psychiatric progress note regarding a patient with PPH: of Depression Anxiety and Insomnia.

Psychiatric Progress Note

Patient Name: [Patient’s Name] Date of Visit: [Date] Time of Visit: [Time]

Chief Complaint: The patient presents with symptoms of depression, anxiety, and insomnia (PPH).

History of Present Illness: The patient reports experiencing a persistent low mood characterized by sadness, hopelessness, and loss of interest in previously enjoyed activities. These depressive symptoms have been present for approximately [duration] and are interfering with daily functioning. The patient describes increased anxiety, including excessive worry, restlessness, and physical symptoms such as muscle tension and irritability. These anxiety symptoms have exacerbated over the past [duration].

The patient also reports difficulty falling asleep and staying asleep, leading to significant impairment in their overall sleep quality and duration.

Mental Status Examination:

  • Appearance: Patient appears disheveled and fatigued.
  • Mood: Depressed, with a flat affect.
  • Affect: Anxious and tense.
  • Thought Process: Tangential at times.
  • Thought Content: Negative thoughts, self-critical.
  • Perception: No perceptual disturbances reported.
  • Cognition: Oriented to person, place, and time. No apparent cognitive deficits.
  • Insight/Judgment: Limited insight into the severity of symptoms.


  1. Major Depressive Disorder (MDD)
  2. Generalized Anxiety Disorder (GAD)
  3. Insomnia Disorder

Treatment Plan:

  1. Pharmacotherapy:
    • Initiate [medication name, dose] for depression.
    • Initiate [medication name, dose] for anxiety.
    • Consider [medication name, dose] for insomnia if sleep disturbances persist.
    • Provide education on potential side effects and benefits of medications.
  2. Psychotherapy:
    • Referral to a licensed therapist for cognitive-behavioral therapy (CBT) to address depressive and anxiety symptoms.
    • Implement relaxation techniques and sleep hygiene strategies as part of therapy.
  3. Lifestyle Modifications:
    • Encourage regular exercise, balanced nutrition, and a consistent sleep schedule.
    • Discuss the importance of reducing caffeine and alcohol intake, especially in the evening.
  4. Follow-Up:
    • Schedule a follow-up appointment in [duration].
    • Monitor medication response and side effects.
    • Assess changes in mood, anxiety levels, and sleep patterns.
  5. Safety Assessment:
    • Evaluate the patient’s safety and risk for self-harm or suicidal ideation.
    • Ensure that the patient has a support system and knows how to access crisis intervention services if needed.
  6. Patient Education:
    • Educate the patient about the nature of depression, anxiety, and insomnia.
    • Discuss the importance of adherence to treatment recommendations.
    • Provide resources for mental health support and crisis hotlines.

Leave a Reply

Your email address will not be published.