NUR 676 Module 6 SOAP Note Example

SOAP Note: Depression With Inadequate Response After Two Antidepressant Trials

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Six SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Depression With Inadequate Response After Two Antidepressant Trials

Many patients with depression do not reach remission with their first antidepressant, and some do not with a second. When improvement stalls, the temptation is to keep adjusting doses without a clear plan or to refer the patient and wait. A better approach is to reassess systematically, confirm that the treatment was adequate, look for missed diagnoses and contributing conditions and then choose the next step with evidence while measuring response closely. Diane is a 45-year-old seen at a composite community clinic whose depression has improved only partly after two medications. This SOAP note documents the reassessment and next steps. It argues that inadequate response calls for structured reassessment, measurement-based adjustments and added treatment modalities, supported by collaborative care.

Subjective

Diane reports that she feels somewhat better than when she started treatment five months ago; she is back at work and sleeping through most nights. But she still feels flat, has little interest in her usual activities, is tired by mid-afternoon and has trouble concentrating. She took sertraline, increased to 150 mg, for ten weeks, with partial improvement and bothersome sexual side effects, then switched to escitalopram, increased to 20 mg, which she has now taken for eight weeks. She says she has missed no more than one dose a week, and pharmacy refill records confirm regular fills. She has not started therapy because of cost and scheduling.

She denies any periods of elevated mood or decreased need for sleep with increased energy, and denies suicidal thoughts when asked directly. She drinks alcohol once or twice a month and uses no drugs. Her partner has noticed that she snores and sometimes gasps at night. Stressors include caring for her mother, who has dementia.

Objective

Blood pressure 132/84, body mass index 33, neck circumference 41 cm. Affect restricted, speech normal, no psychotic features. PHQ-9 score 13, down from 19 at baseline and 14 four weeks ago, with no endorsement of the self-harm item. The Mood Disorder Questionnaire remains negative. AUDIT-C score 1. STOP-Bang questionnaire score 4, suggesting elevated risk of obstructive sleep apnea. Laboratory tests: thyroid-stimulating hormone normal, vitamin B12 normal, complete blood count normal.

Assessment

1. Major depressive disorder, moderate, with partial response after two adequate antidepressant trials. Both trials used adequate doses for at least eight weeks, and adherence is confirmed. Her PHQ-9 has fallen by about a third, short of the 50% reduction that defines response and well above the remission threshold of 5.

2. Possible obstructive sleep apnea; untreated, it saps energy, blurs focus and drags mood down, and it may be part of why her depression has not fully cleared.

3. Caregiver stress, a contributing factor.

Rush et al. (2006) reported results from the STAR*D trial, in which outpatients with depression who did not remit on citalopram could move through up to three further treatment steps involving switches and augmentation. Remission rates were highest at the first step and lower at each subsequent step, but about two thirds of patients who stayed in the study eventually remitted, though relapse was more common among those who took several steps to get there. For Diane, this means that further treatment has a real chance of success, that expectations should be realistic and that remission, not partial improvement, remains the goal.

Choosing the Next Step

Options after two failed SSRIs include switching to a medication from a different class, such as venlafaxine, bupropion or mirtazapine, augmenting the current medication with bupropion or an atypical antipsychotic, adding psychotherapy and treating contributing conditions. Because escitalopram has produced partial benefit and she tolerates it, augmentation was preferred over switching, which would risk losing the gains she has made. Bupropion was chosen as the augmenting agent because it does not cause sexual side effects, which troubled her with sertraline, and may help fatigue and concentration. Atypical antipsychotic augmentation was set aside for now because of metabolic risks, given her weight. The clinic's consulting psychiatrist reviewed the plan through the collaborative care program and agreed.

Psychotherapy was also addressed. Cost and time had been barriers, so the behavioral health clinician offered short-term cognitive behavioral therapy by video at no charge through the clinic's grant-funded program.

Plan

Continue escitalopram 20 mg daily. Add bupropion extended release 150 mg each morning, with the plan to increase to 300 mg after two weeks if tolerated; she was told about possible insomnia, anxiety and a small risk of seizures and screened for seizure history and eating disorders, both negative. Begin cognitive behavioral therapy weekly for twelve weeks. Referral for a home sleep apnea test. Caregiver support resources, including a local respite program, were provided.

Measurement will guide adjustments. Guo et al. (2015) randomized outpatients with major depression to measurement-based care, in which medication doses were adjusted according to rating scale scores and side effects at set intervals, or to standard care based on clinical judgment, and found that measurement-based care led to higher response and remission rates and faster improvement. Diane's PHQ-9 will be repeated every two weeks by the care manager and reviewed at a visit every four weeks, with the psychiatrist reviewing her progress in weekly caseload meetings. If her PHQ-9 has not fallen below 10 after eight weeks at the full bupropion dose, the next step will be discussed with the psychiatrist.

Why Collaborative Care Matters Here

Diane's care is delivered through the clinic's collaborative care program, which reflects the model tested in the IMPACT trial, in which a care manager supported the primary care clinician, tracked depression scores and reviewed patients who were not improving with a consulting psychiatrist (Unützer et al., 2002). In that trial, older adults receiving collaborative care were far more likely to achieve a substantial improvement in depression than those in usual care. For a patient with inadequate response, the model's value is that someone is watching the numbers between visits and that specialist advice is available without a long wait for a psychiatry appointment. The care manager will also check in about caregiver stress and help Diane connect with respite services for her mother, since relief from that burden may matter as much as any medication change.

Conclusion

Diane's depression improved but did not remit after two adequate SSRI trials. Structured reassessment confirmed adequacy and adherence, ruled out bipolar disorder and substance use and uncovered possible sleep apnea. STAR*D supports continued efforts toward remission, measurement-based care supports scheduled PHQ-9 tracking and augmentation with bupropion, psychotherapy and treatment of contributing conditions, overseen through collaborative care, give her the best chance of full recovery.

References

Guo, T., Xiang, Y.-T., Xiao, L., Hu, C.-Q., Chiu, H. F. K., Ungvari, G. S., Correll, C. U., Lai, K. Y. C., Feng, L., Geng, Y., Feng, Y., & Wang, G. (2015). Measurement-based care versus standard care for major depression: A randomized controlled trial with blind raters. American Journal of Psychiatry, 172(10), 1004-1013. https://doi.org/10.1176/appi.ajp.2015.14050652

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836