SOAP Notes for Major Depressive Disorder: Template + Examples (2026)
Overview
This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
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Short answer: a SOAP note for major depressive disorder (MDD) has four parts. Subjective: the client’s report of mood, interest, sleep, appetite, energy, concentration and thoughts of death since the last session, in their words where it helps. Objective: what you observed (appearance, psychomotor activity, speech, affect, thought content), scores such as the PHQ-9, and the interventions you used. Assessment: your judgment about severity and change, what keeps the depression going, and current suicide risk. Plan: the next session, between-session tasks, care coordination and when you will repeat measures.
MDD requires at least five of nine DSM-5-TR symptoms for at least two weeks, one of them depressed mood or loss of interest or pleasure, with distress or impairment. Notes that name the symptoms still present, the score trend and the effect on work, relationships and self-care show why treatment continues.
What to document in a SOAP note for major depressive disorder
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Mood, interest, sleep, appetite, energy and thoughts of death since the last session; recent events and their effect on mood | “Sleeping about 6 hours (4 to 5 at intake); had coffee with a former coworker, first social contact in a month.” |
| Objective | Appearance, psychomotor activity, speech, affect, thought content, PHQ-9 total and item 9, and the interventions used | “PHQ-9 13 today, 19 at intake; item 9 scored 0. Speech slightly slowed; affect constricted, brighter when describing the coffee.” |
| Assessment | Severity and change, factors maintaining symptoms, and your suicide risk formulation | “Moderate range, improving but not yet a response; avoidance of friends maintains isolation; acute risk low.” |
| Plan | Next session focus, tasks, care coordination and repeat measures | “Tell one friend about the layoff before next session; PHQ-9 each session; update the prescriber with consent.” |
Safety. Depression is a major risk factor for suicide, so ask directly every session and record the answer, not only the PHQ-9. A positive item 9 needs a same-day follow-up assessment. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. If depression comes with psychotic symptoms, mania or an inability to care for oneself, consider a higher level of care. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document SOAP Notes for Major Depressive Disorder
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for major depressive disorder, record the client's self-reported emotional state, specific depressive symptoms, and any contextual factors influencing their mood. This section captures the client's perspective on their mental health and any recent changes or triggers.
- Report of current mood and affect, including feelings of sadness, hopelessness, or irritability
- Description of changes in sleep patterns, appetite, and energy levels as experienced by the client
- Identification of any recent stressors or life events perceived as triggers for depressive symptoms
- Client’s report of cognitive symptoms such as difficulty concentrating, indecisiveness, or feelings of worthlessness
- Self-reported presence and frequency of suicidal thoughts or self-harm ideation
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
The Objective section for major depressive disorder should include observable clinical findings, mental status examination results, and descriptions of therapeutic interventions used during the session.
- Clinician’s observation of client’s affect, including flatness, constriction, or variability
- Documentation of psychomotor activity such as agitation, retardation, or restlessness noted during the session
- Results of mental status exam components: appearance, speech, thought process, and orientation
- Use and client response to specific therapeutic techniques applied, such as cognitive restructuring or behavioral activation
- Assessment of client’s engagement and cooperation during the session
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
In the Assessment section for major depressive disorder, synthesize clinical impressions based on subjective reports and objective findings, evaluate treatment progress, and consider diagnostic clarification or comorbidities.
- Clinical impression of current depressive severity and symptom trajectory since last session
- Evaluation of treatment response to prior interventions and medication adherence if applicable
- Consideration of differential diagnoses or comorbid conditions impacting depressive symptoms
- Assessment of client’s insight into their condition and motivation for treatment
- Summary of risk factors and protective factors related to suicidal ideation or self-harm
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section for major depressive disorder outlines the next therapeutic steps, including treatment adjustments, assignments for the client, and coordination of care to support symptom improvement.
- Establishment of specific therapy goals for the upcoming sessions based on current assessment
- Assignment of homework such as mood tracking, behavioral activation tasks, or journaling exercises
- Adjustment or initiation of pharmacological treatment recommendations in collaboration with prescribing providers
- Referral to additional services if needed, such as psychiatry, support groups, or crisis intervention
- Scheduling of follow-up appointments and contingency planning for crisis situations
DAP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
BIRP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
Progress Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
SIRP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
GIRP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
PIE Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
Example SOAP note for major depressive disorder (interpersonal psychotherapy)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 61, major depressive disorder, recurrent, moderate (F33.1), current episode began after he was laid off from a job he held for 30 years. Session 6 of a planned 16-session course of weekly interpersonal psychotherapy (IPT), 50 minutes; problem area: role transition. Sertraline is prescribed and managed by his primary care provider. Treatment-plan goal: rebuild a weekly routine with at least two social contacts.
Subjective: Client reports mood “flat but not as heavy,” sleeping about 6 hours a night (4 to 5 at intake) and eating regular meals again. Applied for 2 jobs. Had coffee with a former coworker, his first social contact outside the family in a month, and said he “felt like myself for an hour.” Still avoids friends at church because he has not told them about the layoff. Taking sertraline as prescribed; no side effects reported. Asked directly: denies thoughts of death or suicide, intent or plan, now and since the last session; no past attempts; no firearms in the home. Alcohol: 1 or 2 beers on weekends, unchanged.
Objective: PHQ-9: 13 (intake 19); item 9 scored 0. Casually dressed, well groomed. Speech slightly slowed; affect constricted, brightened when describing the coffee; thought process linear; thought content focused on lost work identity; no psychotic symptoms; alert and oriented. Interventions: linked this week’s mood change to the coffee contact, as IPT links mood to interpersonal events; explored what he lost and what he valued in his old role; identified possible parts of a new role (mentoring, part-time work); role-played telling a church friend about the layoff, and he chose the words he would use.
Assessment: MDD, recurrent, moderate, improving: PHQ-9 down 6 points (32%) since intake, from the moderately severe to the moderate range, short of the 50% drop often used to define response. Mood improved in the week he had more social contact, which supports the role-transition focus. Shame about the layoff and avoidance of his church friends maintain isolation. Suicide risk formulation: risk factors include recurrent depression, recent job loss, male sex and age; protective factors include his wife and adult daughter, engagement in treatment, no past attempts, no firearm access, and future plans (job applications). Acute risk judged low. Reassess every session and the same day if item 9 is above 0.
Plan: Continue weekly IPT, middle phase. Task chosen by client: tell one church friend about the layoff before the next session. Continue job applications. With his written consent, send the PHQ-9 trend to his primary care provider, who manages sertraline. Repeat PHQ-9 next session; begin planning for the final phase around session 13. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger.
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Tips for SOAP Notes for Major Depressive Disorder
Name the symptoms still present
List which depressive symptoms remain and how often, not only “depressed.” It shows the diagnosis and why treatment continues.
Write the PHQ-9 and item 9
Record the total next to the earlier score and record item 9 separately. A positive item 9 needs a follow-up assessment the same day.
Link mood to events
Note what happened in the week and how mood changed with it. This is the core of IPT and useful in any treatment.
Leave medication to the prescriber
Record what the client reports about medication and side effects, and that you shared it with consent. Do not recommend dose changes in a therapy note.
Show functional impact
Record effects on work, relationships, sleep and self-care, and how they change, so progress is not judged from the score alone.
Record risk every session
Ask directly about suicide and access to means, and write your risk formulation in Assessment, even when the answer is no.
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Further Reading
- DSM-5-TR — Provides diagnostic criteria and classification for Major Depressive Disorder essential for accurate clinical documentation.
- APA Documentation Guidelines — Offers best practices for clinical documentation including SOAP note formatting relevant to mental health disorders.
- NIMH (National Institute of Mental Health) — Contains authoritative information on Major Depressive Disorder to support evidence-based assessment and treatment planning.