Dr Dalley

Glossodia Medical Centre

3/162 Golden Valley Drive

Glossodia

NSW 2756

19/05/2025

Re: Noa Godsell (DOB: 22.03.2000) Review

Dear Dr Dalley,

Thank you for re-referring Noa Godsell for a Wentworth Healthcare PTS mental plan for psychological support for mood dysregulation and suicidal ideation in January, 2025, following on from the previous referral in August, 2024. I write to provide you with a review at the end of this referral. Overall, Noa continues to improve in his mood and functional capacity. He would like to continue to see me, however he is now living mostly in Melbourne – see update and plan at the end of this report.

NB: Noa prefers to use they/their pronouns. He has also started using the name Noa instead of Noah.

Initial Presentation

At the time of his initial consultation in August, 2024, Noa reported having had a psychotic episode in June 2024, which he considered to be a drug induced psychosis. At that time, he reported feeling anxious and paranoid. He had thoughts that “people were out to get me; that I was being monitored (eg. Phone being tracked)”, and he felt aggravated by loud city noises and police cars. Three weeks prior to his first episode of psychosis (FEP), Noah had been diagnosed with ADHD by Dr Alexandra Krupinska and commenced dexamphetamine. He also had a history of recreational substance use, including regular cannabis use for the past five years. Following the FEP, Noah has mostly abstained from substance use.

Following his FEP, Noah returned to Sydney from Melbourne to stay with his family for support, where he recommenced coming to see me in person. He reported emotional dysregulation, from episodes of high anxiety and panic attacks, alternating with elevated mood and with low mood with suicidal ideation. He described his mood as “erratic; I’m crying every day.” His family were actively monitoring his wellbeing and had increased their support to ensure his safety.

During his assessment, Noah was observed to have pressured speech and flight of ideas; He stated, "I feel sped up; I can't control the inner monologue.” He spoke of existential questions that were preoccupying his thoughts and preventing sleep, including environmental catastrophe, climate activism and dystopia. He spoke of the intense driver to “save the world, but there is not enough time, so I have to be hyper-activist”. Some thoughts had a grandiose quality, such as "I can do something everyone else can't; I think I'm being prepared to be a public figure; I’ve got to save the world.” He was unable to sleep due to the activities of his mind, stating “I can't sleep as my brain sees it as the time to solve the world's problems.” He spoke of feeling disconnected; of existing ‘outside my body’, with difficulty grounding himself. Noah reported feeling restless and had been walking for miles every day.

Please refer to previous correspondence for Noa’s comprehensive mental health assessment. However, in short, my impression then, was that Noa had evidence of a 2 – 4 year history of symptomatology consistent with a presentation of mania or hypomania, with pressured speech, flight of ideas and grandiosity. He reported psychotic symptoms and had medical treatment for a first episode of psychosis in June, 2024. Noah then presented with low mood, suicidal ideation and anhedonia. Whilst formal diagnosis is outside of the scope of my practice, I considered the following could be considered: affective disorders; situational crisis (life stressors); recovering from first episode of psychosis; substance use disorder; or trauma disorder.

06.09.24 K10 score: 34/50

Supports

As Noa’s recovery has progressed, they have moved from staying with parents in Gross Wold, to spending more time in Melbourne with their partner of 18 months, Dwayne.

Noa’s family are very supportive.

Noa has appointments with yourself, Dr Dalley, regularly via Telehealth, which he finds a key part of his support team.

Fortnightly consultations with Michelle Hookham.

Medication

TBC

Update

Noa continues to make steady progress with his recovery. Over the past four months, he has attended and actively participated in fortnightly psychotherapeutic sessions, which he uses well to discuss challenges and explore underlying causes of behaviour patterns. Noa has gained considerable insight and is striving to move forward with his life. Throughout this referral period, he has had relationship stressors with Dwayne, which he has discussed and continues to process. He has also struggled with feeling socially isolated and not having a meaningful role and purpose during this period of his life.

In January, 2025, Noa reported excessive sleep and feeling tired all the time. He had a medication review with yourself, and over the next few months, medication was gradually reduced. The tiredness has decreased without any relapse of symptoms.

Noa had a 3-week planned admission to SJOG in February 2025. The intention was for a psychiatric medication review and formal diagnosis. On discharge, Noa reported a positive experienced. Medication was changed, including an increased in Aripiprazole as he had some paranoia; Sertraline changed from night to morning; Clonidine was added for anxiety and ADHD. He left hospital with the plan to start uni and move forward with his life. I encouraged him to take small steps to prevent a relapse and we discussed early warning signs (EWS) of relapse to look out for.

In March, Noa started a university course, which he felt excited about. Unfortunately, he struggled with the work, was falling behind, so decided to defer. We explored limiting assumptions about what was stopping him from continuing and he identified a fear of failure and self-doubt. On further reflection, Noa realised that he was struggling because he was recovering from a mental health episode and perhaps just wasn’t ready to start an intensive course at that time. As a child and adolescent, Noa was exceptionally conscientious and had functioned at a very high level at school and with creative pursuits. He needed education about mental health recovery, medication side effects and reassurance that he would continue to get better and would return to better functioning with time.

By April, Noa’s reported low mood and feeling ‘flat’, had lethargy and low motivation and was concerned about weight gain. I also observed psychomotor retardation in his presentation and considered he may benefit from a medication review, which led to a further adjustment of his medication (Aripiprazole reduced to 5mg). We explored a daily routine to assist motivation and getting out of the house.

By May, Noa reported feeling much better, following the medication reduction. His motivation had improved and he was exploring employment opportunities and had been accepted into a musical. His speech was slightly pressured on the 1st of May and he had a lot of ideas being expressed. We spoke about EWS of relapse of mania and how to manage from escalating by using a low-stimulus environment.

At the time of Noa’s review on the 14th of May, 2025, he reported feeling very well. He presented with stable mood, logical/sequential thought form and normal rate, tone and volume of speech. He had commenced the theatre role and was tolerating increased activity without relapse. All of this indicates that Noa is continuing to recover slowly over time, which I anticipate will continue, providing he takes things slowly and introduces activities gradually.

14.05.2025 K10 score: 27/50

Formulation

25 year old Caucasian unemployed male, who identifies as queer and in a de facto relationship, presenting with mood dysregulation following a first episode of psychosis (or manic episode) in June 2024, followed by an episode of low mood with suicidal ideation, after a previous presentation of elevated mood.

Impression

Consider: Affective disorder.

Recovery from psychotic/manic episode progressing well; currently stable in mood; gradual improvement in functional capacity.

Plan

Noa would like to continue to see me fortnightly as he finds the talking therapy helpful. However, he is now residing predominantly in Melbourne, so does not meet the referral criteria for Wentworth Healthcare’s PTS program. I will leave it with you both to discuss how you want to proceed with referral pathways. The options are:

Fee for service (does not need referral)

Medicare (TCA plan – 5 sessions per year) – fee for service with small Medicare rebate (since I’m a CMHN)

PTS referral at your discretion.

Transfer of care to Headspace and other mental health supports preferred by Noa in Melbourne. I am aware that he had an appointment with Headspace, however, I’m unsure of the outcome.

Yours sincerely,

Michelle Hookham