Individual Therapy

Client reports persistent difficulty with sleep onset, averaging 4-5 hours per night. States feeling stuck and unmotivated. Reports skipping two social outings this week due to low energy. Medication compliance maintained.

Client appeared fatigued with dark circles under eyes. Affect flat, with minimal spontaneous speech. Grooming adequate but less polished than typical. PHQ-9 score: 16 (moderately severe). Weight stable.

Depressive symptoms remain in moderate-severe range with sleep disturbance as primary driver of functional impairment. Behavioral withdrawal is maintaining depressive cycle. Current treatment approach needs intensification.

Introduce behavioral activation scheduling. Provide sleep hygiene psychoeducation. Consider recommending prescriber review of medication dosage. Set specific, small social goals for the week. Next session: 02/20/2026.