Assignment: Assessing and Treating Pediatric Clients with Mood Disorders
Assignment: Assessing and Treating Pediatric Clients with Mood Disorders When pediatric clients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders. Note: This Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press. Note: To access the following medications, click on the The Prescriber's Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter. Review the following medications: • paroxetine • selegiline • sertraline • trazodone • venlafaxine • vilazodone • vortioxetine • amitriptyline • bupropion • citalopram • clomipramine • desipramine • desvenlafaxine • doxepin BACKGROUND INFORMATION The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression. • Client complained of feeling “sad” • Mother reports that teacher said child is withdrawn from peers in class • Mother notes decreased appetite and occasional periods of irritation • Client reached all developmental landmarks at appropriate ages • Physical exam unremarkable • Laboratory studies WNL • Child referred to psychiatry for evaluation • Client seen by Psychiatric Nurse Practitioner MENTAL STATUS EXAM Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age appropriate. He is not endorsing active suicidal ideation but does admit that he often thinks about himself being dead and what it would be like to be dead. The PMHNP administers the Children's Depression Rating Scale, obtaining a score of 30 (indicating significant depression) RESOURCES § Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale--Revised. Los Angeles, CA: Western Psychological Services. Decision Point One Select what the PMHNP should do: Begin Zoloft 25 mg orally daily. Click to see options it will take you to decision point two and three Begin Paxil 10 mg orally daily. Click to see options it will take you to decision point two and three Begin Wellbutrin 75 mg orally BID. Click to see options it will take you to decision point two and three. To prepare for this Assignment: • Review this week’s Learning Resources. Consider how to assess and treat pediatric clients requiring antidepressant therapy. The Assignment Examine Case Study: An African American Child Suffering From Depression. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. • At each decision point stop to complete the following: o Decision #1  Which decision did you select?  Why did you select this decision? Support your response with evidence and references to the Learning Resources.  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.  Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? o Decision #2  Why did you select this decision? Support your response with evidence and references to the Learning Resources.  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.  Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? o Decision #3  Why did you select this decision? Support your response with evidence and references to the Learning Resources.  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.  Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? • Also include how ethical considerations might impact your treatment plan and communication with clients. All references require creditable sources, nothing less than 5 years. References require doi or http Example of paper, please do not use as it will be plagiarism Treating pediatric clients with depression Assessing and treating pediatric clients with depression Major depressive disorder (MDD) in children and adolescents is a common condition that affects the physical, emotional, and social development (Mullen, 2018). MDD is a serious disorder that causes significant problems in mood, thinking and behavior at home, school and with peers (National Alliance of Mental Health, 2018.) Risk factors include a family history of depression, parental conflict, poor peer relationships, deficits in coping skills and negative thinking (Mullen, 2018). Antidepressant drugs are often an effective way to treat depression in children and adolescents (Mullen, 2018), This paper will explore a case study of an 8-year-old African American male exhibiting signs of depression. After the PMHNP administers the Children’s Depression Rating Scale, the client obtains a score of 30 indicating significant depression (Laureate Education, 2016e). Decisions made and outcome Choices for decision 1: Begin Zoloft 25 mg orally daily. Begin Paxil 10 mg orally daily. Begin Wellbutrin 75 mg orally BID. My decision: As the PMHNP caring for this client, Zoloft 25 mg daily would be the first choice of therapy for this client. Why I selected this drug: Zoloft is one the most common antidepressant drugs that affects the chemicals in the brain. It belongs to a therapeutic class of drugs called selective serotonin reuptake inhibitors or SSRIs. Zoloft is FDA approved for the treatment of depression (Garland, Kutcher, Virani, and Elbe 2016). SSRIs are known to have fewer side effects and the most commonly used antidepressant for children (Mullen, 2018). Long term use is safe and is non-habit forming (Stahl, 2014b). The FDA advises starting at lower doses for pediatric patients given their lower body weights, in order to avoid excessive plasma levels (FDA, n.d.) the PMHNP, I am expecting the efficacy of this drug to have full remission and long-term recovery (Garland, Kutcher, Virani, and Elbe, 2016). I did not choose Paxil, because this drug is not recommended for children due to the short half-life which can lead to withdrawal when the medication is stopped suddenly. It carries a black box warning due to an increased suicide risk, clients are more likely to become suicidal when they first start taking the medication and whenever the dose is increased (National Alliance on Mental Illness, 2018). In a reanalysis of a 200l study published in the so, in the published in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) Paxil was never FDA approved for children and adolescents and to date it still isn’t. I did not choose Wellbutrin a non-tricyclic antidepressant drug has an FDA waring that this drug has an increased risk of suicidal thinking and behavior (suicidality) in children and adolescents in short-term studies of MDD and other psychiatric disorders (FDA n.d.). This drug is more likely to trigger epileptic seizure than any other antidepressant. The possibility of seizures increased at higher doses or following increased dose. Another precaution is tricyclic antidepressants may affect the heart rhythm and these effects are more common in children and adolescents (Watkins, 2013). There are some studies that show tricyclic antidepressants worked better for clients with ADHD (Watkins, 2013). Outcome: The client returns to clinic in four weeks with no change in symptoms. Because the onset of the therapeutic actions is not immediate, the client will not show signs of improvement at time of return to the clinic. Therapeutic actions are not commonly instant and are often delayed 2-4 weeks (Stahl, 2014b). My expected outcome: The expected goal of treatment is for a complete remission of the current symptoms as well as prevention of future relapses (Stahl, 2014b). As the PMHNP, I would like to see positive changes in quality of life with the ability to go to school, have social relationships, and have enjoyment in life (Townsend, 2015). The expected outcome is also for the drug to reach a safe and therapeutic level (Vitiello, 2012). Decision point 2: Change to Prozac 10 mg orally daily. My decision: The FDA approve antidepressant Prozac (SSRI), has been approved for the use in children and teens, ages 8 and older to treat depression. Prozac is also recommended as a first-line treatment for childhood and adolescent depression treatment for childhood and adolescent depression (Cheung, Kozloff, Sacks, 2013). Prozac is the most commonly used antidepressant medication for children and adolescents (Cheung, et al., 2013). Prozac is generally well-tolerated in children, and the side effects of Prozac are often mild and short-lasting and if the side effects do occur, they usually happen at the start of treatment and often resolve a few weeks without additional intervention (Cheung, 2016). Outcome: Client returns to clinic in four weeks with no change in symptoms. Decision point three: Increase to 20 mg My decision: Because the patient has been a low dose, it is safe to increase the dosage. FDA approval for dosing children 8 years old and older is 5 –30mg/day. At this point I do not see the need to change to another SSRI or to add another medication, I want to avoid polypharmacy, and continuue with the Zoloft to reach a therapeutic level (Stahl, 2014b). Outcome: Student Guidance There is no indication to discontinue the Zoloft and change to another SSRI. The client has not yet reached a therapeutic level. Adding another medication can lead to harmful side effects, it can also make it impossible to know which medication is working and it may be confusing to the caregiver when giving the medication and also, it may be expensive with more than one medication and cause an economic burden (Cheung, et al., 2016). Ethical decisions that may impact the treatment plan and communication with clients There are always special ethical concerns in the treatment for children with mental health concerns. Children with depression are especially vulnerable because of developmental considerations and the severity of the illness (Nelson, 2002). The PMHNP must be knowledgeable about any medications that are prescribed including side effects, black box warnings and dosages (Limandri, 2019). The PMHNP must adhere to all aspects of the Code of Ethics for Nurses, with the 9 provisions as the guidelines (ANA, 2014). To conclude when prescribing antidepressants for the pediatric client, the PMHNP must have a detailed and comprehensive understanding of drugs, how they are absorbed, metabolized and eliminated by the body and what receptor sites they target once the drug is absorbed (Edward, 2015). When starting clients on antidepressant therapy, the PMHNP must monitor closely for clinical worsening, suicidality, or unusual changes in behavior particularly in the first few months of starting therapy or after dose changes (Limandri, 2019). It is essential the PMHNP avoids polypharmacy for potential drug-drug interactions (Stahl, 2014b). It is important to find the safest and most effective medication for the child. PMHNPs’ must always adhere to the Code of Ethics for Nurses when treating and prescribing. Antidepressant SSRI drugs are often an effective way to treat depression in children and adolescents. Antidepressant use in children and adolescents must be monitored closely, and before prescribing any medication the PMHNP must always pay attention to the black box warnings, especially the antidepressants with black box warnings about increased risk of suicidal thinking and behavioral (ANA, 2014). ------ - free essay sample Psychopharmacologic Approaches to Treatment Student’s Name Institutional Affiliation Course Professor’s Name Date Psychopharmacologic Approaches to Treatment Introduction The case study of an African-American who is suffering from depression describes the various decisions required to provide treatment to mood disorders. Mood disorders are common among Africa-American communities and thus effective treatment is required. The first decision was to determine that Zoloft is a safe and reliable medication in the treatment of depressive symptoms (Mansouripour & Kumar, 2019). The second and third decision was to maintain the prescription of the medication since it triggered positive outcomes. Provision of treatment to depressive patients involves ethical considerations meant to reduce the side effects of the drug. Psychopharmacologic approaches are necessary for treatment of depression using various decisions to improve positive outcomes and reduce side effects. Decision #1 Choices for decision 1: The first decision involves prescribing Zoloft 25mg orally daily, Wellbutrin 75mg orally BID and Paxil 10mg orally daily. My decision: The best decision as a PMHNP who is treating pediatric patients is to prescribe Zoloft 25mg orally daily (Oliveira et al., 2018). The first choice will be prescribed and examined after the first two weeks. Reasons for selecting Zoloft: Zoloft 25mg orally daily is an evidence-based antidepressant medication. The drugs affect the brain this altering the behavior and mood of a child. The medication is categorized among therapeutic drugs called SSRI or selective serotonin reuptake inhibitors (Stahl, 2013). Zoloft is a recommended drug for depressive symptoms. The approval of the drugs is based on the ability of the medication to trigger fewer side effects, especially among depressive children. Additionally, random-control trials have indicated that the drug is safe for long term use without habit-forming addictive effects (Stahl, 2013). FDA states that it is safe to prescribe lower doses to pediatric patients to reduce the risk of overdose or severe side effects. For instance, a high dosage of Zoloft causes suicidal thoughts among patients (Gordon & Melvin, 2014). The prescription of the drugs should be based on body weight to prevent high plasma levels. As a PMHNP, I expect that the drug will work effectively to promote positive behavior, promote full recovery, and reduce depressive symptoms. I did not opt for Paxil since the medication is not safe for children. The drug can trigger withdrawal symptoms when the medication is stopped. The drug has other negative effects on a child such as suicidal thoughts (Strawn et al., 2017). For example, statistics indicate that children are likely to commit suicide when they start taking the medication or when the dose is increased. It is thus not safe for children and adolescents (Strawn et al., 2017). Consequently, due to the negative effects of the drug it has not been approved by FDA until today. I did also not choose Wellbutrin although is it an antidepressant drug. FDA has indicated in their previous reports that the drug is not safe for children due to the increased suicidal thoughts and behavior upon taking it (Strawn et al., 2017). Random-control trials and systematic reviews have also found that the drug is not safe for children with psychiatric disorders. FDA also reports that the medication is likely to cause epileptic seizures compared to other psychotic drugs (Strawn et al., 2017). The possibility of epileptic seizures increases upon administration or an increase in the dose. Wellbutrin also causes a change in heart rhythm which can severely affect the health condition of children as well as adults. However, little evidence is available showing that Wellbutrin is effective for ADHD patients. Outcome: The client returned to the health center after four weeks. The patient did not present any change in depressive symptoms. One of the reasons for the lack of evidence in therapeutic changes that may take time between 2-4 weeks or the dose should be increased. Expectations: The expected outcome was a significant decrease in depressive symptoms. For example, I expected to hear from the parents that the child has improved in terms of going to write my essay school, playing and interacting with peers, eating food and sleep (Magellan Health, Inc, 2013). Another expectation was that the drug should be safe and therapeutically beneficial to the patient with minimal side effects. Decision #2 Choices for Decision #2: The second decision was made after the patient returned to the clinic after four weeks. One of the activities is to assess if the patient had shown changes in the depressive symptoms. For example, the expectation was to learn that the basic depressive symptoms such as appetite and sleep had improved. The second decision was to increase the Zoloft to 50mg orally daily. The purpose of increasing the dosage is derived from evidence-based practice that Zoloft can be increased to enhance effectiveness (Lorberg et al., 2019). Additionally, it is important to realize that some depressive symptoms may not occur within a short time such as 4 weeks. In the second decision, the patient will stay for another 4 weeks taking an increased dosage. FDA also warns patients and clinicians that they should not prescribe Zoloft medication in large doses at the beginning (Lorberg et al., 2019). The purpose is to reduce the risk of adverse side effects. Therefore, the expectation is to realize a significant reduction in depressive symptoms and suppress them significantly. One of the second thoughts in the treatment plans is to change the drug. However, it is not necessary to change the drug since Zoloft has been named among the proven medication among depressive children. Therefore, perhaps if the dosage increases the depressive symptoms such as lack of sleep or appetite. It is thus important to stick with the drug and evaluate the effectiveness after increasing the drug (Lorberg et al., 2019). If the drug does not present any outcome after the second visit, it would be necessary to reevaluate the suppressive statements and probably seek treatment using different drugs. The second lead to a decision that also pertains to the delivery of custom care to patients. Decision #3 Decision #3 is based on the outcome of decision #2. The outcomes of decision #2 indicated that the prescription of a higher dose was effective in significantly reducing the symptoms. According to the records, the symptoms of depression reduced by 50 percent in the fourth week of taking Zoloft 50mg orally daily. For instance, the parent reported that the patient had improved interaction with peers, appetite, and sleep. Decision #3 is thus to maintain the prescription of Zoloft 50mg orally daily for another set of four weeks. The purpose of the prescription is to continue reducing the negative behaviors associated with depression (Stahl, 2013). Another reason why the drug should not be maintained is that the drug is not causing negative side effects associated with Zoloft. For instance, an increase in Zoloft dose is likely to increase suicidal thoughts among patients (Oliveira et al., 2018). The suicidal thoughts can translate into real actions leading to physical harm or death. However, despite the absence of the negative side effects it is essential to keep the patient at close monitoring (Gordon & Melvin, 2014). The clinician should also communicate with the parent or guardian to inform them about the risks of taking a higher dose of Zoloft. FDA recommends that patients of depression should not take higher doses of Zoloft at the beginning of treatment (Gordon & Melvin, 2014). The reason is that patients react differently to treatment causing varying side effects. Decision #3 will thus involve maintaining the dose at 50mg orally daily. The expected outcomes were realized since the depression symptoms were reduced by 50 percent. The expectations and the outcomes were similar since the medication had positive results. Notably, the similarities in the expectations and outcomes were evident through improved sleep, eating habits and interaction with peers (Gordon & Melvin, 2014). Clinicians will recommend to the patient to continue taking the medication and come back for further examination and review after another four weeks. Ethical Approaches to Treatment Prescription and treatment of pediatric patients involve various ethical issues that will impact treatment and communication to patients. For example, FDA recommended that patients below 18 years should not decide to take Zoloft without the approval of a parent or guardian (Stahl, 2013). If the medication is provided without proper communication and approval, it would amount to unethical behavior. Patients with depressive symptoms should not take higher doses in the initial prescription. According to FDA clinicians should prescribe lower doses to reduce the risk of severe side effects such as suicide (Lorberg et al., 2019). For instance, if a patient dies after prescription of Zoloft, a clinician will be held responsible for the amount of drug they prescribed. The prescription should be accompanied by close monitoring of the patient. Clinicians are thus required to communicate to the parent or guardian about the expected side effects of the drug (Lorberg et al., 2019). The awareness will ensure parents keep watch on the child and take appropriate action when necessary. FDA requires pharmaceutical companies to always warn patients and clinicians about the side effects of the drug. For instance, FDA requires companies to place a warning message on the packaging boxes of the medication (Lorberg et al., 2019). The warning message should indicate that the drug should be used with precaution to limit the suicidal side effects. Clinicians have an ethical and moral responsibility of communicating the African-American patients or their children the importance of medication. Despite the expected side effects, African-Americans should seek treatment and come back for follow-up clinics (Oliveira et al., 2018). The purpose of communication is to counter a growing perception among the African-American communities that depression requires only a spiritual solution. Although the community will engage in praying to a higher power and ask for healing, they should find a healthcare center to seek treatment. Conclusion Treatment of mood disorders using psychopharmacologic approaches requires various decisions. All the decisions are aimed at improving the quality of health of a patient. Initially, the decisions are meant to determine the best drug for the patient. Subsequent decisions including decision #2 and #3 are meant to determine whether to continue with the treatment or not. In the write my case study of an African-American with depressive symptoms, Zoloft was the best medication available for treatment. The medication was increased to 50mg orally daily and the outcome was positive. However, despite the positive outcome, clinicians should prescribe the drug keeping in mind the ethical considerations. Clinicians should understand the FDA's ethical requirements of the prescribing Zoloft and communicate to patients or guardians. References Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal? Journal of Pediatrics and Child Health, 50(11), 847–854. DOI:10.1111/jpc.12655 Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. Retrieved from http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf Oliveira, A. S., Martinez-de-Oliveira, J., Donders, G. G., Palmeira-de-Oliveira, R., & Palmeira-de-Oliveira, A. (2018). Anti-Candida activity of antidepressants sertraline and fluoxetine: effect upon pre-formed biofilms. Medical Microbiology and Immunology, 207(3-4), 195-200. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. Strawn, J. R., Dobson, E. T., & Giles, L. L. (2017). Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety. Current Problems in Pediatric and Adolescent Health Care, 47(1), 3-14.