Therapy and Medication Note Template

Summary:

The patient, a 52-year-old female, presented for her monthly medication management and therapy session. She reports improved mood stability since starting Lamotrigine, with fewer hypomanic episodes. However, she continues to experience mild depressive symptoms, particularly in the mornings. She has been more consistent with her sleep schedule and has reduced alcohol consumption.

Strengths include increased awareness of her mood patterns and better adherence to her treatment plan. Challenges include persistent morning fatigue and occasional rumination about past relationship conflicts. Treatment goals focus on achieving mood stability and developing healthier interpersonal boundaries.

Chief Complaint:

The patient reports feeling more stable overall but is concerned about morning depression and low energy that persists until midday.

History of Present Illness (HPI):

Since increasing her Lamotrigine dose six weeks ago, the patient has had no hypomanic episodes and only one brief period of low mood lasting three days. She reports feeling generally more even-tempered and less reactive to stressors. Sleep has improved from 4-5 hours per night to 6-7 hours with the addition of Trazodone.

She has reduced her alcohol intake from daily wine consumption to weekends only. The patient started a new job as a library assistant three weeks ago, which she finds fulfilling but occasionally stressful when interacting with difficult patrons.

Topics Discussed:

The session focused on strategies to manage morning depression, including behavioral activation and adjusting her morning routine. We discussed her progress in setting boundaries with her adult daughter, who frequently calls asking for financial help. The patient expressed pride in declining a recent request without feeling guilty. We also explored her adjustment to her new job and processing feelings about her divorce finalized last month.

Interventions Used:

Supportive therapy was used to validate her progress and reinforce positive changes. We reviewed behavioral activation techniques, specifically scheduling morning activities to combat low energy. Psychoeducation was provided about bipolar disorder maintenance and the importance of consistent medication adherence and sleep hygiene.

The patient was receptive and engaged, demonstrating good understanding of the connection between her routines and mood stability. She actively participated in developing a modified morning routine plan.

Tests and Scores:

MDQ (Mood Disorder Questionnaire) completed: Positive screen for bipolar disorder, consistent with established diagnosis.

PHQ-9 score: 8, indicating mild depression (down from 14 at last visit).

Mental Status Exam:

Appearance: Neatly dressed in business casual attire, appropriate makeup and grooming.

Behavior: Cooperative, maintained good eye contact, appropriate social engagement.

Mood/Affect: Patient stated mood as "pretty good, maybe 7 out of 10." Affect was euthymic and full range, congruent with reported mood.

Thought Process/Content: Goal-directed and organized. No flight of ideas or tangentiality. Denied suicidal or homicidal ideation. No evidence of psychosis.

Cognition/Insight/Judgment: Alert and oriented to person, place, time, and situation. Memory intact. Good insight into her condition and treatment needs. Judgment appropriate.

Medications:

Current Medications: Lamotrigine 200 mg twice daily for mood stabilization, Trazodone 50 mg at bedtime for sleep, Levothyroxine 75 mcg daily for hypothyroidism.

Patient-Reported Adherence: Excellent medication adherence. Uses a pillbox organizer and has not missed any doses in the past month.

Side Effects: Reports mild morning grogginess from Trazodone but finds it acceptable given improved sleep quality. No rash or other concerning side effects from Lamotrigine.

Assignments and Plan:

Assignments: Patient will implement morning behavioral activation plan including 10-minute walk upon waking and eating breakfast within 30 minutes of getting up. She will continue mood tracking app to identify patterns.

Plan: Continue current medication regimen as mood stability is improving. Will reassess morning depression in one month - if persistent, may consider adding low-dose Wellbutrin. Continue monthly therapy and medication management sessions. Encouraged to maintain reduced alcohol use and regular sleep schedule.

Safety Assessment:

Patient denies current or recent suicidal ideation. No history of suicide attempts. Denies self-harm behaviors. Protective factors include supportive relationship with her sister, engagement with new job, and commitment to treatment. No concerns for harm to others.

Follow-Up Email:

Session summary sent to patient via secure portal, including morning routine recommendations and reminder to track mood daily. Provided crisis line number and instructions to contact office if mood symptoms worsen before next appointment.

Diagnostic Codes:

F31.81 Bipolar II Disorder, Most Recent Episode Depressed, Mild

F51.01 Primary Insomnia (improving)

Billing Codes:

ICD-10: F31.81, F51.01

CPT: 99214 for medication management, 90836 for psychotherapy (45 minutes)

To-Dos:

Schedule next appointment in 4 weeks.

Patient to complete mood tracking daily and implement morning behavioral activation plan.

If morning depression does not improve in 2-3 weeks, patient to call office to discuss adding adjunctive antidepressant.