Depression and insomnia follow-up

Clinical note

Depression and insomnia follow-up

CC: Mood follow-up, established patient.
HPI: 41 y/o with major depressive disorder, recurrent, moderate, on sertraline 100 mg for 8 weeks. PHQ-9 today 12, down from 19. Reports insomnia with sleep onset delay 60+ minutes most nights, no early waking. Denies SI/HI.
Exam: Alert, cooperative, affect brighter than last visit.
A/P: 1. Major depressive disorder, recurrent, moderate, improving, increase sertraline to 150 mg. 2. Insomnia, sleep hygiene reviewed, CBT-I referral, no hypnotic for now.
MDM: moderate (chronic illness with progression, prescription drug management).