Suicidal Ideation and Depression in Adolescent
SOAP Note
Subjective
Reason for Visit: The patient is a 15-year-old Puerto Rican adolescent female presenting with symptoms of depression. Her parents report significant marital problems and are considering divorce. The patient's mother has a history of depression and anxiety, and the father has bipolar disorder with previous hospitalizations.
Presenting Concerns: The patient reports feeling frequently sad, crying often, overeating, experiencing guilt, having a low self-concept, anxiety, irritability, difficulty sleeping, hopelessness, and trouble concentrating. Additionally, she struggles with interpersonal relationships, has negative thoughts about her appearance and academic abilities, and feels guilty about her parents' marital problems. She sometimes feels like disappearing.
Past Medical History: Asthma, eyeglasses, overweight, Major Depressive Disorder (MDD) diagnosed 3 years ago, treated intermittently with supportive psychotherapy and antidepressants (fluoxetine and sertraline) for 2 years (dosage unknown). The initial episode was triggered by romantic rejection. The current episode seems related to parental marital problems, academic difficulties, and social issues at school.
Social History: Lives with both parents and a younger sibling.
Family History: Mother with depression and anxiety, father with bipolar disorder and past hospitalizations.
Objective
Mental Status Exam: Appears sad and tearful with low energy. Speech is slowed and her mood is described as depressed. Denies suicidal ideation with intent or plan but admits to passive suicidal thoughts. Reports difficulty concentrating during the interview.
Physical Exam: Not documented in this case presentation.
Assessment
Impression: Major Depressive Disorder (MDD), recurrent, moderate episode with features of anxiety.
Differential Diagnosis: Bipolar Disorder with depressive episode (less likely due to patient's mother's history and lack of documented manic episodes), Adjustment Disorder with depressed mood.
Plan
Pharmacological: Fluoxetine (Prozac) 20mg daily, started at this visit. Monitor for clinical response and potential side effects. Consider medication adjustment based on response and tolerability.
Non-Pharmacological:
- Cognitive Behavioral Therapy (CBT): Individual CBT sessions focusing on identifying and modifying negative thought patterns that contribute to depression and low self-esteem. Skills training for coping with stress, managing emotions, and problem-solving.
- Referral for Family Therapy: Facilitate communication and conflict resolution between parents, address the impact of marital problems on the patient's well-being, and encourage a supportive family environment.
- Patient Education: Provide psychoeducation on depression, including causes, symptoms, treatment options, and self-management strategies.
- Follow-up: Schedule weekly appointments for the first month, then bi-weekly for the next 2 months, followed by monthly appointments thereafter. Monitor response to treatment and adjust interventions as needed.
Prognosis: With comprehensive treatment, including medication management, CBT, and family therapy, the patient's depressive symptoms are likely to improve. Long-term follow-up and monitoring for potential future episodes are crucial.