Psychiatry Progress Note

Psychiatrist's Note: Date and Time: 01/11/2024 Contact Type: This was a clinic review focused on medication management and ongoing symptom assessment. Participants: Dr. Emily Carter (Psychiatrist) Ms. Sarah Johnson (Patient) Background: Ms. Sarah Johnson, a 34-year-old female, presented for a follow-up appointment regarding her ongoing management of Bipolar I Disorder, currently experiencing a depressive episode. She was initially diagnosed three years ago and has a history of fluctuating mood states, with previous hospitalisations for both manic and severe depressive episodes. The current contact was initiated to assess the efficacy of her recently adjusted antidepressant regimen and to address persistent anhedonia and low energy. Psychotropic Medication: Lithium Carbonate 600mg, twice daily Sertraline 100mg, once daily Lorazepam 0.5mg, as needed for anxiety (max 3 times per week) Review and Discussion: During the review, Ms. Johnson reported a slight improvement in her overall mood since the last contact, noting that her 'deep sadness feels a bit lighter.' However, she continues to struggle significantly with anhedonia, stating, "Nothing really brings me joy anymore, even things I used to love." Her energy levels remain low, making it difficult to engage in daily activities, and she has missed several days of work this past week. Sleep quality has improved somewhat with regular sleep hygiene practices. She denies any active suicidal ideation but acknowledged passive thoughts of wishing she 'could just disappear' when feeling overwhelmed. Family concerns were raised by Ms. Johnson regarding her mother's increasing worry about her withdrawal from social activities. We discussed coping mechanisms for low mood and the importance of adhering to her medication schedule. The potential impact of her current mood state on her work performance was also explored, and she agreed to consider speaking with her employer about a temporary reduced schedule. Mental State Examination: Ms. Johnson presented as casually dressed but appeared somewhat dishevelled. Her psychomotor activity was slightly reduced. Speech was of normal volume and rate but lacked typical prosody. Affect was restricted and congruent with her reported low mood. Thought process was linear, but thought content revealed pervasive themes of hopelessness and anhedonia. No perceptual disturbances were reported or observed. She denied current suicidal intent, though acknowledged passive ideation. Cognitive functions appeared intact, and she demonstrated fair insight into her illness and the need for ongoing treatment. Plan: 1. Increase Sertraline to 150mg daily to address persistent anhedonia and low energy. 2. Continue Lithium Carbonate at current dose; monitor blood levels at next appointment. 3. Recommend engaging in a structured daily activity, even if initially unpleasurable, to counter anhedonia. 4. Encourage re-engagement with previous CBT strategies for managing depressive symptoms. 5. Advise discussing potential temporary work accommodation with her employer. Follow-Up: Ms. Johnson will be reviewed in two weeks to assess her response to the increased Sertraline dosage and to monitor for any side effects. Summary: Ms. Johnson reports a slight improvement in mood but continues to experience significant anhedonia and low energy, necessitating an increase in her Sertraline dosage to 150mg daily.