Unit 4 Suicide Assessment SOAP notes and1pageessay. Due 5-30-24

Criteria

Clinical Notes

Subjective

Subjective:

Patient Information: LM, a 32-year-old Caucasian male, presents for evaluation today.

CC: "I've been feeling really down and unmotivated lately."

HPI: LM reports a 6-month history of persistent depressed mood, lack of motivation, and feelings of hopelessness. He describes having decreased energy levels, making it difficult for him to complete daily tasks or engage in activities he once enjoyed. LM also endorses difficulty concentrating, citing issues focusing at work. He has experienced a loss of interest in hobbies and pastimes that previously brought him joy, such as playing basketball with friends. Disturbed sleep is another primary complaint, with LM reporting early morning awakenings around 3-4 AM and an inability to fall back asleep. Despite these symptoms, LM denies any active suicidal ideation or intent, though he admits to sometimes wishing he "didn't wake up." He has not experienced any significant changes in appetite or weight.

Current Medications: LM reports no current medication use.

Allergies: No known drug allergies.

Past Medical History:

- Seasonal allergies

- Otherwise unremarkable

Past Psychiatric History: LM denies any prior psychiatric diagnoses or treatment.

Social History:

- Employment: Works full-time as an accountant

- Living situation: Lives alone in an apartment after a divorce

- Children: None

- Substance use: Occasional social drinker, denies recreational drug use

- Support system: Limited, as most friends have moved away from the area

Family History:

- Mother has a history of depression

- Father struggled with alcohol use disorder

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History,

Social History.

Objective

Objective:

ROS: Comprehensive review of systems is negative except for the depressive symptoms described in the HPI.

Vitals:

- BP 124/82 mmHg

- HR 78 bpm

- RR 16 breaths/min

- Temp 98.6°F

- BMI 26.5 kg/m2 (calculated based on stated height and weight)

MSE:

- Appearance: Appropriately groomed and dressed

- Behavior: Cooperative attitude toward interview, but poor eye contact maintained

- Speech: Spoken softly with slow rate and low tone

- Mood: Depressed mood reported

- Affect: Blunted range and reactivity, congruent with stated depressed mood

- Thought Process: Exhibited slowed, circumstantial thought process

- Thought Content: Preoccupied with feelings of hopelessness and worthlessness. Denies any suicidal or homicidal ideation, intent or plan. No delusional content noted.

- Perception: Denies any current auditory or visual hallucinations

- Cognition: Attention and concentration appear intact based on interview. Insight and judgment fair.

- Other: Psychomotor activity normal with no abnormal movements

Psychiatric Screening Measures:

- PHQ-9 score: 18 (Moderately Severe Depression)

- GAD-7 score: 8 (Mild Anxiety)

Labs/Diagnostics: No labs or diagnostic testing completed at this visit.

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening

measure results.

Assessment

Assessment:

Diagnosis: Major Depressive Disorder, Single Episode, Moderate (F32.1)

LM meets the DSM-5 diagnostic criteria for Major Depressive Disorder, Single Episode, Moderate severity based on the following symptoms:

- Depressed mood most of the day, nearly every day, as indicated by subjective report of persistent low mood and feelings of hopelessness for the past 6 months.

- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, as evidenced by loss of interest in previously enjoyed activities like playing basketball.

- Significant weight loss or gain, or decrease or increase in appetite: No significant weight change reported, appetite appears stable.

- Insomnia or hypersomnia nearly every day: Early morning awakenings reported with inability to fall back asleep.

- Fatigue or loss of energy nearly every day: Decreased energy levels endorsed.

- Feelings of worthlessness or excessive/inappropriate guilt nearly every day: Feelings of hopelessness and worthlessness reported.

- Diminished ability to think, concentrate or indecisiveness nearly every day: Difficulty concentrating reported, including issues focusing at work. (American Psychiatric Association. (2013).

The symptoms cause clinically significant distress and impairment in LM's social and occupational functioning, as he has withdrawn from social activities and has concentration issues impacting his work performance. The episode is not better explained by a substance or medical condition. LM denies any manic or hypomanic episodes.

While LM endorses mild anxiety based on the GAD-7 score, his primary presentation meets criteria for a moderately severe major depressive episode at this time. No other psychiatric comorbidities are evidenced. (LeMoult & Gotlib 2019)

Potential Obstacles to Treatment:

· Limited social support system and loss of his primary marital support after divorce

· Stigma associated with seeking mental health treatment as a male

· Potential intolerance or side effects with antidepressant medications

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes,

treatment options, and patient input regarding treatment options (if possible), including obstacles to

treatment.

Plan

Include a specific

Plan:

1. Pharmacological Intervention:

- Start sertraline 50 mg PO daily for treatment of major depressive disorder

- Sertraline is a selective serotonin reuptake inhibitor (SSRI) and is recommended as a first-line pharmacotherapy for moderate or severe major depressive episodes

- The 50 mg daily dose is a typical starting dose that is well-tolerated

- Titrate sertraline dose up gradually as needed and tolerated, with a maximum dose of 200 mg/day

- Allow 4-6 weeks at a therapeutic dose to fully evaluate patient response

- Dose increases of 50 mg every 1-2 weeks can be considered if insufficient response

- Monitor closely for potential adverse effects such as nausea, insomnia, agitation, sexual dysfunction

- Provide patient education on managing side effects

- If side effects are intolerable, consider cross-taping to a different SSRI (Ruberto et al., 2020)

2 . Psychotherapy:

- Refer for Cognitive Behavioral Therapy (CBT)

- CBT is an evidence-based psychotherapy for depression

- It can help LM identify and change negative thought patterns contributing to low mood

- CBT also provides behavioral strategies to increase activity and improve coping

- Consider adding Interpersonal Therapy (IPT)

- IPT focuses on improving interpersonal relationships and social functioning

- May be beneficial for LM who has limited social support after divorce

- Can help him grieve loss of relationships and build healthier connections (Kendrick et al., 2022)

3. Laboratory Tests:

- Order basic metabolic panel to evaluate electrolytes, kidney and liver function

- Check thyroid stimulating hormone (TSH) to rule out thyroid disorder

- Check vitamin D level, as deficiency can contribute to depressive symptoms (Kendrick et al., 2022)

4 . Follow-Up:

- Schedule follow-up appointment in 4 weeks

- This will allow time to evaluate initial response to sertraline

- Medication adjustments can be made at follow-up if inadequate response

- Encourage lifestyle changes:

- Regular aerobic exercise can help improve mood and energy

- Good sleep hygiene habits to optimize sleep quality

- Engage in pleasant/rewarding activities to increase positive reinforcement

5. Referrals:

- Provide referrals to therapists in the area who specialize in CBT and IPT

- Furnish information on local depression support groups

- This can help decrease LM's sense of isolation

- Connecting with others with similar experiences is therapeutic

plan, including

medications & dosing

& titration

considerations, lab

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective.  Clinical psychology review,  69, 51-66. https://doi.org/10.1016/j.cpr.2018.06.008

Ruberto, V. L., Jha, M. K., & Murrough, J. W. (2020). Pharmacological treatments for patients with treatment-resistant depression.  Pharmaceuticals,  13(6), 116. https://doi.org/10.3390/ph13060116

Kendrick, T., Pilling, S., Mavranezouli, I., Megnin-Viggars, O., Ruane, C., Eadon, H., & Kapur, N. (2022). Management of depression in adults: summary of updated NICE guidance.  bmj,  378. https://doi.org/10.1136/bmj.o1557

work ordered,

referrals to psychiatric

and medical

providers, therapy

recommendations,

holistic options and

complimentary

therapies, and

rationale for your

decisions. Include

when you will want to

see the patient next.

This comprehensive

plan should relate

directly to your

Assessment.

Criteria

Clinical Notes

Subjective

Subjective:

Patient Information: LM, a 32-year-old Caucasian male, presents for evaluation today.

CC: "I've been feeling really down and unmotivated lately."

HPI: LM reports a 6-month history of persistent depressed mood, lack of motivation, and feelings of hopelessness. He describes having decreased energy levels, making it difficult for him to complete daily tasks or engage in activities he once enjoyed. LM also endorses difficulty concentrating, citing issues focusing at work. He has experienced a loss of interest in hobbies and pastimes that previously brought him joy, such as playing basketball with friends. Disturbed sleep is another primary complaint, with LM reporting early morning awakenings around 3-4 AM and an inability to fall back asleep. Despite these symptoms, LM denies any active suicidal ideation or intent, though he admits to sometimes wishing he "didn't wake up." He has not experienced any significant changes in appetite or weight.

Current Medications: LM reports no current medication use.

Allergies: No known drug allergies.

Past Medical History:

- Seasonal allergies

- Otherwise unremarkable

Past Psychiatric History: LM denies any prior psychiatric diagnoses or treatment.

Social History:

- Employment: Works full-time as an accountant

- Living situation: Lives alone in an apartment after a divorce

- Children: None

- Substance use: Occasional social drinker, denies recreational drug use

- Support system: Limited, as most friends have moved away from the area

Family History:

- Mother has a history of depression

- Father struggled with alcohol use disorder

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History,

Social History.

Objective

Objective:

ROS: Comprehensive review of systems is negative except for the depressive symptoms described in the HPI.

Vitals:

- BP 124/82 mmHg

- HR 78 bpm

- RR 16 breaths/min

- Temp 98.6°F

- BMI 26.5 kg/m2 (calculated based on stated height and weight)

MSE:

- Appearance: Appropriately groomed and dressed

- Behavior: Cooperative attitude toward interview, but poor eye contact maintained

- Speech: Spoken softly with slow rate and low tone

- Mood: Depressed mood reported

- Affect: Blunted range and reactivity, congruent with stated depressed mood

- Thought Process: Exhibited slowed, circumstantial thought process

- Thought Content: Preoccupied with feelings of hopelessness and worthlessness. Denies any suicidal or homicidal ideation, intent or plan. No delusional content noted.

- Perception: Denies any current auditory or visual hallucinations

- Cognition: Attention and concentration appear intact based on interview. Insight and judgment fair.

- Other: Psychomotor activity normal with no abnormal movements

Psychiatric Screening Measures:

- PHQ-9 score: 18 (Moderately Severe Depression)

- GAD-7 score: 8 (Mild Anxiety)

Labs/Diagnostics: No labs or diagnostic testing completed at this visit.

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening

measure results.

Assessment

Assessment:

Diagnosis: Major Depressive Disorder, Single Episode, Moderate (F32.1)

LM meets the DSM-5 diagnostic criteria for Major Depressive Disorder, Single Episode, Moderate severity based on the following symptoms:

- Depressed mood most of the day, nearly every day, as indicated by subjective report of persistent low mood and feelings of hopelessness for the past 6 months.

- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, as evidenced by loss of interest in previously enjoyed activities like playing basketball.

- Significant weight loss or gain, or decrease or increase in appetite: No significant weight change reported, appetite appears stable.

- Insomnia or hypersomnia nearly every day: Early morning awakenings reported with inability to fall back asleep.

- Fatigue or loss of energy nearly every day: Decreased energy levels endorsed.

- Feelings of worthlessness or excessive/inappropriate guilt nearly every day: Feelings of hopelessness and worthlessness reported.

- Diminished ability to think, concentrate or indecisiveness nearly every day: Difficulty concentrating reported, including issues focusing at work. (American Psychiatric Association. (2013).

The symptoms cause clinically significant distress and impairment in LM's social and occupational functioning, as he has withdrawn from social activities and has concentration issues impacting his work performance. The episode is not better explained by a substance or medical condition. LM denies any manic or hypomanic episodes.

While LM endorses mild anxiety based on the GAD-7 score, his primary presentation meets criteria for a moderately severe major depressive episode at this time. No other psychiatric comorbidities are evidenced. (LeMoult & Gotlib 2019)

Potential Obstacles to Treatment:

· Limited social support system and loss of his primary marital support after divorce

· Stigma associated with seeking mental health treatment as a male

· Potential intolerance or side effects with antidepressant medications

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes,

treatment options, and patient input regarding treatment options (if possible), including obstacles to

treatment.

Plan

Include a specific

Plan:

1. Pharmacological Intervention:

- Start sertraline 50 mg PO daily for treatment of major depressive disorder

- Sertraline is a selective serotonin reuptake inhibitor (SSRI) and is recommended as a first-line pharmacotherapy for moderate or severe major depressive episodes

- The 50 mg daily dose is a typical starting dose that is well-tolerated

- Titrate sertraline dose up gradually as needed and tolerated, with a maximum dose of 200 mg/day

- Allow 4-6 weeks at a therapeutic dose to fully evaluate patient response

- Dose increases of 50 mg every 1-2 weeks can be considered if insufficient response

- Monitor closely for potential adverse effects such as nausea, insomnia, agitation, sexual dysfunction

- Provide patient education on managing side effects

- If side effects are intolerable, consider cross-taping to a different SSRI (Ruberto et al., 2020)

2 . Psychotherapy:

- Refer for Cognitive Behavioral Therapy (CBT)

- CBT is an evidence-based psychotherapy for depression

- It can help LM identify and change negative thought patterns contributing to low mood

- CBT also provides behavioral strategies to increase activity and improve coping

- Consider adding Interpersonal Therapy (IPT)

- IPT focuses on improving interpersonal relationships and social functioning

- May be beneficial for LM who has limited social support after divorce

- Can help him grieve loss of relationships and build healthier connections (Kendrick et al., 2022)

3. Laboratory Tests:

- Order basic metabolic panel to evaluate electrolytes, kidney and liver function

- Check thyroid stimulating hormone (TSH) to rule out thyroid disorder

- Check vitamin D level, as deficiency can contribute to depressive symptoms (Kendrick et al., 2022)

4 . Follow-Up:

- Schedule follow-up appointment in 4 weeks

- This will allow time to evaluate initial response to sertraline

- Medication adjustments can be made at follow-up if inadequate response

- Encourage lifestyle changes:

- Regular aerobic exercise can help improve mood and energy

- Good sleep hygiene habits to optimize sleep quality

- Engage in pleasant/rewarding activities to increase positive reinforcement

5. Referrals:

- Provide referrals to therapists in the area who specialize in CBT and IPT

- Furnish information on local depression support groups

- This can help decrease LM's sense of isolation

- Connecting with others with similar experiences is therapeutic

plan, including

medications & dosing

& titration

considerations, lab

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective.  Clinical psychology review,  69, 51-66. https://doi.org/10.1016/j.cpr.2018.06.008

Ruberto, V. L., Jha, M. K., & Murrough, J. W. (2020). Pharmacological treatments for patients with treatment-resistant depression.  Pharmaceuticals,  13(6), 116. https://doi.org/10.3390/ph13060116

Kendrick, T., Pilling, S., Mavranezouli, I., Megnin-Viggars, O., Ruane, C., Eadon, H., & Kapur, N. (2022). Management of depression in adults: summary of updated NICE guidance.  bmj,  378. https://doi.org/10.1136/bmj.o1557

work ordered,

referrals to psychiatric

and medical

providers, therapy

recommendations,

holistic options and

complimentary

therapies, and

rationale for your

decisions. Include

when you will want to

see the patient next.

This comprehensive

plan should relate

directly to your

Assessment.