December 31st, 1991

The patient was seen for 30 minutes as scheduled. He was seen alone for 10 minutes but his parents came along on this visit because of increasing concern over his depression. The patient was not very talkative and his parents indicated that this has been an increasing problem at home. Last night his mother found him crying but he would not let her express any warmth or tenderness towards him and would not let her hug him. He said that he felt that his relationship is on the rocks with all of his family and friends. He tends to view depression as situational but also admits he is having difficulty falling asleep, yet sleeps an excessive number of hours during the day. The one area of his life in which he is functioning is his job. He works at McDonald's and has been working there almost daily over Christmas vacation. He wants to work three days a week when he starts back to school next week. I am concerned about the increasing level of depression. His response to Nortriptyline has been just fair, but it also appears he was not taking the additional Desipramine as requested. Since it is somewhat confusing at this point as to whether he is over sedated on the Nortriptyline or still not receiving an adequate dose, I recommended we stop the Desipramine completely, and have him take 150 mg of Nortriptyline a night and increase to 200 mg if he is not sleeping through the night. IN addition, I feel it is time to add Lithium to see if we can get an additional antidepressant effect. He and his parents were given a booklet to read on Lithium and he was cautioned about specific side effects. I want him to start on 300 mg BID and get a serum lithium level, CBC and differential, chemistry screen, urinalysis and thyroid hormone level done in one week. I will see him again next week.

The Cheese Man, M.D.

Cc: Dr. D.T.