NURS 6630 Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
Walden University Assignment: Assessing and Treating Pediatric Patients With Mood Disorders-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University Assignment: Assessing and Treating Pediatric Patients With Mood Disorders assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
Whether one passes or fails an academic assignment such as the Walden University Assignment: Assessing and Treating Pediatric Patients With Mood Disorders depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
The introduction for the Walden University Assignment: Assessing and Treating Pediatric Patients With Mood Disorders is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
After the introduction, move into the main part of the Assignment: Assessing and Treating Pediatric Patients With Mood Disorders assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
The incidence of major depressive disorder (MDD), including pediatric depression, is increasing dramatically in the United States. This trend is associated with genetic factor, which significantly increases the risk of depression in various age brackets, including children (Shadrina et al., 2020). Therefore, the risk of becoming depressed is 4 times higher among children of depressed parents compared to healthy parents. Hence, mental health providers should focus on diagnosing MDD in children and developing the most appropriate pharmacological treatment to meet the healthcare needs of an individual patient. In the provided case study, the client is an African American 8yo male whose mother accompanies him to ER. He is portraying depressive symptoms. The client reports feeling “sad.” His mother reveals that the teacher’s report indicated withdrawing from his peers in class. The mother added that she had noticed decreased appetite and becoming irritated occasionally. The client was referred to a psychiatrist for further evaluation. Upon conducting a mental status exam, the Psychiatric Nurse Practitioner reported that the client is alert and oriented X 3. His speech is clear. He is coherent, spontaneous, and goal-directed. His self-reported mood is “sad” with a blunt affect. However, the client smiled appropriately during the clinical interview. He denies auditory or hallucinations. Additionally, the psychiatric nurse practitioner does not notice paranoid or delusional thought processes. The client appears to be age-appropriate with clear judgment and insight. He denies suicidal ideation or thoughts. Nonetheless, the client reports thinking about himself being dead and the feeling of being dead. Upon administering the Children’s Depression Rating Scale, the client’s score was 30, portraying significant depression. This paper presents three pharmacological interventions for managing and treating a client’s depressive symptoms, considering the patient’s pharmacokinetics and pharmacodynamics processes.
Decision Point 1
The first treatment intervention involves beginning Zoloft 25 mg orally daily. The FDA recommends selective
serotonin reuptake inhibitors (SSRIs) as the first antidepressant for treating depression in children and adults. Furthermore, Tini et al. (2022) reported that selective serotonin reuptake inhibitors (SSRIs) effectively treat several psychiatric symptoms, including obsessive-compulsive disorder (OCD) and depression, in children aged 6 to 12 years. Zoloft 25 mg orally daily was selected since it’s an SSRI; hence effective in managing presented depressive symptoms in the 8yo African-American male. Therefore, beginning Zoloft 25 mg orally daily is the best treatment option for this client.
Other potential options, including beginning Paxil 10 mg orally daily and beginning Wellbutrin 75 mg orally BID, were rejected. Beginning Paxil 10 mg orally daily was dismissed since it is not recommended for treating depression in children and adults. Instead, Paxil is recommended as the first-line treatment for anxiety in pediatrics and adults (Strawn et al., 2018). Additionally, Wellbutrin was rejected due to severe side effects, including the risk of anorexia, seizure, dry mouth, headache, and insomnia (Lee et al., 2021). Hence, beginning the client’s treatment with Wellbutrin 75 mg orally BID would increase the risk of these drug-related side effects.
Beginning Zoloft 25 mg orally daily was expected to improve the client’s depressive symptoms. According to Tini et al. (2022), Zoloft 25 mg orally daily is an SSRI, effective in treating depressive symptoms in children and adolescents. Nonetheless, the client did not report a change in the initial symptoms upon returning to the clinic after 4 weeks.
In developing this treatment, the PMHNP adhered to the ethical consideration of beneficence that holds that mental health providers should focus on benefiting their clients through the administered treatment. Hence, the PMHNP started the client’s treatment with Zoloft 25 mg orally since it would improve his depressive symptoms.
Decision Point 2
The second decision is Sertraline 50 mg by mouth daily. This treatment option was selected following the ineffectiveness of Zoloft 25 mg orally in improving the client’s symptoms. The client did not report a change in the initial symptoms after taking Zoloft 25 mg orally for 4 weeks. According to Tini et al. (2022), Sertraline’s dosage for treating depression in children can be titrated upwards to 250 mg to enhance its effectiveness. Hence, increasing the client’s dosage to 50 mg by mouth daily would strengthen the effectiveness of Sertraline in improving initial depression symptoms.
Other alternatives include Prozac 10 mg by mouth daily and Sertraline 37.5 mg by mouth daily. Prozac 10 mg by mouth daily was rejected due to its inefficacy in treating significant depressive symptoms in children. Zhou et al. (2022) reported that Prozac 10 mg is effective for treating acute depressive symptoms in children. Hence, this option is inappropriate for this client since he was diagnosed with significant depression. Additionally, Sertraline 37.5 mg by mouth daily was rejected since the client did not report improvement in depressive symptoms after taking Zoloft 25 mg orally for four weeks. Similarly, Sertraline 37.5 mg by mouth daily would not result in the desired improvement in depressive symptoms.
Sertraline of 50% mg by mouth daily was expected to reduce the client’s depressive symptoms by 50%. According to Tini et al. (2022), the effectiveness of Sertraline in treating depression in children increase with dosage. The client reported a 50% decrease in initial symptoms upon returning to the clinic after 4 weeks.
While developing this treatment plan, the PMNHP adhered to the ethical principles of beneficence. The most beneficial option, Sertraline 50 mg by mouth daily, was prescribed to the patients. The PMHNP dismissed other options, including Prozac 10 mg by mouth daily and Sertraline 37.5 mg daily, due to their inefficacy in treating the client’s depressive symptoms.
Decision Point 3
The third treatment option involves maintaining the current dose, Sertraline 50 mg by mouth daily. The decision to maintain the current dose was preferred due to its effectiveness in improving the client’s depressive symptoms. The client reported a 50% decline in depressive symptoms after taking Sertraline 50 mg for four weeks. Therefore, continuing this dosage for the next four weeks would result in total remittance of the reported depressive symptoms. Furthermore, studies indicate that the current antidepressant dosage should be maintained if a positive response to a medication with minimum or zero side effects are reported (Dell’Osso et al., 2020). Therefore, maintaining the current dosage is the best treatment option for this client.
Other options, including changing to SNRI and increasing to Sertraline 75 mg by mouth daily, were dismissed. Changing to SNR was rejected since the client was responding well to Sertraline 50 mg by mouth daily, which is an SSRI. Thus, a new drug class with no history of improving the client’s depressive symptoms should not be introduced at this stage of the treatment process. Additionally, increasing to Sertraline 75 mg by mouth daily was rejected. During week eight clinic visits, the client reported a 50% reduction in symptoms with no drug-related side effects. These results indicated that the client responded positively to the current dosage; hence an alternative dosage is unnecessary. Additionally, the risk of side effects and adverse drug events in SSRIs increases with dosage (Edinoff et al., 2021). Hence, increasing the current dosage to Sertraline 75 mg raises the risk of adverse reactions and drug-related side effects.
Maintaining the current dose, Sertraline 50 mg by mouth daily, would result in total remittance of presented depressive symptoms. The client reported a 50% decline in depressive symptoms after taking Sertraline 50 mg for four weeks. Additionally, Tini et al. (2022) said that the effectiveness of Sertraline in treating depression in children increases with dosage. Hence, maintaining the current dosage would further improve depressive symptoms.
In developing this treatment plan, the PMHNP adhered to the ethical principle of parent autonomy. This ethical guideline gives the parents the right to consent during the treatment of individuals with no consenting capacity, including individuals below 18 years (Bieber et al., 2020). In this case, the mother was involved in making all significant decisions since the client is a minor with no capacity to consent.
Conclusion
The paper has presented three pharmacological decisions for treating depressive symptoms in an 8yo African- American male. The first treatment intervention involves beginning Zoloft 25 mg orally daily. This medication was preferred since it’s a selective serotonin reuptake inhibitor (SSRIs), effective in treating depression in children. On the contrary, beginning Paxil 10 mg orally daily and beginning Wellbutrin 75 mg orally BID were rejected. Beginning Paxil 10 mg orally daily was dismissed since it is not recommended for treating depression in children and adults. Additionally, Wellbutrin was rejected due to severe side effects, including the risk of anorexia, seizure, dry mouth, headache, and insomnia. After taking this medication for four weeks, the client did not report improvement in the initial symptoms. The second decision is Sertraline 50 mg by mouth daily, which was selected following the ineffectiveness of Zoloft 25 mg orally in improving the client’s symptoms, implying that a higher dosage was needed. Other alternatives, including Prozac 10 mg by mouth daily and Sertraline 37.5 mg by mouth daily, were rejected. Prozac 10 mg by mouth daily was rejected due to its inefficacy in treating significant depressive symptoms in children. Additionally, Sertraline 37.5 mg by mouth daily was rejected since the client did not report improvement in depressive symptoms after taking Zoloft 25 mg orally for four weeks, implying that 37.5 mg would not result in the desired improvement in depressive symptoms. The client reported a 50% decrease in initial symptoms upon returning to the clinic after 4 weeks. The third treatment option involves maintaining the current dose, Sertraline 50 mg by mouth daily. This decision was preferred due to its effectiveness in improving the client’s depressive symptoms, implying that continuing with this dosage for the next four weeks would result in total remittance of the reported depressive symptoms. Other options, including changing to SNRI and increasing to Sertraline 75 mg by mouth daily, were dismissed since the client was responding well to Sertraline 50 mg by mouth daily, hence no need for an alternative dosage or drug class.
References
Bieber, E. D., Edelsohn, G. A., McGee, M. E., Shekunov, J., Romanowicz, M., Vande Voort, J. L., & McKean, A. J. (2020). The Role of Parental Capacity for Medical Decision-Making in Medical Ethics and the Care of Psychiatrically Ill Youth: Case Report. Frontiers in Psychiatry, 1094. https://doi.org/10.3389/fpsyt.2020.559263
Dell’Osso, B., Albert, U., Carrà, G., Pompili, M., Nanni, M. G., Pasquini, M., … & Fiorillo, A. (2020). How to improve adherence to antidepressant treatments in patients with major depression: a psychoeducational consensus checklist. Annals of General Psychiatry, 19(1), 1-8. https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-020-00306-2
Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., … & Kaye, A. M. (2021). Selective serotonin reuptake inhibitors and adverse effects: a narrative review. Neurology International, 13(3), 387-401. https://doi.org/10.3390/neurolint13030038
Lee, W. K., Au Yeung, K. L., Lam, H. B., Wong, C. K., Wong, T. C., Fu, C. K., … & Ki‐Yan Mak, D. (2021). Consensus statements on the clinical understanding and use of bupropion in Hong Kong. CNS Neuroscience & Therapeutics, 27, 20-24. https://doi.org/10.1111/cns.13376
Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics factors in major depression disease. Frontiers in psychiatry, 9, 334. Doi: 10.3389/fpsyt.2018.00334.
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070. Doi: 10.1080/14656566.2018.1491966
Tini, E., Smigielski, L., Romanos, M., Wewetzer, C., Karwautz, A., Reitzle, K., … & Walitza, S. (2022). Therapeutic drug monitoring of Sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Comprehensive Psychiatry, 115, 152301. https://doi.org/10.1016/j.comppsych.2022.152301
Zhou, X., Teng, T., Zhang, Y., Del Giovane, C., Furukawa, T. A., Weisz, J. R., … & Xie, P. (2020). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. The Lancet Psychiatry, 7(7), 581-601. DOI:https://doi.org/10.1016/S2215-0366 (20)30137-
Sample Answer 2 for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
According to theNational Institute of Mental Health,approximately 9% of teenagers from the age of 12 to 17 years have depression disorder in the United States.Ghandour et al., (2019) reported that about 3.2% of African American adolescents presented with suicidal thoughtsin 2018as 1.4%tried to commit. Despite the burden associated with this mental disorder, several treatment options are available to help manage the symptoms and promote the quality of life of children and adolescents with this disorder.
The assigned case study demonstrates an African American boy child diagnosed with depression. The patient reports symptoms such as irritability, feeling sad, decreased appetite, and withdrawalfrom social gatherings like school. The conducted mental status examination revealed that the patient is suicidal, but has never tried to kill himself. The patient however denies hallucinations and delirium among other psychotic symptoms. Based on clinical practice guidelines and DSM-5 diagnostic criteria,together with a score of 30 on theChildren’s Depression Rating Scale,the patient’s primary diagnosis is depression.
The patient’s age, African American race, and anxiety diagnosis are some of the factors which might affect the choice of drugs for the management of the patient’s symptoms. For instance, most antipsychotic agents are associated with suicidal attempts, among other side effects hence must be monitored closely when use among children and adolescents. Additionally, a study conducted by (Leichsenring et al., 2021) reported that African Americans are more likely tocarry alleles that slow down the metabolism of most antidepressants such as tricyclic antidepressants (TCA), leading to a ‘slowmetabolizer’ phenotype hence higher blood TCA plasma level, in addition to more rapid response. The purpose of this paper is to demonstrate the decision-making process of the most effective medication to include in the patient’s treatment plan, while observing pharmacokinetic and pharmacodynamic factors, in addition to ethical considerations which might impact this care process.
Decision #1
Selected Decision and Rationale
The initial intervention is to start the patient on Zoloft 25 mg orally once daily. Sertraline belongs to the class of selective serotonin reuptake inhibitors (SSRIs), recommended in national clinical guidelines as the first-line for the management of depression in children and adults (Walkup, 2017).
Considering the patient’s specific factors, Zoloft is the best choice of drug for the management of depressive symptoms displayed by the patient. anxiety symptoms. For instance,most studies recommend the use of sertraline among children as a result of its great effectiveness and desirable safety profile reported by the few conducted clinical trials. The drug acts by inhibiting the central nervous system (CNS) neuronal uptake of serotonin(5HT) (Pile et al., 2020). Among children, the recommended starting dose is 25mg. The drug is absorbed slowly in the GIT with a peak plasma level being attained after 6 to 8 hours, necessary to elicit optimal therapeutic action. Studies have also identified several polymorphisms in genes encoding P-450 isoenzymes (2D6 and 2C19) among African Americans which affect the metabolism of the drug. However, when used in low disease, the drugs have displayed great effectiveness with an appealing safety profile.
Wellbutrin on the other hand is not recommended for children less than 18 years due to evidence deficits in its safety and effectiveness (Ghandour et al., 2019). The drug is also associated with high suicidal incidence, hence not appropriate for this patient as he already displayed symptoms of suicidal ideation. Paxil is also not appropriate for this patient as it is also associated with high suicide incidences as the FDA issued a black box warning for use of the drug among this vulnerable population (Leichsenring et al., 2021). It should only be considered in case there is no other suitable option which in this case is Zoloft as described above.
Expected Outcome
The drug is expected to display at least 50% remission of the patient’s depression symptoms within the next 4 to 8 weeks. As a result, theChildren’s Depression Rating Scalescores are expected to decrease to less than 10 from 30. Only common self-limiting side effects such as dry mouth increased sweating and headache might be expected(Walkup, 2017).
Ethical Considerations
Given that the patient is under the age of 18 years, it will be necessary for the PMHNP to adequately inform the patient’s parents about the available treatment options and their benefits and risks to involve them in decision making concerning the health of their child(Pile et al., 2020). Parents and guardians have legal authority in making healthcare decisions for their children.
Decision #2
Selected Decision and Rationale
The second decision is to increase the Zoloft dose from 25mg to 50mg PO daily. Studies show that the dose of Zoloft should be increased at intervals of 25mg to 50 mg per day once weekly when the desired therapeutic response has not been attained among children, while closely monitoring the patient’s symptoms(Ghandour et al., 2019).
This decision was based on the treatment outcome as the patient reported no changes in his depressive symptoms after four weeks of therapy. Increasing the dose of Zoloft to 50 mg is the best decision at this point, and evaluate the patient outcome after another 4 weeks. Studies show t that it takes between 8 to 12 weeks for sertraline to attain optimum therapeutic action in completely managing depression symptoms(Leichsenring et al., 2021). However, the dose must be increased gradually, while monitoring patient symptoms to attain an optimum dose. The patient also displayed no adverse effects, indicating great tolerance to the medication, hence no reason to alter the medication.
Increasing the dose to 37.5mg is not appropriate as this would only display similar results, as that titration rate is not recommended in several clinical guidelines(Walkup, 2017). Consequently, this will only prolong the period of use of the drug to the point where optimum dose will be attained. Discontinuing the use of sertraline, is also not necessary at this point, as studies only recommend it in case the maximum dose has been reached with no effect or the patient displays adverse effects(Pile et al., 2020). Consequently, studies recommend that the dose be reduced gradually first before switching to another drug like Prozac which is associated with several adverse effects as described above.
Expected Outcome
With the dose increment of Zoloft to 50mg, the patient is expected to display atleast 50% remission of symptoms this time round unlike within the first 4 weeks(Ghandour et al., 2019). His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10. No side effects are expected since the patient already displayed great tolerance to the drug.
Ethical Considerations
The PMHNP has a legal obligation of preventing harm and promoting the health of the patient (Dawson, 2018). As such, considering a dose increment of the drug was the best choice in managing the patient’s symptoms, with limited side effects (Walkup, 2017). This decision promotes ethical principles such as beneficence and non-maleficence.
Decision #3
Selected Decision and Rationale
The last decision is to maintain the dose of Zoloft at 50mg once daily and continue evaluating the progress of the patient. The evidence-based practice recommends dose maintenance once the optimum level has been maintained until the patient’s symptoms have been resolved completely (Pile et al., 2020).
This decision was supported by the outcome the patient displayed in the last four weeks with a 50% reduction in depressive symptoms. The outcome shows great effectiveness and adherence to the medication by the patient, hence the need to maintain the dose. Studies show that it may take the drug another 4 to 8 weeks for Zoloft to completely manage symptoms of depression once the optimum dose has been achieved (Leichsenring et al., 2021). Additionally, this dose is still low hence limiting the possibility of side effects or toxicity.
Increasing the dose of Zoloft is not necessary as this will only lead to increased risks of adverse effects and toxicity due to increased plasma levels(Dawson, 2018). Additionally, the patient’s age does not allow a higher dose of the drug, as this could lead to increased suicidal ideation. Changing the treatment regimen to another drug, is also not appropriate as this will only lead to new complications (Walkup, 2017). This will also affect the patient compliance with the treatment regimen.
Expected Outcome
The patient is expected to display completely managed depression symptoms within the next four weeks. His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10(Dawson, 2018). The patient’s quality of life will improve within this time, with no side effects reported as a result of the displayed tolerance and adherence to the treatment.
Ethical Considerations
At this point, the PMHNP is required to consider the ethical principle of nonmaleficence. Out of all the available options, maintaining the dose is the only choice that will benefit the patient with no harm (Pile et al., 2020). The patient’s parents must however be informed of the red flags like suicidal ideation and the importance of sticking to the treatment regimen to enhance optimal care outcomes.
Conclusion
Depression is a common mental problem among children below the age of 17 years. It affects both their social and academic life with additional mental and physical health burdens. Researchers have however been able to confirm the effectiveness of several treatment options for the management of depression among this vulnerable population (Ghandour et al., 2019). For the African American child with depression, factors such as his race and age were considered in choosing the best drug in the management of his symptoms. The first choice was Zoloft 25 mg once daily, which is an SSRI recommended by most clinical guidelines as a first-line for the management of depression among children due to its great effectiveness reported in most studies (Pile et al., 2020). Other alternatives such as Paxil and Wellbutrin were not appropriate due to their increased risk of suicide.
The second decision was to increase the dose to 50mg given the lack of effectiveness within the first 4 weeks. Increasing the dose to 37.5mg or replacing the drug with Prozac is not necessary as the former will lead to a similar outcome as the latter will compromise the patient’s tolerance (Walkup, 2017). The last decision was to maintain the dose at 50mg and monitor patient outcome for the next 4 weeks. The patient displayed great effectiveness and tolerance of the second intervention hence the need to maintain the dose. Increasing the dose to 75 or replacing the drug was not necessary as a result of the increased risk of toxicity and adverse events (Leichsenring et al., 2021). On the other hand, the PMHNP had to observe several legal and ethical considerations given that the patient is a minor such as the right to information, beneficence, and non-maleficence (Dawson, 2018).
References
Dawson, R. S. (July 01, 2018). Depression in children and adolescents: The pediatrician at the front lines. Pediatric Annals, 47, 7.)https://doi.org/10.3928/19382359-20180618-01
Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (January 01, 2019). Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. The Journal of Pediatrics, 206, 256-267.https://doi.org/10.1016/j.jpeds.2018.09.021
Leichsenring, F., Luyten, P., Abbass, A., Rabung, S., & Steinert, C. (January 01, 2021). Treatment of depression in children and adolescents. The Lancet. Psychiatry, 8, 2, 96-97.DOI:https://doi.org/10.1016/S2215-0366(20)30492-2
Pile, V., Shammas, D., & Smith, P. (January 01, 2020). Assessment and treatment of depression in children and young people in the United Kingdom: Comparison of access to services and provision at two-time points. Clinical Child Psychology and Psychiatry, 25, 1, 119-132.https://doi.org/10.1177/1359104519858112
Walkup, J. T. (May 01, 2017). Antidepressant efficacy for depression in children and adolescents: Industry- and NIMH-funded studies. American Journal of Psychiatry, 174, 5, 430-437.https://doi.org/10.1176/appi.ajp.2017.16091059
Sample Answer 3 for Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
According to the National Institution of Mental Health, approximately 9% of children and adolescents from age 12 years to age 17 years, are diagnosed with depression each year (Lamy & Erickson, 2018). Despite the negative impact of depression on the patient’s life, only a few individuals seek medical attention, which worsens the condition in the majority of the population. However, thanks to evidence-based practice for the current pharmacological and psychotherapeutic interventions available in the management of depressive disorders among children and adolescents (Bitsko et al., 2022). The purpose of this discussion is to illustrate the clinical decision-making on the most appropriate drug of choice for the treatment of an African American male patient with depression based on pharmacodynamic and pharmacokinetic factors.
The provided case study demonstrates an 8-year-old African American male patient with symptoms of depression. The patient is positive for loss of appetite, feeling sad, being irritable and withdrawn, even from his peers at school. Upon conducting a mental status examination, the patient acknowledges that he often thinks about death and how it would feel like to be dead. He however denies a history of suicidal attempts. The patient recorded a score of 30 on the Children’s Depression Rating Scale (CDRS), which led to the diagnosis of major depressive disorder. Other than the patient’s symptoms, CDRS scores, and diagnosis of MDD, additional factors which might affect the pharmacodynamic and pharmacokinetic process of drugs administered include his African American race and his age. These factors will affect the choice of drug for this patient.
Decision #1
Selected Decision and Rationale
Initiate Zoloft 25mg once daily. Previous evidence demonstrates great effectiveness in the use of selective serotonin reuptake inhibitors like Zoloft in the management of depression among children below the age of 18 years (Mullen, 2018). The mode of action of this medication is through neuronal inhibition of serotonin (5HT) uptake in the central nervous system. The drug has a desirable safety profile, which led to its approval by the FDA for the management of depressive disorders among pediatric patients except for those with obsessive-compulsive disorder (Kupfer, 2022). However, due to the risks of suicidal ideation and suicidality among children, close monitoring of the patient and the use of low doses (25mg) are recommended. Studies show great adherence and tolerance of the medication by most pediatric patients as the drug undergoes first-pass metabolism in the liver with reduced side effects.
Paxil could not be considered at this point, as studies show that the drug is associated with increased side effects and high risks of suicidality among children as compared to Zoloft (Hetrick et al., 2021). As such, the drug is only recommended when there is no other alternative for children above the age of 10 years.
Wellbutrin is also not recommended for children below the age of 18 years due to its increased risk of seizure (Lamy & Erickson, 2018). As such, the drug is only recommended for use as send option, when the first drug is ineffective, or if the patient has depression with comorbid ADD.
Expected Outcome
The patient is expected to report at least 50% remission of symptoms within the next 4 weeks. His CDRS scores are expected to reduce to less than 20 (Mullen, 2018). He is also expected to be more joyful and engage with his peers appropriately within this time.
Ethical Consideration
Since the patient is below the age of 18 years, her parents or caregivers have legal responsibilities for making decisions concerning his health (Hetrick et al., 2021). As such, the PMHNP must educate the patient’s parents on the diagnosis, and available treatment options before deciding on which drug to go with.
Decision #2
Selected Decision and Rationale
The second intervention is to increase the dose of Zoloft from 25mg to 50mg once daily. The patient displayed great adherence and compliance to the initial intervention, as no side effects were reported. However, no changes in the patient’s symptoms were realized which calls for dose increment to attain optimal therapeutic levels (Bitsko et al., 2022). Clinical guidelines recommend a dose increment of Zoloft by 25mg every week from an initial dose of 25mg once daily to attain the optimal threshold (Kupfer, 2022). This helps reduce the risks of side effects and toxicity.
Increasing the Zoloft dose to 37.5mg is inadequate as no changes will be experienced (Hetrick et al., 2021). The patient may also end up losing trust in the PMHNP and refuse to take the medication, even when the optimum dosage has not been attained, compromising the entire treatment process.
Changing the drug to Prozac was also not appropriate as the patient had already displayed great tolerance and adherence to Zoloft (Mullen, 2018). Prozac is also associated with increased risks of suicidal ideation which is inappropriate for the patient given the history of suicidal ideation.
Expected Outcome
Within the next 4 weeks, the patient is expected to report back to the clinic with at least 50% remission of symptoms, with the increased dose (Bitsko et al., 2022). His CDRS scores as mentioned earlier are expected to reduce to less than 20. He is also expected to sleep and eat well and engage with her peers in school.
Ethical Consideration
Legal and ethical guidelines require clinicians to prevent harm and promote the health of the patient (Lamy & Erickson, 2018). As such, this intervention to maintain the same drug and increase the dose was necessary since the patient displayed great tolerance and adherence to the medication. Changing the regime could otherwise harm the patient.
Decision #3
Selected Decision and Rationale
The last decision was to maintain the dose of Zoloft at 50mg orally once daily and continue monitoring the patient for progress. This decision was based on the outcome reported by the patient’s mother from the initial intervention. The patient displayed great compliance and adherence to the medication which lead to more than 50% remission of depressive symptoms with no side effects reported. Studies show that when the optimal dose of Zoloft has been attained, the drug will take between 6 to 8 weeks for the complete remission of depressive symptoms (Mullen, 2018). As such, it was necessary to maintain the dose to avoid side effects and monitor the patient’s progress for a better outcome.
Increasing the Zoloft dose to 75mg was not necessary as this would otherwise have led to the occurrence of side effects like increased agitation. Consequently, studies show that at high doses, Zoloft can increase the risks of suicidality among children below the age of 18 years (Kupfer, 2022).
Changing the treatment regimen to an SNRI was also not appropriate, as this would only compromise the patient’s compliance and adherence, leading to side effects. Previous evidence also demonstrates increased incidences of suicidal ideation with the use of SNRIs as compared to SSRIs like Zoloft (Bitsko et al., 2022).
Expected Outcome
Based on the previous outcome, the patient is expected to report even further remission of depression symptoms over the next four weeks. He should display a CDRS score of less than 10 (Mullen, 2018). He should improve in school performance and play with peers more frequently.
Ethical Consideration
The PMHNP is required to observe the legal and ethical obligation of promoting the patient’s well-being and preventing harm (Lamy & Erickson, 2018). As such, the nurse needs to make decisions that are well supported by the patient’s parents, based on positive outcomes as displayed by previous interventions.
Conclusion
Depression is a common mental illness reported among pediatric patients. Despite limited evidence supporting the use of antidepressants, several studies have proven their effectiveness and reduced risks of side effects in the management of depression among children such as SSRIs like Zoloft (Lamy & Erickson, 2018). As such, for the pediatric patient in the provided case study, the first intervention for the management of depression was to administer Zoloft 25mg once daily and monitor the patient for dose adjustment aiming at attaining the optimal dose (Mullen, 2018). The other two medications were not appropriate for the patient as Paxil is known to increase the risks of suicidal ideation, while Wellbutrin is not recommended for patients under the age of 18 years (Hetrick et al., 2021). The second intervention was to increase the dose of Zoloft to 50mg once daily, based on the reported outcome from the initial intervention (Hetrick et al., 2021). The patient displayed great adherence and tolerance to the medication which called for no change of regimen. Increasing the dose to 37.5 mg was not appropriate as a similar effect would have been realized.
The last intervention was to maintain the dose at 50 mg once daily as the patient displayed great tolerance and compliance to the medication with no side effects. Increasing the dose to 75 mg once daily would lead to side effects while changing the regimen to an SNRI would compromise patients’ compliance and increase the risks of suicidal ideation (Bitsko et al., 2022). Given that the patient is a minor, several ethical considerations were to be considered by the PMHNP. For instance, the patient’s parents have a legal obligation of deciding the health of her child hence the need to be adequately informed about the diagnosis and the treatment options (Kupfer, 2022). The PMHNP also has the legal obligation of promoting the health of the child and prevent harm.
References
Bitsko, R. H., Claussen, A. H., Lichstein, J., Black, L. I., Jones, S. E., Danielson, M. L., … & Meyer, L. N. (2022). Mental health surveillance among children—the United States, 2013–2019. MMWR supplements, 71(2), 1. DOI: 10.15585/mmwr.su7102a1
Hetrick, S. E., McKenzie, J. E., Bailey, A. P., Sharma, V., Moller, C. I., Badcock, P. B., … & Meader, N. (2021). New generation antidepressants for depression in children and adolescents: a network meta‐analysis. Cochrane Database of Systematic Reviews, (5). https://doi.org/10.1002/14651858.CD013674.pub2
Kupfer, D. J. (2022). The pharmacological management of depression. Dialogues in clinical neuroscience.
https://doi.org/10.31887/DCNS.2005.7.3/dkupfer
Lamy, M., & Erickson, C. A. (2018). Pharmacological management of behavioral disturbances in children and adolescents with autism spectrum disorders. Current problems in pediatric and adolescent health care, 48(10), 250-264. https://doi.org/10.1016/j.cppeds.2018.08.015
Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283. https://doi.org/10.9740/mhc.2018.11.275