Mental health note

Chief Complaint: Patient presents with persistent low mood, anhedonia, and difficulty sleeping for the past three months. Past Medical & Psychiatric History: Diagnosed with Major Depressive Disorder five years ago. Currently taking sertraline 100mg daily. No previous hospitalisations. No other relevant medical conditions. Family History: Mother has a history of depression. Social History: Employed as a teacher. Reports moderate alcohol consumption (2-3 drinks per week). Has a supportive partner and a close network of friends. Mental Status Examination: Appearance: Well-groomed, appears stated age. Behaviour: Slightly slowed psychomotor activity. Speech: Normal rate and rhythm. Mood: Subjectively reports low mood. Affect: Constricted. Thoughts: No suicidal or homicidal ideation reported. Perceptions: No hallucinations or delusions reported. Cognition: Oriented to person, place, and time. Intact memory. Insight: Acknowledges the need for treatment. Judgment: Good. Risk Assessment: Suicidality: Denies suicidal ideation or intent. Diagnosis: Major Depressive Disorder, moderate severity (F33.1) based on DSM-5 criteria. Treatment Plan: Medications: Continue sertraline 100mg daily. Psychotherapy: Recommend individual cognitive behavioural therapy (CBT). Follow-up appointments and referrals: Schedule follow-up appointment in four weeks. Referral to a CBT therapist. Safety Plan: Patient has identified coping strategies and support contacts.