Dr Thashangan Murugathas (referrer) and

Dr Gunjan Singh (regular GP)

Crestwood Family Practice

Suite 3, 21–31 Lexington Drive

Bella Vista, NSW 2153

18.02.2025

Re: David Best (DOB: 11.03.1968) Extended PTS plan review

Dear Dr Murugathas and Dr Singh,

Thank you for referring David Best under Wentworth Healthcare’s MHNIP in September 2024, for psychological support for low mood, anxiety and PTSD. He has attended fortnightly consultations since that time, and I write to provide you with a review.

David has had previous Wentworth Healthcare referrals to see me between January, 2021 and May, 2022 and again in early 2024.

Initial presentation

At the time of his initial consultation under this plan, Dave reported a deterioration in mental health following multiple biopsychosocial stressors, including complications of a right ankle injury from an MVA in January, 2023; right shoulder injury; unsatisfactory resolution of a workplace injury/workers compensation claim; significant deterioration in mobility; loss of employment opportunities and a relationship breakdown with his children.

At that time, he described his mood as “very low” and expressed thoughts of wanting to give up. He stated “I have nothing worth living for; I feel useless; it’s just battle after battle; I have no support; people are running daggers into me; I’m half the person I was; my friends didn’t even visit me in hospital” He reported suicidal ideation, with thoughts to cut his throat. He stated “6 weeks ago, I had had enough; I was crying and had no more fight left in me.” David stated “I have had several "breakdowns", where these thoughts intensified, however his dog, Ghost is a protective factor and he stated "I couldn't do that to her." Dave expressed the feeling of being a victim in many situations, to the point where he felt cursed. He reported low self-worth and hopelessness about his recovery and of ever finding a meaningful purpose in his life with the added impairments stemming from the accident.

29.03.24 K10: 40/50 – very high level of psychological distress

(see previous correspondence for more information)

Mental health history (brief summary)

David has a background history of adverse childhood events.

He was diagnosed with anxiety and depression in 2011.

PTSD caused by CSA and witnessing/assisting multiple traumatic events during work with Fire Brigade and MVAs.

Physical health

MVA in January, 2023 where he sustained a right grade 3 open trimalleolar ankle fracture,

Setback in December 2023 when ankle developed an internal infection requiring IV antibiotics and prolonged courses of oral antibiotics throughout 2024

Progressive post-traumatic arthritis to the ankle joint and chronic pain

Left shoulder surgery August, 2024

Diabetes

High cholesterol Lipitor.

LFTs high

2020 Dave cancer of the salivary glands and lymph on his right jaw surgical excision.

Supports

Dave lives alone with his dog in a rental property in Windsor. He has a property in Tenterfield, NSW and plans to move there in the near future.

Now on the DSP

Dave has two good friends locally and one friend in Tenterfield, Northern NSW.

Update

Dave had been making steady progress with his mental health recovery in the first half of 2024. He described his mood as “up and down”, largely dependent on his ankle injury. When the swelling, infection and pain were high, his mobility and mood were low and he felt despondent about his recovery. In September, 2024, he had a cortisone injection into the joint, and has had subsequent injections, which have resulted in significant improvement, physically and emotionally. During this period, Dave also reconnected with his children, which was positive. His son Craig was going through relationship stressors and Dave provided emotional support for him, albeit also causing concern for Dave about what his son was going through.

On November 19th, 2024, Dave received a phone call informing him that Craig had taken his life. Dave contacted me highly distressed and spoke about the preceding events and the logistics of what he had to manage. I spoke with him every day of the following week to provide emotional support. Dave coped reasonably well in the circumstances, particularly when he had the distraction of organisational things to manage, and when he felt included with family members in sharing their grief.

Since that time, bereavement has been the focus of Dave’s life. He reports a labile mood, moving between sadness and loss and trying to move forward with his life. He denies suicidal ideation or any thoughts of hurting himself or others. He has times of feeling able to cope, alternating with being overwhelmed emotionally by unexpected things, such as a song. There is residual anger towards Craig’s ex-partner for the circumstances that contributed to Craig’s suicide, and her blocking access of their baby (Dave’s first granddaughter). I have provided grief counselling, encouraging him to allow time to experience the grief, whilst also moving towards the next phase of his life.

In December 2024, Dave reported a constant depressed mood. He spoke with you and commenced anti-depressant medication, which has been helpful. Since then, Dave says he has been “getting back on track; eating better; wanting to re-engage with the world and finding a new routine.” He has also been more animated in sessions, smiling and laughing more and ruminating less on negative things.

13.12.24 K10 score: 46/50 (deterioration in psychological wellbeing associated with Craig’s death)

Formulation

56 year old unemployed man, living alone in rental property, with a history of CPTSD, presenting with anxiety and depression, in background of complex psychosocial stressors, including work-related trauma, adverse childhood events and recently bereaved by suicide.

Impression

Grief and loss

Trauma disorder

Low mood

Plan

Continue fortnightly consultations.

Monitor mood and mental health.

Therapeutic intervention as needed.

Yours sincerely,

Michelle Hookham