Creating a Depression Treatment Plan for Your Clients in Therapy

Depression affects people of all races, ages, ethnicities, and genders. Although women are diagnosed with depression more often, men may be less comfortable discussing their mental health concerns. The root causes of depression vary from person to person, but several risk factors are known to contribute, including genetic, biological, environmental, and psychological factors. For example, having a family history of depression or experiencing major life events such as trauma, stress, and loss can increase the risk.

Individuals with major depressive disorder may experience some or many of the following symptoms:

  • Feeling sad or emotionally “empty”
  • Feeling hopeless or pessimistic
  • Experiencing irritability, frustration, and restlessness
  • Feeling guilt, worthlessness, or helplessness
  • Losing interest in hobbies and previously enjoyed activities
  • Having poor concentration and difficulty making decisions
  • Experiencing sleep disturbances
  • Noticing appetite changes and unintended weight gain or loss
  • Having physical pains and aches or digestive problems
  • Experiencing thoughts of death, suicide, or attempting suicide

The intensity of depression can vary, directly influencing the required treatment. Those with severe symptoms, such as active suicidal ideation and an inability to cope with daily life, often need inpatient psychiatric care. These programs help individuals address the root causes of their depression and learn to manage their symptoms effectively. Outpatient treatment programs offer more flexibility, providing individual therapy, group therapy, medication management, or a combination of these interventions.

Antidepressants are often used alongside behavioral therapies. These medications can be effective by altering how the brain processes or produces neurotransmitters, which play a crucial role in mood and stress regulation. Finding the right medication regimen can be a trial-and-error process, as there is no one-size-fits-all solution. It takes time for the effects of antidepressants to become noticeable and even longer for individuals to adjust to dosage changes.

Several therapeutic approaches are used to treat depression, including cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Individual and group therapy sessions can be beneficial, as well as family counseling.

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Setting Goals and Objectives With Clients in Your Depression Treatment Plan

When you are ready to develop a treatment plan for depression, you have likely already completed an evaluation or assessment. In a clinical setting, this part of the process may be carried out by other members of a multidisciplinary team. During an intake assessment, you aim to gather detailed information about the client’s depressive symptoms and their severity, level of functioning, mental health history, physical health concerns, and the reasons they sought help.

You will likely use screeners, questionnaires, or other measures during your assessment, such as:

  • Patient Health Questionnaire-9 (PHQ-9)
  • Beck Depression Inventory (BDI)
  • Hamilton Depression Rating Scale (HDRS or HAM-D)
  • Center of Epidemiologic Studies Depression Scale (CES-D)
  • Montgomery-Asberg Depression Rating Scale (MADRS)

Depending on your client’s current symptoms and concerns, it may be helpful to use the Mental Health Risk Assessment, available through TherapyPatron for professionals.

What to Include in a Treatment Plan for Depression + Example

During the remainder of this article, we will be walking through the different components of a sample treatment plan for depression that aligns with the customizable treatment plan available on TherapyPatron’s website. While you are working on developing treatment plans for your client, we encourage you to consider the use of various worksheets that can be incorporated into your sessions, such as:

John’s story:

John is a 45-year-old male with a history of major depressive disorder (MDD). He has been experiencing worsening symptoms over the past six months. John is married with two children and works as an accountant. He has no significant medical history but has struggled with depression intermittently since his early 30s. He denied working with any medical or mental health professionals before his current admission.

John’s wife brought him to the emergency department after he expressed suicidal thoughts and refused to go to work for the past two weeks. John reports persistent feelings of hopelessness, overwhelming sadness, and severe fatigue. He has lost interest in activities he once enjoyed, such as playing with his children and watching sports. John has also experienced significant weight loss due to decreased appetite and struggles with insomnia, often lying awake for hours at night. John explained that he has been having a hard time controlling his thoughts, and that he spends a lot of time worrying.

During the initial evaluation, John presented with a flat affect, minimal eye contact, and slow speech. He reports feeling worthless and guilty, particularly about being a burden to his family. John acknowledges having recurrent thoughts of death and has contemplated various methods of suicide, although he has made no attempts. He describes his concentration as poor, impacting his job performance significantly. John was admitted into the inpatient psychiatric program for treatment.

Agencies Involved and Plans for Care Coordination

Based on the information provided, John does not appear to be working with other agencies at this time. His wife brought him into an ER for an evaluation, and he was then admitted for inpatient psychiatric care. He may be referred to local agencies at his time of discharge, but at this time it is not necessary.

Example for John:

Care Coordination: None at this time

Clinical Diagnoses

John’s clinical presentation includes persistent depressive symptoms including an overwhelming sense of sadness, loss of interest in activities, significant weight loss, insomnia, fatigue, feelings of worthlessness and guilt, poor concentration, and suicidal ideation. These symptoms align with the criteria for Major Depressive Disorder, Recurrent, Severe with Suicidal Ideation. His insomnia and anxiety are secondary symptoms that are often associated with his primary diagnosis of major depressive disorder.

Example for John:

Clinical Diagnosis: Major Depressive Disorder, Recurrent, Severe with Suicidal Ideation

  • (F33.2)
  • Generalized Anxiety Disorder (F41.1)
  • Insomnia Related to Major Depressive Disorder (F51.01)

Current Medications and Responses

During John’s intake assessment, a medical professional would determine medications that could be used to support him in his mental health journey. Based on his symptoms, he may benefit from the use of an antidepressant, and medication to help with his insomnia. His medical provider would continue monitoring and adjusting his dose as needed.

Example for John:

Medications:

  • Zoloft, 50 mg daily
  • Trazodone, 50-100 mg at bedtime

Presenting Problem and Related Symptoms

This section of your treatment plan should provide enough detail to inform other healthcare providers of the case when they read it. This can be important in a treatment setting that uses a multidisciplinary team, including an inpatient psychiatric program. This case conceptualization should accurately describe your client’s symptoms, level of functioning, and goals for treatment.

Example for John:

John Doe, a 45-year-old married man with two children, presented with severe depressive symptoms and active suicidal ideation. He reported persistent sadness, hopelessness, and worthlessness over the past six months, which worsened recently due to job loss and financial stress. John has a history of recurrent depressive episodes, treated with various antidepressants with partial success. His symptoms now include severe insomnia, anxiety, frequent crying spells, and withdrawal from family and friends.

A mental status examination revealed John as disheveled, agitated, and tearful, with a depressed mood and restricted affect. He expressed suicidal ideation with a plan, and exhibited impaired judgment and limited insight into his illness. The primary diagnosis is Major Depressive Disorder, Recurrent, Severe with Suicidal Ideation (F33.2), with secondary diagnoses of Generalized Anxiety Disorder (F41.1) and Insomnia Disorder (F51.01).

The treatment plan includes immediate inpatient psychiatric care for safety and stabilization, pharmacotherapy and Cognitive Behavioral Therapy (CBT). A comprehensive safety plan, family involvement in treatment, and detailed discharge planning for outpatient follow-up are also essential components. With intensive treatment, there is potential for significant improvement, though long-term management and regular monitoring are crucial to prevent relapse.

Goals and Objectives

Your goals and objectives should be specific to your client’s symptoms and level of functioning. It is also important to be mindful of their access to resources and motivation to change. Goals should be attainable and realistic based on their current situations, strengths, and attributes. Treatment plan goals should also incorporate evidence-based treatments and interventions.

Example for John:

Goal 1: Alleviate Depressive Symptoms

Objective 1: John will engage in Cognitive Behavioral Therapy (CBT) to challenge and change negative thought patterns.

Objective 2: John will improve his sleep hygiene routine

Objective 3: John will reduce feelings of hopelessness and increase motivation.

Goal 2: Improve Anxiety and Stress Management

Objective 1: John will learn and implement effective coping strategies for managing anxiety.

Objective 2: John will decrease overall stress levels by adopting healthy lifestyle habits.

Objective 3: John will enhance his social support network to mitigate feelings of isolation.

Goal 3: Ensure Long-term Stability and Prevent Relapse

Objective 1: John will adhere to his medication regimen and monitor for side effects.

Objective 2: John will develop a comprehensive relapse prevention plan.

Objective 3: John will create a balanced lifestyle that supports mental health maintenance.

Specific Interventions to Be Used

You may use this section of your treatment plan to list out the specific treatment interventions that you plan to use, which can be used as a reference at a later time. Your interventions should align with your treatment plan goals and objectives as it is written today. You may have ideas of what you would like to do in the future with your client, but it is important to be mindful of where they are today in their mental health journey. Interventions can also align with evidence-based practices, ensuring that you’re using treatment approaches that are known to be effective.

Example for John:

Intervention/Action: Learn about and implement cognitive restructuring strategies to address negative thought patterns and beliefs.

Responsible Person: Counselor A and John

Intervention/Action: Implement mindfulness meditations into daily routine to help with anxiety symptoms.

Responsible Person: John

Intervention/Action: Create a worry log to keep track of thoughts that provoke psychological distress, bringing it to each session for review.

Responsible Person: John

Intervention/Action: Practice regular deep breathing and progressive muscle relaxation techniques daily

Responsible Person: John

Intervention/Action: Develop a detailed safety plan to address safety concerns

Responsible Person: Counselor A and John

Family Involvement

In this example, it sounds as though it would be appropriate to have family counseling sessions with his wife. She may benefit from psychoeducation focusing on learning about depression, coping strategies, and ways in which she can support John. Once he has reached a place where his symptoms are stabilized, couples counseling may be appropriate to help strengthen their relationship, and improve communication.

Example for John:

Family counseling with his wife, focusing on psychoeducation about depression

Additional Services and Interventions

While John is active in an inpatient program, he will receive comprehensive care which will likely include group therapy, individual therapy, and other holistic treatment approaches. While John is active in an inpatient treatment program, there is no need for additional services and interventions, as he is already receiving whole-person care.

Example for John:

Additional treatment services: None at this time

Estimation for Completion

The length of John’s treatment will be dependent on several factors, including his symptoms and progress made. This means that his completion date can be modified as needed. His insurance coverage may also play a role in the duration of his programming.

Example for John:

Estimated time of completion 8 weeks, to be modified as needed based on individual needs

Aftercare Plans

Aftercare plans for John should be written as if he were to discharge today. There are occasions where clients discharge unexpectedly, which is why it’s important to be prepared with resources they can access at home. This portion of your treatment plan should be adjusted accordingly as he progresses in treatment, as the clinical recommendations will differ at different stages of treatment.

Example for John:

Follow up with primary care physician and a local mental health professional for 1:1 treatment. Group therapy sessions are also recommended

Final Thoughts On Creating a Depression Treatment Plan

Working with clients experiencing depression and related disorders often requires comprehensive care from a multidisciplinary team, especially in cases like John’s where inpatient treatment is necessary. This team can include medical professionals for medication management, social workers, nurses, and clinicians who collaborate to provide well-rounded care.

Depression can significantly impact a client’s functioning and overall quality of life. As mental health professionals, we can help clients find hope by drawing on their strengths and attributes. By providing a safe and welcoming environment, we can use evidence-based approaches to address their symptoms and concerns, supporting them in achieving optimal mental health and wellness.

TherapyPatron.com helps mental health professionals better serve their clients. Our (editable, fillable, printable PDF) therapy worksheets can help you streamline your practice, effectively deliver different types of therapy, and support your clients be the best version of themselves.

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    Depression Worksheets Bundle (Editable, Fillable, Printable PDFs)

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Find worksheets for your clients dealing with depression

Resources:

  • “Depression.” National Institute of Mental Health. Accessed June 27, 2024. https://www.nimh.nih.gov/health/topics/depression. 
Kayla VanGuilder, MA, LCMHC
Author: Kayla VanGuilder, MA, LCMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.

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