Suicidal Ideation and Depression in Adolescent

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The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times and were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and anxiety and indicated that the patient’s father suffered from bipolar disorder and had been receiving psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious psychiatric symptoms.

The patient is failing several classes in school, and her family was in the process of looking for a new school due to her failing grades and difficulties getting along with her classmates. She presented the following symptoms: frequent sadness and crying, increased appetite and overeating, guilt, low self‐concept, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. In addition, she presented difficulties in her interpersonal relationships, persistent negative thoughts about her appearance and scholastic abilities, as well as guilt regarding her parents’ marital problems. She states that sometimes she feels the world would never know if she disappeared.

The patient’s medical history reveals that she suffers from asthma, used eyeglasses, and is overweight. Her mother reported that she had been previously diagnosed with MDD 3 years ago and was treated intermittently for 2 years with supportive psychotherapy and anti‐depressants (fluoxetine and sertraline; no dosage information available). This first episode was triggered by rejection by a boy for whom she had romantic feelings. Her most recent episode appeared to be related to her parents’ marital problems and to academic and social difficulties at school.

Chafey, M. I. J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103. https://doi.org/10.1002/da.20457

This assignment requires a comprehensive SOAP format. So, all information from the subjective, objective, assessment, and plan must be included. In the plan portion make sure to include the following:

Pharmacological treatment needs to be specific; give a particular medication with dosing and frequency

Non-pharmacological treatment-give a specific example like CBT, MBSR, Patient Education Referral to other providers, Follow-up.

 

Sample Solution

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.

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