"Post-holiday crash. Just feel flat. Nothing to look forward to." Reports overeating, hypersomnia (10+ hrs/night). No SI/HI. Minimal motivation to return to work.

Appearance: casual, neat. Gait normal. Affect: blunted, restricted. Mood: "meh." Speech: soft, limited spontaneity. Thought process: linear, goal-directed. Insight: fair. Judgment: intact for immediate decisions.

Continues to meet criteria for MDD, moderate. Seasonal component likely. Medication adherence: states taking 200mg QD "most days." Encouraged to add light therapy in AM. Scheduled follow-up for Feb. Reminded of crisis line. Agreed to try walking 10 min daily.

"I'm just tired all the time. Work feels pointless." Reports persistent anhedonia, social withdrawal. Still getting up and going to work, but "on autopilot." Denies suicidal thoughts. Sleep still excessive on weekends.

Appearance: slightly fatigued, dark circles. Affect: constricted, minimal reactivity. Mood: "depressed." Speech: slow, low volume. Content: ruminations about loneliness, no close friends. Insight: good. Judgment: grossly intact.

Continued MDD, chronic pattern. No medication side effects reported. Discussed behavioral activation — challenging to implement due to lack of energy. Encouraged to join a small group or volunteer to reduce isolation. Reluctant but agreed to consider. Continue current meds. Follow up in 4 weeks.

"Spring is here and I still feel like garbage. Everyone at work is tense. I'm writing up so many kids." Reports increasing irritability at work; feels unappreciated by students and staff. Sleeping 6-7 hrs with frequent awakenings. Appetite low. No SI/HI.

Appearance: neat, but posture slumped. Affect: irritable, anxious undertone. Mood: "frustrated." Speech: pressured at times when discussing work. Thought process: linear, circumstantial. Insight: fair — recognizes she may be overly critical but defends it as "necessary." Judgment: moderately impaired by stress.

MDD with anxious distress. Work-related burnout emerging. Reviewed sleep hygiene; suggested evening wind-down routine. Discussed cognitive reframing for perfectionistic tendencies at work. Patient resistant to the idea of reducing strictness. Encouraged brief walks during lunch. Maintain meds. Referral to a psychiatric nurse for medication review not indicated at this time.

Patient arrived on time; visibly fatigued, heavier dark circles. States: "I got completely reprimanded today. Principal and Assistant Principal called me in and told me I'm too strict. They downgraded every single one of my write-ups. Said I'm 'overwhelming the system.'" Reports feeling humiliated and burned out. "I'm just trying to do my job. Nobody else enforces the rules."

Also mentioned: "I had to drop my cat off for surgery after this. Then I have to go home to that empty apartment. I don't want to go home." Denied active suicidal ideation, but expressed passive wishes: "I wish I could just disappear for a while." No plan, no intent.

Appearance: disheveled hair, clothing slightly wrinkled. Affect: flat, tearful at times, but quickly suppressed. Mood: "empty, worthless." Speech: low, hesitant, long pauses. Thought process: ruminative, focused on injustice at work. Cognition: intact. Insight: partial — acknowledges being burned out but externalizes blame onto administration. Judgment: impaired — considering driving around aimlessly instead of going home to decompress. Denies SI/HI, but passive rumination is concerning.

Severe MDD with burnout, acute stress reaction. Workplace conflict is a significant stressor today. Patient is emotionally exhausted and showing early signs of decompensation. Reviewed crisis safety plan. Encouraged to go straight home, take a warm bath, and call a friend. Patient nodded but seemed disengaged. Discussed increasing therapy frequency (weekly) to manage acute stress; she agreed tentatively.

Urgent follow-up scheduled for 04/29/2026. Provided crisis line card. She placed it in her bag. Expressed wanting to "drive around for a while" after the vet appointment to clear her head. I gently discouraged isolation and encouraged going home. She did not confirm compliance.