Can you provide a SOAP note for a 35‑year‑old female with a three‑month history of persistent low mood, anhedonia, fatigue, difficulty concentrating, decreased appetite with 5‑lb weight loss, insomnia, feelings of worthlessness, denying suicidal ideation but with passive thoughts of being a burden, no recent substance use, no significant medical illnesses, no prior psychiatric diagnoses, and a family history of depression in her mother?

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Last updated: September 15, 2026 • View editorial policy

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SOAP Note for Major Depressive Disorder

This 35-year-old female meets DSM-5 criteria for moderate to severe major depressive disorder and should be offered either cognitive behavioral therapy (CBT) or a second-generation antidepressant (SGA) as monotherapy, with the choice based on her preferences regarding treatment effects, adverse effects, cost, and accessibility 1, 2.

SUBJECTIVE

Chief Complaint

"I've been feeling down and have no interest in things for the past three months."

History of Present Illness

  • Duration: 3 months of persistent symptoms

  • Core symptoms (DSM-5 criteria met):

    • Depressed mood most of the day, nearly every day
    • Anhedonia (loss of interest/pleasure in activities)
    • Insomnia
    • Fatigue/loss of energy
    • Difficulty concentrating
    • Decreased appetite with 5-lb unintentional weight loss
    • Feelings of worthlessness

  • Suicidality assessment 3:

    • Denies active suicidal ideation
    • Denies suicide plan or intent
    • Passive death wishes present: Reports feeling like "a burden" to others
    • Reasons for living: [Document specific protective factors]
    • Access to lethal means: [Document firearms/medications in home]

  • Functional impairment: [Document impact on work, relationships, self-care]

Psychiatric History

  • No prior psychiatric diagnoses
  • No prior psychiatric hospitalizations
  • No prior suicide attempts

Substance Use History

  • Denies current alcohol, tobacco, or illicit drug use 3

Medical History

  • No significant medical illnesses
  • Not currently on medications

Family Psychiatric History

  • Mother with history of depression 3

Psychosocial History 3

  • Stressors: [Document financial, housing, occupational, relationship issues]
  • Trauma history: [Screen for childhood abuse, domestic violence, combat exposure]
  • Social support: [Document support system strength]
  • Cultural factors: [Document cultural beliefs about mental illness]

OBJECTIVE

Vital Signs

  • Height, weight, BMI 3
  • Blood pressure, heart rate, temperature

General Appearance 3

  • Appears stated age, casually dressed
  • Poor eye contact
  • Psychomotor retardation noted [or agitation if present]
  • Nutritional status: appears thin, consistent with reported weight loss

Mental Status Examination 3

Appearance: [As above]

Behavior: Cooperative, minimal spontaneous movement

Speech: Decreased rate and volume, increased latency to respond

Mood: "Depressed" (patient's words)

Affect: Constricted, dysphoric, congruent with mood

Thought Process: Linear and goal-directed, no tangentiality or circumstantiality

Thought Content:

  • Denies current suicidal ideation with plan or intent
  • Passive death wishes: "feels like a burden"
  • Denies homicidal ideation
  • Denies delusions
  • Preoccupied with feelings of worthlessness

Perception: Denies auditory or visual hallucinations

Cognition:

  • Alert and oriented to person, place, time, situation
  • Attention/concentration: impaired (difficulty with serial 7s or spelling "world" backward)
  • Memory: grossly intact

Insight: Fair (recognizes symptoms but may not fully appreciate need for treatment)

Judgment: Fair to poor (evidenced by delay in seeking care)

Physical Examination

  • Skin: No stigmata of self-injury or substance use 3
  • Neurological: Normal gait, coordination; no involuntary movements 3

ASSESSMENT

Primary Diagnosis: Major Depressive Disorder, single episode, moderate to severe severity (DSM-5: 296.22 or 296.23)

Diagnostic Criteria Met (≥5 symptoms for ≥2 weeks with functional impairment) 1:

  1. Depressed mood
  2. Anhedonia
  3. Significant weight loss/decreased appetite
  4. Insomnia
  5. Fatigue
  6. Feelings of worthlessness
  7. Diminished concentration

Suicide Risk Assessment 3:

  • Current risk level: Low to moderate
  • Risk factors: Passive death wishes, family history of depression, feelings of worthlessness, social isolation [if present]
  • Protective factors: Denies active SI/plan, [document specific reasons for living, social supports]
  • Safety plan: Required before discharge

Differential Diagnoses to Consider:

  • Hypothyroidism (obtain TSH)
  • Anemia (obtain CBC)
  • Vitamin deficiencies (B12, folate, vitamin D)
  • Substance-induced mood disorder (ruled out by history)
  • Bipolar disorder (no history of mania/hypomania)
  • Adjustment disorder (symptoms exceed 3 months, severity warrants MDD diagnosis)

PLAN

Diagnostic Workup

  • TSH, CBC, CMP, vitamin B12, folate, vitamin D to rule out medical causes
  • PHQ-9 score: [Document baseline score for monitoring] 1

Treatment Recommendation

The American College of Physicians strongly recommends offering either CBT or a second-generation antidepressant as monotherapy for moderate to severe MDD 1, 2. The choice should be made through shared decision-making after discussing:

Option 1: Cognitive Behavioral Therapy (CBT)

  • Benefits: No medication side effects, teaches coping skills, prevents relapse
  • Considerations: Requires weekly sessions (typically 12-16 weeks), may have limited local availability, cost/insurance coverage
  • Referral: [Provide specific CBT therapist referral]

Option 2: Second-Generation Antidepressant

First-line SGAs (choose based on patient-specific factors):

  • Sertraline 50 mg daily (increase to 100-200 mg as tolerated)
  • Escitalopram 10 mg daily (increase to 20 mg as tolerated)
  • Fluoxetine 20 mg daily (increase to 40-60 mg as tolerated)

Patient-specific considerations for medication selection:

  • Insomnia present → Consider sertraline or escitalopram (take in morning)
  • If hypersomnia were present → Consider fluoxetine or bupropion
  • Appetite/weight concerns → Avoid mirtazapine (increases appetite)

Medication counseling points:

  • Takes 4-6 weeks for full effect
  • Common side effects: nausea, headache, sexual dysfunction, initial anxiety
  • Do not stop abruptly (discontinuation syndrome)
  • No alcohol use while on medication

Option 3: Combination Therapy (CBT + SGA)

ACP suggests combination therapy as an option for moderate to severe MDD 2, though this is a conditional recommendation with lower-certainty evidence. Consider if:

  • Patient has severe symptoms
  • Prior failed monotherapy
  • Patient preference after discussing increased treatment burden

Safety Planning 3

  • Crisis resources: National Suicide Prevention Lifeline (988), local crisis line, emergency department
  • Lethal means restriction: [Document discussion about firearms, medications]
  • Emergency contacts: [Document family/friends to contact in crisis]
  • Warning signs: Worsening hopelessness, increased isolation, giving away possessions
  • Coping strategies: [Document patient-specific strategies]

Follow-up

  • Return in 2 weeks for medication monitoring (if SGA chosen) or symptom reassessment
  • Earlier if: Worsening suicidal thoughts, inability to function, medication side effects
  • Repeat PHQ-9 at each visit to track response 1
  • Expected timeline: Acute phase treatment 6-12 weeks, continuation phase 4-9 months if remission achieved 1

If No Response to Initial Treatment

For patients not responding to initial SGA after adequate trial (6-8 weeks at therapeutic dose) 2:

  • Switch to CBT or augment with CBT, OR
  • Switch to different SGA or augment with second pharmacologic agent (e.g., bupropion, mirtazapine, aripiprazole)

Patient Education

  • Explained MDD diagnosis, natural course, and treatment options 3
  • Discussed risks of untreated illness: chronicity, functional decline, suicide risk
  • Reviewed treatment benefits and risks
  • Patient verbalized understanding and agreed to [CBT/medication/combination] treatment plan

Documentation

  • Suicide risk: Low to moderate (passive death wishes, no plan/intent, protective factors present)
  • Homicide risk: None (no aggressive ideation) 3
  • Treatment rationale: Moderate to severe MDD warrants evidence-based monotherapy per ACP guidelines; [CBT/SGA] chosen based on patient preference regarding [specific factors discussed] 3, 1, 2

References

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