1025: Client presents for initial evaluation, reporting that she “feels all over the place and it is time that she receives some treatment.” “At times I feel empty inside, sometimes feel hyped up, and at times, like now, I feel sad”. On assessment, the client has a constricted affect, and her eyes were cast downward. Client reports that her depression has been present for as long as she can remember, including throughout grade school. Her first clearly recalled depressive episode occurred in the sixth grade, when she felt she was "not living up to my own expectations." These episodes varied in duration—some lasting several months, others only a few hours—but typically persisted for 2 to 4 weeks. Onset could range from a day to a week, while the offset was often abrupt, resolving within a day or less. She reported intermittent difficulty falling asleep. Lately, she has had to use 2-3 tablets of diphenhydramine to help her fall asleep. She denied experiencing racing thoughts but acknowledged being told on numerous occasions that she spoke in ways that felt ‘pressured.’ She also endorsed distractibility and noted frequent difficulty completing tasks. During times of good mood or when she felt "aligned with others,” she found herself more productive, particularly in creative endeavors. However, at other times, even simple tasks felt overwhelming. She described experiencing "a flurry of thoughts," particularly while writing or during creative projects. At age 23, she experienced what she referred to as "an explosive outburst of rage," which culminated in her punching a hole in her roommate’s car's windshield. She reports this occurred during a two-day ‘episode’ of her being irritable. Medical history of tension headaches, mild eczema in winter months, and seasonal allergic rhinitis. The client consumes 1-2 glasses of alcohol a year. She does smoke cigarettes daily and started smoking when she was 20.

1130:

• lamotrigine 25 mg p.o. daily
• follow-up in two weeks
• obtain thyroid panel
• trazodone 50 mg p.o. at bedtime
• discontinue diphenhydramine

1025: Client presents for initial evaluation, reporting that she “feels all over the place and it is time that she receives some treatment.” “At times I feel empty inside, sometimes feel hyped up, and at times, like now, I feel sad”. On assessment, the client has a constricted affect, and her eyes were cast downward. Client reports that her depression has been present for as long as she can remember, including throughout grade school. Her first clearly recalled depressive episode occurred in the sixth grade, when she felt she was "not living up to my own expectations." These episodes varied in duration—some lasting several months, others only a few hours—but typically persisted for 2 to 4 weeks. Onset could range from a day to a week, while the offset was often abrupt, resolving within a day or less. She reported intermittent difficulty falling asleep. Lately, she has had to use 2-3 tablets of diphenhydramine to help her fall asleep. She denied experiencing racing thoughts but acknowledged being told on numerous occasions that she spoke in ways that felt ‘pressured.’ She also endorsed distractibility and noted frequent difficulty completing tasks. During times of good mood or when she felt "aligned with others,” she found herself more productive, particularly in creative endeavors. However, at other times, even simple tasks felt overwhelming. She described experiencing "a flurry of thoughts," particularly while writing or during creative projects. At age 23, she experienced what she referred to as "an explosive outburst of rage," which culminated in her punching a hole in her roommate’s car's windshield. She reports this occurred during a two-day ‘episode’ of her being irritable. Medical history of tension headaches, mild eczema in winter months, and seasonal allergic rhinitis. The client consumes 1-2 glasses of alcohol a year. She does smoke cigarettes daily and started smoking when she was 20.

Two week follow-up appointment

0944: Client returns for a two-week follow-up after starting lamotrigine and trazodone. She reports that she has stopped taking diphenhydramine for sleep as instructed and is now sleeping 5–6 hours per night with trazodone, though she still feels tired in the morning. She denies any new skin rash or flu-like symptoms. She states, “I still have a lot of ups and downs, but I feel like I’m a bit more steady lately.” She continues to smoke and reports an uptick in cigarette smoking because she is not sleeping well. She also started journaling her moods daily. No new outbursts or impulsive episodes were reported. The thyroid panel returned within normal limits. No suicidal or homicidal ideation expressed.