Comprehensive Evaluation and Management of Depressive Disorder: A Case Study Utilizing the SOAP Note Format

SOAP notes remain a crucial tool utilized in healthcare to document patient details and guide the care plan. Management of mental health conditions such as depression is a common example of a condition that SOAP notes would create a comprehensive treatment plan for the patient. According to Lew et al. (2023), the SOAP note can improve communication among healthcare providers and create the care plan as a checklist essential for patient care. In mental health, misdiagnosis and underdiagnosis of conditions remain a challenge for healthcare providers (Ayano et al., 2021). Following this need, the paper will provide a SOAP note for a major depressive patient, identifying subjective and objective data, making assessments of the patient, and determining the care plan.

Subjective Data

Chief Complaint

"I feel sad and down almost all the time and dislike associating with my friends and other family members. I sometimes feel worthless considering the struggle I have influenced my family with, particularly school fees and poor performance."

History of Presenting Illness

The client is an 18-year-old female present in the clinic with a chief complaint of increased feelings of sadness, always low mood, and lack of interest in associating with others, including family members. The feeling has been persistent for over six months, and the patient was under school nurse care, who referred the patient to the clinic for psychiatric evaluation. The patient describes the increased feeling of sadness as associated with past childhood when they experienced robbery due to the death of their young brother and lack of interest in any activity, including eating. The parents mention having found their daughter with a knife, trying to take her life, and there are increased complaints from teachers over her poor academic performance. The parents also note that their daughter refuses to attend any family gatherings and is always indoors when not in school, with poor communication and refusal to eat. There is a family history of psychiatric disorder, particularly the mother with puerperal psychosis. The patient is in high school, living with parents and one sister, and is six years old. She denies headaches, blurred vision, and hearing problems. Communicate is always fatigued, always sad, and has feelings of hopelessness. However, she denies thoughts of self-harm.

Objective Data

Her vital signs include BP 110/80 mmHg, temperature 36.0°C, pulse 110 bpm, RR 22 bpm. The mental examination results include oriented x4, dressed in mixed colors, untidy hair, and looking as per the stated age. She is cooperative but with a flat effect and always loses interest in the interview as she stares at the door. Her speech is normal based on the tone and volume. Her thought process is linear but always focused on the negative theme, particularly the death of her brother. There are no delusions or hallucinations noted, but suicide ideations were noted from the parents' reports. Her insight and judgment is fair.

Assessment

Primary Diagnosis

Major Depressive Disorder, single episode, unspecified F32.9

It is a psychiatric condition that is characterized by persistent feelings of low mood, lack of interest in interacting with the surroundings, and lack of participation in nearly all activities. According to Bains and Abdijadid (2023), DSM-5 provides criteria for diagnosing major depression in which there must be at least five of the symptoms of depression for more than two weeks and cause social and occupational impairment. The recognized signs and symptoms include feeling sad and low mood almost every day, low interest in nearly all activities most of the day, weight loss, especially with poor appetite, fatigue with loss of energy, feelings of guilt and worthlessness, lack of concentration, isolation and suicide attempt including ideations. The patient presents with nearly all the symptoms and a potential diagnosis of major depressive disorder, with a single episode unspecified.

Differential Diagnosis

Dysthymia F33

It is a psychiatric condition also known as persistent depressive disorder and a chronic form of depression. The signs and symptoms include consistent low mood and energy, poor self-esteem, and difficulty concentrating. Other symptoms correlate with major depressive disorder but are not severe enough to cause social or occupational impairments. The symptoms must be persistent for two years, a factor the patient has not experienced (Patel & Rose, 2023). The difference between dysthymia and major depressive disorder includes MDD having episodes that can remit while dysthymia is always persistent.

Plan

The plan of care for the patient includes treatment both pharmacologically and non-pharmacologically. According to Bains and Abdijadid (2023), the pharmacological management of major depression includes selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, atypical antidepressants, tricyclic antidepressants, monoamine oxidase inhibitors, and mood stabilizers. Nonpharmacological therapy includes psychotherapy, electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, and esketamine. Other factors to be considered include psychoeducation, such as educating the patient and the parents about depression, the available treatment options, and the need to adhere to medication.

Conclusion

The use of SOAP notes exists as a significant tool for healthcare efficiency and evidence-based approach. The merits shared included improved healthcare collaboration and timely delivery of services. In mental health, its use has been shown to lower the rate of misdiagnosis and underdiagnosed cases. The format has been utilized for major depressive cases by thoroughly assessing patient details such as the patient's chief complaint, past medical and surgical history, family background, and presenting symptoms. These factors would guide informed clinical decisions, primarily regarding treatment options. Therefore, there is a need to advocate the improved use of SOAP notes in the management of psychiatric conditions such as major depressive disorder.