PMHNP SOAP notes on a 26 years old female patient with depression Anxiety and manic
episodes who is taking Zyprexa, Depakote and fluoxitine but says medication is not working.
which medications to try next for her
ChatGPT said:
Here is a detailed SOAP note for a 26-year-old female patient with Depression, Anxiety, and
Manic Episodes who reports medication non-effectiveness despite being on Zyprexa
(Olanzapine), Depakote (Valproate), and Fluoxetine (Prozac):
PMHNP SOAP Note
S: Subjective
CC: “My medications aren't working. I still feel anxious, depressed, and sometimes I
can’t sleep for days when my energy goes up.”
HPI: 26-year-old female with a known history of bipolar disorder (type unspecified),
generalized anxiety disorder (GAD), and major depressive disorder (MDD). She has been
on Zyprexa 10 mg, Depakote 1000 mg, and Fluoxetine 40 mg for the past 6 months
with no significant improvement in mood, anxiety, or manic symptoms. She reports
persistent low mood, anxiety, restlessness, insomnia, and occasional elevated energy,
racing thoughts, and impulsivity.
ROS: No suicidal or homicidal ideation. Denies hallucinations or delusions.
Medication adherence: Patient reports adherence to prescribed regimen.
Substance Use: Denies alcohol or illicit drugs.
Psychosocial: Lives alone, unemployed, minimal social support. Reports feeling
overwhelmed.
O: Objective
General appearance: Alert, restless, and somewhat disheveled
Mood/Affect: “Tired and anxious”; affect mildly labile
Speech: Pressured at times, tangential
Thought process: Circumstantial, with some flight of ideas
Thought content: No suicidal/homicidal ideation or delusions
Insight/Judgment: Limited
Labs: Recent valproate level: 45 mcg/mL (subtherapeutic); LFTs normal
Vital signs: Within normal limits
A: Assessment
Diagnosis:
o Bipolar I Disorder, current episode mixed (F31.13)
o Generalized Anxiety Disorder (F41.1)
o Major Depressive Disorder, recurrent, moderate (F33.1)
Clinical impression: Patient is experiencing a mixed mood state with ongoing anxiety
and treatment resistance to current regimen. Subtherapeutic valproate levels may explain
partial symptom persistence. Risk of antidepressant-induced mania (via fluoxetine) is a
concern in context of bipolar disorder.
P: Plan
1. Medication Changes:
o Discontinue Fluoxetine: May contribute to cycling in bipolar disorder.
o Titrate Depakote to therapeutic range (target 50–125 mcg/mL); increase dose
under monitoring.
o Switch Zyprexa to Lurasidone (Latuda) 20–40 mg daily: FDA-approved for
bipolar depression; lower metabolic risks.
o Consider Lamotrigine as an alternative mood stabilizer if patient primarily
experiences depressive episodes.
o Consider Lithium (if labs permit): gold standard for mood stabilization,
especially effective for suicide prevention.
o Alternative Antipsychotics if poor response to Latuda:
Quetiapine (Seroquel) – mood stabilizing, approved for bipolar
depression
Cariprazine (Vraylar) – effective for bipolar I depression and mixed
episodes
2. Psychotherapy:
o Initiate Cognitive Behavioral Therapy (CBT) for anxiety and depression
o Referral for bipolar-focused psychoeducation and emotion regulation strategies
3. Monitoring and Labs:
o Check valproate level, CBC, LFTs, and pregnancy test before starting
Lamotrigine or Lithium
o Monitor metabolic profile (A1C, lipids) if antipsychotics are continued/changed
4. Safety Planning:
o No current suicidal ideation; reinforce access to emergency care
o Educate on mood episode warning signs and when to seek help
5. Follow-Up:
o Weekly monitoring for the next 4 weeks
o Psychiatric follow-up in 1 week to assess tolerability and symptom change post-
med adjustment
PMHNP SOAP Note
S: Subjective
CC: “My medications aren't working. I still feel anxious, depressed, and sometimes I
can’t sleep for days when my energy goes up.”
HPI: 26-year-old female with a known history of bipolar disorder (type unspecified),
generalized anxiety disorder (GAD), and major depressive disorder (MDD). She has been
on Zyprexa 10 mg, Depakote 1000 mg, and Fluoxetine 40 mg for the past 6 months
with no significant improvement in mood, anxiety, or manic symptoms. She reports
persistent low mood, anxiety, restlessness, insomnia, and occasional elevated energy,
racing thoughts, and impulsivity.
ROS: No suicidal or homicidal ideation. Denies hallucinations or delusions.
Medication adherence: Patient reports adherence to prescribed regimen.
Substance Use: Denies alcohol or illicit drugs.
Psychosocial: Lives alone, unemployed, minimal social support. Reports feeling
overwhelmed.
O: Objective
General appearance: Alert, restless, and somewhat disheveled
Mood/Affect: “Tired and anxious”; affect mildly labile
Speech: Pressured at times, tangential
Thought process: Circumstantial, with some flight of ideas
Thought content: No suicidal/homicidal ideation or delusions
Insight/Judgment: Limited
Labs: Recent valproate level: 45 mcg/mL (subtherapeutic); LFTs normal
Vital signs: Within normal limits
A: Assessment
Diagnosis:
o Bipolar I Disorder, current episode mixed (F31.13)
o Generalized Anxiety Disorder (F41.1)
o Major Depressive Disorder, recurrent, moderate (F33.1)
Clinical impression: Patient is experiencing a mixed mood state with ongoing anxiety
and treatment resistance to current regimen. Subtherapeutic valproate levels may explain
partial symptom persistence. Risk of antidepressant-induced mania (via fluoxetine) is a
concern in context of bipolar disorder.
P: Plan
1. Medication Changes:
o Discontinue Fluoxetine: May contribute to cycling in bipolar disorder.
o Titrate Depakote to therapeutic range (target 50–125 mcg/mL); increase dose
under monitoring.
o Switch Zyprexa to Lurasidone (Latuda) 20–40 mg daily: FDA-approved for
bipolar depression; lower metabolic risks.
o Consider Lamotrigine as an alternative mood stabilizer if patient primarily
experiences depressive episodes.
o Consider Lithium (if labs permit): gold standard for mood stabilization,
especially effective for suicide prevention.
o Alternative Antipsychotics if poor response to Latuda:
Quetiapine (Seroquel) – mood stabilizing, approved for bipolar
depression
Cariprazine (Vraylar) – effective for bipolar I depression and mixed
episodes
2. Psychotherapy:
o Initiate Cognitive Behavioral Therapy (CBT) for anxiety and depression
o Referral for bipolar-focused psychoeducation and emotion regulation strategies
3. Monitoring and Labs:
o Check valproate level, CBC, LFTs, and pregnancy test before starting
Lamotrigine or Lithium
o Monitor metabolic profile (A1C, lipids) if antipsychotics are continued/changed
4. Safety Planning:
o No current suicidal ideation; reinforce access to emergency care
o Educate on mood episode warning signs and when to seek help
5. Follow-Up:
o Weekly monitoring for the next 4 weeks
o Psychiatric follow-up in 1 week to assess tolerability and symptom change post-
med adjustment
