SOAP Note on Major Depressive Disorder

Patient Information

Name: Jane Doe

Age: 35 years old

Sex: Female

CC: "Depressed mood and lack of energy."

HPI: Jane is a 35-year-old woman who began experiencing symptoms of depression around six months ago. Her symptoms came on gradually without a clear precipitating event. She describes her core symptoms as a persistent low mood, lack of interest and pleasure in activities she used to enjoy, like reading and going out with friends, low energy and fatigue, poor sleep with early morning awakenings, and feelings of worthlessness (Patel & Rose, 2023). Her symptoms seem to be generalized without a specific location. Nothing, in particular, makes her feel better or worse. She denies any manic episodes, psychotic symptoms, or suicidal ideation. Her symptoms began around two years after her divorce from her husband of 10 years, which was a difficult life stressor for her. Jane reports poor concentration, indecisiveness, and feeling slowed down. She has not received any previous treatment for her current depressive symptoms. The severity of her symptoms seems to wax and wane, with some days feeling slightly better than others.

Current Medications: None

Allergies: No known drug allergies

PMHx: No previous medical conditions

Soc Hx: Divorced two years ago after a 10-year marriage, works as an accountant, and lives alone.

Fam Hx: Mother had postpartum depression after the birth of Jane's younger sibling

ROS: Poor appetite with 10 lb weight loss over six months, low libido

Subjective Data

General: Feelings of sadness, lack of motivation and energy, worthlessness

HEENT: No complaints

Cardiovascular: No complaints

Respiratory: No complaints

Gastrointestinal: Poor appetite

Neurological: Difficulty concentrating, slowed movements (O’Donnell et al., 2019)

Psychiatric: Depressed mood, anhedonia, insomnia, feelings of worthlessness

Other areas reviewed were noncontributory

Objective Data

Physical Exam

Vitals: BP 120/80, P 72, RR 16, T 98.6F

General: Appears tired, flat affect, psychomotor retardation

Diagnostic Studies: PHQ-9 score of 18 (moderate-severe depression)

Assessment

1. Major Depressive Disorder
2. Adjustment Disorder with Depressed Mood
3. Persistent Depressive Disorder

The primary diagnosis is Major Depressive Disorder, given the significant depressive symptoms lasting over six months with associated impairments in social and occupational functioning. Her recent divorce is a likely psychosocial contributor.

Plan

The plan for Jane includes obtaining baseline Patient Health Questionnaire (PHQ-9) scores to monitor the severity of her depressive symptoms. She will be started on the SSRI antidepressant sertraline 50mg daily (Bains & Abdijadid, 2023). Non-pharmacological treatments will include referral for cognitive behavioral therapy and recommendations for aerobic exercise 3 times per week, stress management techniques like mindfulness, and increasing social engagement. If she does not show improvement after eight weeks, augmentation with bupropion or a medication switch can be considered. A follow-up is then anticipated in 4 weeks to review the response to treatment and consider modification of the treatment plan as guided by her complaint and PHQ-9 score (Patel & Rose, 2023). These aspects will include improving sleep quality and diet, and repeating what used to be enjoyable to engage in.

Reflection

In this particular case of a patient with depressive symptoms, assessment of psychosocial antecedents, such as the recent divorce, would be relevant during assessment. It is hugely beneficial to involve the patient in systematically and thoroughly planning the intentional multifaceted treatment approach. I would incorporate extensive education about MDD and her recovery process and engage in close monitoring with frequent modifications to medications and therapeutic and lifestyle changes due to her condition. They also need to understand that involving family could help in the process of her recovery.

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