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.

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