Initial Assessment

History of Presenting Complaints: John Doe, a 35-year-old male, presented with persistent feelings of sadness, lack of interest in daily activities, and fatigue for the past six months. He reports difficulty sleeping and concentrating, which has affected his work performance. John also mentioned experiencing occasional panic attacks characterized by shortness of breath and palpitations. Psychiatric Review of Systems: - Depression: Persistent sadness, anhedonia, fatigue, insomnia, difficulty concentrating - Mania: Client did not endorse - Anxiety: Panic attacks, restlessness - Psychosis: Client did not endorse - Trauma: Client did not endorse - Eating Disorder: Client did not endorse - ADHD: Client did not endorse - Autism Spectrum: Client did not endorse - ODD / Conduct / Antisocial: Client did not endorse - Personality Disorder: Client did not endorse Past Psychiatric History: - Diagnosed with Major Depressive Disorder two years ago, treated with cognitive behavioral therapy - No hospitalizations - Currently taking Sertraline 50mg daily - Previously trialed Fluoxetine Past Medical History: - Hypertension, managed with Lisinopril - Appendectomy at age 20 Family History: - Mother diagnosed with Bipolar Disorder Substance use History: - Occasional alcohol use, last consumed two weeks ago - No history of smoking or recreational drug use Social History: - Born and raised in Chicago, currently living in New York with his wife - Works as a software engineer, holds a bachelor's degree in computer science - Strong social support from family and friends - No current legal issues Risk Assessment: - No current suicidality or homicidality Diagnosis: Major Depressive Disorder, Generalized Anxiety Disorder Treatment Plan: - Continue Sertraline 50mg daily - Schedule family meeting to discuss support strategies - Refer to psychologist for ongoing therapy - Follow-up appointment in four weeks