Psychiatric Discharge Note

Reason for Encounter

• Planned discharge from Partial Hospitalization Program (PHP) following successful completion of dual-diagnosis treatment for Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD).

Admission Information

• Admitted on 15/09/2023 under the care of Dr. Evelyn Vance, MD, and the Dual-Diagnosis PHP Team.
• MDD, recurrent, severe without psychotic features; AUD, severe.

Course of Treatment

• Marcus Vance was admitted on 15/09/2023.
• Reported depressed mood, anhedonia, insomnia, passive SI, daily heavy EtOH consumption (1 pint vodka/day), and mild withdrawal tremors.
• Participated in daily CBT and DBT group sessions, individual psychotherapy, and MAT. Started on sertraline (Zoloft®) 100 mg PO daily and naltrexone (Revia®) 50 mg PO daily. Engaged actively in all therapeutic modalities.
• Maintained 28 days of continuous sobriety confirmed via random UDS/EtG. Attended 100% of scheduled PHP sessions and developed effective distress tolerance and mindfulness coping strategies.
• Significant reduction in depressive symptoms (PHQ-9 decreased from 21 to 6) and complete resolution of anxiety and insomnia.
• Successfully met all PHP treatment goals and is clinically appropriate for step-down discharge on 13/10/2023.

Suicide Risk Assessment

• Low acute risk. Patient explicitly denies suicidal ideation, intent, or plan, and denies homicidal ideation or thoughts of self-harm. C-SSRS negative.

Risk Mitigation

• Relapse prevention plan established, focusing on urge surfing to manage cravings, avoiding high-risk social triggers, and utilizing DBT grounding techniques.
• Provided contact details for Dr. Sarah Jenkins (Outpatient Psychiatrist, 312-555-0198) and Oak Street Recovery Center (312-555-0144).
• Supplied crisis resources, including the 988 Suicide & Crisis Lifeline (24-hour hotline) and local mobile crisis team contacts.

Discharge Condition/Prognosis

• Stable, euthymic, 28 days sober, demonstrating effective management of depressive symptoms and alcohol cravings.
• Good prognosis contingent upon adherence to outpatient psychiatric follow-up, MAT, and regular AA participation.
• High likelihood of sustaining sobriety and maintaining affective stability through ongoing engagement with the structured Intensive Outpatient Program (IOP) aftercare plan.

Assessment & Formulation

• Marcus Vance, 42-year-old male.
• Admitted to PHP for stabilization of severe recurrent MDD and severe AUD following acute medical detox.
• Successfully completed the 4-week PHP curriculum, achieving 28 days of sobriety and near-remission of depressive symptoms.
• Demonstrated high motivation, active participation in CBT/DBT groups, medication adherence, and strong insight into the interplay between his mood and substance use.
• Discharge to lower level of care (IOP) is recommended based on sustained clinical stability, absence of acute safety risks, and demonstrated mastery of relapse prevention skills.

Status on Discharge

• Psychiatric: Mood euthymic, affect bright. Denies SI/HI, hallucinations, or delusions. Sustained sobriety with strong confidence in utilizing DBT coping skills.
• Functional: Restored sleep architecture (7–8 hours/night), consistent ADLs, re-established healthy daily routines, improved communication with spouse, and preparing to return to work next week.
• Medical: Medically stable with no new complaints; LFTs normalizing. Advised to follow up with PCP, Dr. Robert Miller, for routine health maintenance.

Discharge Plan

• Discharged to home with spouse in Chicago, IL.
• Step-down to IOP at Oak Street Recovery Center starting 16/10/2023 at 09:00, alongside weekly individual therapy with Thomas Wright, LCSW.
• Advised to attend local AA meetings at least 3 times weekly and secure a temporary sponsor.
• Continue sertraline (Zoloft®) 100 mg PO daily and naltrexone (Revia®) 50 mg PO daily; 30-day supply sent to pharmacy. Follow-up appointment scheduled with Dr. Sarah Jenkins on 27/10/2023 at 14:00.
• Psychoeducation provided to patient and spouse regarding relapse prevention strategies, identifying early warning signs (e.g., isolation, sleep disruption), and utilizing sober support networks.
• Provided printed directory of Chicago-area AA meetings, SMART Recovery links, and the 24-hour 988 Suicide & Crisis Lifeline.
• Instructed to contact Dr. Jenkins, call 988, or present to the nearest emergency department immediately if experiencing acute psychiatric symptoms, SI, or imminent risk of relapse.