Problem:
Patient S.A, a 33 year old Hispanic male, with Diagnosis of Depressive Disorder with Anxiety, Bipolar lI Disorder, Depressed type and Cannabis Use Disorder, Majoroderate presents on 12/09/24 for follow-up, reporting ongoing feelings of sadness, low energy, and difficulty concentrating. He states, "I'm still struggling to get motivated, but the mood swings are less intense." He also describes persistent worry and occasional panic attacks, triggered by financial stress and interpersonal conflicts. The patient reports reduced cannabis use, from daily to two to three times per week, but admits difficulty in quitting entirely. Sleep has improved slightly with the current regimen, but he continues to wake up feeling fatigued. Appetite is adequate, and he denies significant weight changes. He denies suicidal ideation, mania, or psychotic symptoms. Affect was Flat, Mood had anxious feature, Speech, normal rate and volume, coherent and logical, thought Process, Goal-directed, no evidence of delusions or psychosis. No overt signs of intoxication or withdrawal from cannabis observed, or agitation or psychomotor retardation noted. The patient is making progress in stabilizing mood symptoms, with fewer mood swings and reduced cannabis use. However, depressive and anxiety symptoms persist, likely contributing to difficulty in achieving functional recovery. The current medication regimen of Lamotrigine for mood stabilization and Escitalopram for depressive and anxiety symptoms appears partially effective. Continued focus on cannabis cessation and psychotherapy is necessary to address the interplay of substance use and mental health symptoms. Continue Lamotrigine 100 mg daily for mood stabilization. Consider titration to 150 mg if depressive symptoms persist. Continue Escitalopram (Lexapro) 10 mg daily for depression and anxiety. Monitor for increased anxiety or hypomanic symptoms. Add Hydroxyzine 25 mg as needed for acute anxiety or panic attacks. Recommend ongoing Cognitive Behavioral Therapy (CBT) to address depressive and anxiety symptoms, Initiate Motivational Enhancement Therapy (MET) to support cannabis cessation, Encourage engagement in structured daily activities to improve motivation, Recommend relaxation techniques, such as mindfulness or progressive muscle relaxation, to manage anxiety. Refer to a cannabis cessation support group or program. Provide educational resources on the impact of cannabis use on mental health. Schedule follow-up in two weeks to assess mood stability, cannabis use reduction, and medication efficacy, Monitor for signs of hypomania or mania during treatment escalation. Need Assignment Help?
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