Let’s talk about depression. It’s not just feeling sad for a day. It is a real medical condition. It affects how you feel, think, and act. It can make everyday tasks feel very hard. Doctors help people with depression every day. To do this well, they need a clear system. This system helps them understand the problem and make a plan.

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In medicine, many doctors use a tool called a “SOAP note.” It is a way to organize information. SOAP stands for: Subjective, Objective, Assessment, and Plan. It is a simple list of facts and ideas. Today, we will use this SOAP note format to explain depression. This will make a complicated topic easier to understand. We will also look at an example. This guide is for anyone who wants to learn.

Think of a SOAP note like a story. First, the patient tells their story (Subjective). Then, the doctor sees and measures things (Objective). Next, the doctor figures out what it all means (Assessment). Finally, they decide what to do next (Plan). Let’s begin our story about a person named Alex. Alex is seeing a doctor for help.

Writing the Depression SOAP Note

Part 1: The “S” – Subjective (What the Patient Tells You)

This is the patient’s story in their own words. The doctor listens and writes it down. It includes feelings, problems, and history. You cannot measure this part with a machine. You must listen carefully.

1. Chief Complaint (CC): This is the main reason for the visit. The patient says it in a few words. For depression, it often sounds like:

• “I feel sad all the time.”
• “I have no energy.”
• “I can’t enjoy anything anymore.”

Example for Alex: CC: “I’ve been feeling really down and tired for about two months.”

2. History of Present Illness (HPI): This tells the story of the chief complaint. Doctors use the acronym “OLD CARTS” to remember what to ask.

• Onset: When did it start?
• Location: Where do you feel it? (For depression, often “all over” or “in my head and body.”)
• Duration: How long does it last? (All day? Most of the day?)
• Character: What does it feel like? (Empty, heavy, numb?)
• Aggravating/Relieving: What makes it worse or better?
• Radiation: Does the feeling spread? (From sadness to body aches?)
• Timing: Is it worse at a certain time? (Often mornings are worse.)
• Severity: On a scale of 1 to 10, how bad is it?

Example for Alex:

• Onset: Started gradually after the school semester began 2 months ago.
• Location: “In my mind and my whole body.”
• Duration: Feels low most of the day, nearly every day.
• Character: “A heavy blanket I can’t take off. I feel numb.”
• Aggravating: Being alone, schoolwork, thinking about the future.
• Relieving: Nothing helps much. Maybe watching a little TV.
• Timing: Worst in the mornings. Very hard to get out of bed.
• Severity: Rates it a 7 out of 10.

3. Other Symptoms: Depression has many common signs.

• Loss of interest in hobbies (name: anhedonia).
• Big changes in weight or appetite.
• Sleep problems (too much or too little).
• Feeling restless or very slow.
• Low energy, fatigue.
• Feelings of worthlessness or guilt.
• Trouble thinking or making decisions.
• Thoughts of death or suicide.

Example for Alex: Alex says, “I don’t want to play guitar anymore. I sleep 10 hours but still feel exhausted. I can’t focus on my homework. I feel like I’m letting my family down. Sometimes I wonder if everyone would be better off without me.” Alex denies any current plan to hurt himself.

4. Past History & Social Situation: This gives context. Depression does not happen in a vacuum.

• Medical History: Other health problems?
• Psychiatric History: Has this happened before? Any family history of depression?
• Social History: Who do you live with? What is school/work like? Do you use drugs or alcohol?
• Medications: What are you taking now?

Example for Alex: No major medical issues. His cousin has depression. He lives with his parents and a sister. He is a high school sophomore. Grades have dropped from B’s to D’s. He denies smoking, alcohol, or drugs. He is not on any medications.

Part 2: The “O” – Objective (What the Doctor Sees and Measures)

This is what the doctor can see, hear, feel, or measure. It is the evidence. It supports or adds to the patient’s story.

1. Physical Appearance & Behavior (Observed): How does the patient look and act in the office?

• Do they make eye contact?
• Is their clothing clean and neat?
• How is their posture? (Often slumped with depression.)
• Do they cry? Do they move slowly?
• How is their facial expression? (Often flat or sad.)

Example for Alex: Alex is slouched in his chair. He makes little eye contact. His clothes are wrinkled. His facial expression does not change much. He speaks very softly. He moves slowly.

2. Vital Signs & Physical Exam: The doctor checks basic body functions. Sometimes depression can affect these.

• Vital Signs: Blood pressure, heart rate, temperature.
• General Exam: The doctor might listen to the heart and lungs. They check for other causes of fatigue, like thyroid problems.

Example for Alex: Vital signs are normal. Physical exam is normal.

3. Mental Status Exam (MSE): This is a key check-up for the mind. It’s like a physical exam for brain function.

• Appearance: (Already noted above).
• Speech: Is it slow, fast, or normal?
• Mood: What they say they feel inside (e.g., “sad”). This is Subjective.
• Affect: What emotion the doctor sees on the outside (e.g., flat, sad, bright). This is Objective.
• Thought Process: Are thoughts logical and connected?
• Thought Content: Any harmful ideas? (Suicidal thoughts are asked about here.)
• Cognition: Are they alert? Do they know the date and place?
• Insight: Do they understand they are ill?
• Judgment: Can they make good decisions?

Example for Alex:

• Speech: Slow and quiet.
• Mood: “Hopeless.”
• Affect: Flat and constricted (shows very little emotion).
• Thought Process: Logical but slow.
• Thought Content: Has passive thoughts like “I wish I wasn’t here.” Denies active plan to harm self.
• Cognition: Alert. Knows date, place, and person.
• Insight: Fair. He knows something is wrong.
• Judgment: Intact for safety.

4. Screening Tools/Scales: These are short questionnaires. They give a score to help measure depression severity.

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• Common one: PHQ-9 (Patient Health Questionnaire-9). It has 9 questions about symptoms.

Example for Alex: Alex completes a PHQ-9. His score is 18, which is in the “moderately severe depression” range.

Part 3: The “A” – Assessment (What the Doctor Thinks Is Going On)

This is the doctor’s professional opinion. It puts the “S” and “O” together. It is the diagnosis or problem list.

1. Summary Statement: The doctor starts with a short summary. They describe the patient and the main issue.

• Example for Alex: “Alex is a 16-year-old male with a 2-month history of worsening low mood, anhedonia, low energy, poor concentration, and passive suicidal thoughts. Symptoms are affecting his school performance.”

2. Diagnosis: This is the label for the illness. Doctors use a book called the DSM-5. It lists criteria for depression (called Major Depressive Disorder).

• To be diagnosed, a patient must have 5 or more symptoms for 2 weeks or more. One symptom must be either (1) depressed mood OR (2) loss of interest. Symptoms must cause big problems in life.

Example for Alex’s Diagnosis:

• Major Depressive Disorder, single episode, moderate severity.
• Why? Alex has: 1) Depressed mood, 2) Loss of interest in guitar, 3) Fatigue/low energy, 4) Feelings of worthlessness, 5) Trouble concentrating. That’s 5 symptoms for 2 months. His PHQ-9 score of 18 confirms a moderate-severe level.

3. Rule Out (Differential Diagnosis): The doctor thinks about other problems that look like depression. They must “rule them out” or prove they are not the cause.

• Medical Problems: Thyroid disease, vitamin deficiency, chronic illness.
• Other Mental Health Conditions: Bipolar disorder, anxiety disorder, and adjustment disorder.
• Substance-Induced: Depression caused by drugs or alcohol.

Example for Alex: The doctor will consider: Hypothyroidism (low thyroid hormone can cause fatigue and low mood), Generalized Anxiety Disorder, and Adjustment Disorder with Depressed Mood. The normal physical exam makes medical causes less likely. The length and number of his symptoms point more to Major Depression.

4. Risk Assessment: This is very important. The doctor must check how safe the patient is.

• They ask directly about thoughts of suicide or harming others.
• They check for risk factors: feeling hopeless, being alone, having a plan, and access to weapons.
• They make a safety plan.

Example for Alex: Alex has passive thoughts (“wish I wasn’t here”) but denies a plan, intent, or access to means. He agrees to tell his parents or call 988 if these thoughts get worse. This means he is at lower immediate risk, but still needs close watch.

Part 4: The “P” – Plan (What the Doctor and Patient Will Do)

This is the action plan. It is created with the patient. The plan should address each problem in the Assessment.

1. Treatment Plan (The Main Actions):

• Psychotherapy (Talk Therapy): This is often the first step. Cognitive Behavioral Therapy (CBT) is very good for depression. It helps change negative thought patterns. Alex will start seeing a therapist weekly.
• Medication: Sometimes, medicine can help. Antidepressants like SSRIs (e.g., sertraline) are common. They help balance brain chemicals. For Alex, given his moderate-severe score, the doctor recommends starting a low dose of an SSRI. They discuss benefits and side effects.
• Lifestyle & Education: The doctor gives advice on things Alex can do.
  • Sleep Hygiene: Go to bed and wake up at the same time.
  • Activity Scheduling: Plan one small, pleasant activity each day, even if he doesn’t feel like it (e.g., a 10-minute walk).
  • Nutrition: Eat regular, healthy meals.
  • Learn: Alex and his parents will learn about depression as a medical illness.

2. Safety Plan: This is a specific plan for suicidal thoughts.

• 1. Recognize warning signs (feeling trapped).
  1. Use coping skills (list 3 things: call a friend, listen to music, go for a run).
  1. Contact family/parents.
  1. Contact a therapist or a doctor.
  1. Go to the nearest emergency room or call 988 (Suicide & Crisis Lifeline).
• Alex will write this down with his parents.

3. Follow-up & Monitoring: Depression treatment takes time. Follow-up is key.

• Alex will see his doctor in 2 weeks to check on medication side effects.
• He will see his therapist weekly.
• He will take the PHQ-9 again at each visit to track progress.
• His parents are involved for support and safety monitoring.

4. Other Steps:

• School: Alex agrees to let the doctor send a note to the school counselor. This can help him get academic support during treatment.
• Lab Tests: The doctor orders a simple blood test to rule out thyroid problems or anemia, just to be sure.

The Bottom Line: The Complete Depression SOAP Note for Alex

Putting it all together, here is what Alex’s SOAP note might look like:

Why This Matters

Understanding depression through a SOAP note does two big things. First, it shows that depression is a real medical condition with clear symptoms. It is not a choice or a weakness. Second, it shows that treatment is a structured plan. It is not just “feel better.” It involves steps for the mind, body, and environment.

If you see yourself or someone you know in Alex’s story, please know this: Help is available, and it works. The first step is talking to someone—a parent, a school counselor, a doctor, or a helpline. Just like a doctor uses a SOAP note to build a plan, you can start building your own path to feeling better. It begins by telling your story.

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