S – Subjective
Chief Complaint (CC): “I feel sad all the time and have no energy to do anything.”
History of Present Illness (HPI): Patient reports persistent low mood, loss of interest in previously enjoyable activities, fatigue, and difficulty concentrating for the past 6 weeks. Symptoms are present nearly every day, lasting most of the day. Reports feelings of worthlessness and guilt. Appetite decreased, with unintentional weight loss of 5 kg. Sleep disturbed (early morning awakening). Denies manic or hypomanic episodes. Admits to passive suicidal ideation (“I wish I wouldn’t wake up”) but no active plan.
Psychiatric History: One prior depressive episode at age 19, treated with psychotherapy. No hospitalizations. Family history: mother with depression, father with alcohol use disorder.
Substance Use: Occasional alcohol use, denies illicit drugs. Caffeine moderate (2 cups/day).
Social History: University student, currently struggling academically. Lives with roommates, limited family support. Reports social withdrawal and isolation.
Review of Systems (ROS):
Mood: Persistent sadness, hopelessness.
Sleep: Insomnia, early awakening.
Appetite: Decreased.
Energy: Low, fatigued.
Concentration: Poor.
Safety: Passive suicidal ideation, no plan.
O – Objective
General Appearance: Disheveled, minimal eye contact, psychomotor retardation noted.
Mental Status Examination (MSE):
Orientation: Alert and oriented ×3.
Speech: Slow, soft, monotone.
Mood: “Sad, empty.”
Affect: Flat, congruent with mood.
Thought Process: Linear but slowed.
Thought Content: Passive suicidal ideation, feelings of worthlessness.
Perceptions: No hallucinations or delusions.
Cognition: Impaired concentration, intact memory.
Insight/Judgment: Fair insight, judgment impaired by hopelessness.
Vital Signs: Within normal limits.
Physical Exam: No acute abnormalities.
Labs/Screening: Thyroid function normal, CBC normal. PHQ‑9 score: 21 (severe depression).
A – Assessment
Primary Diagnosis: Major Depressive Disorder, single episode, severe, without psychotic features.
Differential Diagnoses:
Bipolar Disorder – ruled out (no history of mania/hypomania).
Persistent Depressive Disorder (Dysthymia) – symptoms shorter than 2 years.
Adjustment Disorder with depressed mood – symptoms exceed typical duration and severity.
Substance-Induced Mood Disorder – ruled out by history and labs.
Risk Assessment:
Suicide risk: Moderate due to passive ideation.
Safety risk: Impaired functioning academically and socially.
Protective factors: Supportive roommates, willingness to seek help.
P – Plan
Pharmacological Interventions:
Initiate SSRI (e.g., sertraline, fluoxetine) as first-line.
Monitor for side effects (GI upset, sexual dysfunction, insomnia).
Consider augmentation with atypical antipsychotic or mood stabilizer if resistant.
Psychotherapy:
Cognitive Behavioral Therapy (CBT) to address negative thought patterns.
Interpersonal Therapy (IPT) to improve relationships and social functioning.
Psychoeducation about depression, treatment adherence, and relapse prevention.
Lifestyle/Supportive Measures:
Encourage regular exercise and balanced diet.
Sleep hygiene strategies.
Limit alcohol and caffeine.
Encourage social engagement and structured daily routine.
Safety Planning:
Establish crisis plan for suicidal ideation (emergency contacts, hotline).
Frequent follow-up visits to monitor risk.
Involve roommates/friends in support network with patient consent.
Follow-Up:
Weekly sessions initially to monitor medication response and mood.
Reassess PHQ‑9 scores regularly.
Long-term goal: Remission of depressive symptoms, restoration of functioning, prevention of relapse.
✅ Summary
This SOAP evaluation for Major Depressive Disorder highlights persistent low mood, anhedonia, and functional impairment, distinguishing it from Bipolar Disorder (which includes mania/hypomania). The treatment plan emphasizes SSRIs, psychotherapy, lifestyle changes, and safety monitoring.