SOAP (T&E)

Symptom Description and Subjective Report

The client described the following symptoms

• The client reported depressed mood, anhedonia, middle insomnia, and daytime fatigue.
• The client reported symptoms occur daily (7 days/week).
• The client reported depressive episodes last 4–6 hours per day, with nocturnal awakenings lasting 90 minutes.
• The client reported moderate intensity.
• The client reported impaired concentration at work, missed deadlines, and neglect of household chores.
• Alone in a private room at home with the door closed; confidentiality and privacy confirmed.

Objective Content

• The client reported occupational burnout, fear of professional failure, and guilt regarding social withdrawal from family.
• The client reported feeling overwhelmed by a recent promotion, stating, "I feel like I am drowning in emails and everyone expects me to fail."
• The therapist used cognitive restructuring to challenge catastrophic thoughts regarding work performance; the therapist used behavioral activation to address social isolation and anhedonia; the therapist used sleep hygiene education to target middle insomnia.
• Receptive to cognitive reframing, engaged actively in identifying cognitive distortions, and agreed to trial a scheduled evening routine.

Additional Notes / Assessment

• Making steady progress in recognizing negative automatic thoughts, though vegetative depressive symptoms persist. Continues on sertraline (Zoloft®) 100 mg PO QAM with good tolerability.
• At home via secure telehealth video platform.
• PHQ-9: 14 (moderate depression); GAD-7: 9 (mild anxiety).

Plan

• Continue sertraline (Zoloft®) 100 mg PO QAM and weekly CBT. Homework: complete daily thought record and engage in two 20-minute walks this week.
• Review thought record logs and evaluate adherence to sleep hygiene protocol; practice grounding techniques between sessions.
• 24/10/2023 at 14:00 America/Chicago.
• Telehealth video session.