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.