still up and down at times, but better" he reported occasional suicidal ideation, but stated “I have no intent or plan now.”

Allister was focusing well on plans for the future, engaging in conversations about how to decide where to take his career path next. There was no alteration in perception.

He had good insight and judgement about his progress.

K10: 24/50 (was 39/50) – showing a significant improvement.

Impression

Doing well. Mood much improved and currently stable.

Plan

Continue psychological work with new provider under work cover.

Close PTS SOS referral.

Regards,

Michelle Hookham