Feb 23, 2024 ASSESSING AND TREATING PEDIATRIC PATIENTS WITH MOOD DISORDERS NURS 6630
ASSESSING AND TREATING PEDIATRIC PATIENTS WITH MOOD DISORDERS NURS 6630
ASSESSING AND TREATING PEDIATRIC PATIENTS WITH MOOD DISORDERS NURS 6630
In this case study, the patient is an African-American child admitted to the healthcare facility accompanied by the mother. The boy is experiencing symptoms of depression. Some of the reported symptoms include withdrawal, reduced appetite, and often gets angry on the slightest provocation (Laureate Education, 2016). However, the patient exhibits good physical outlook with normal results from the laboratory testing. Additionally, the patient’s developmental stages were all attained at the appropriate age hence the need to carry out more assessment on the patient’s psychological condition.
Further analysis reveals the patient has sad feelings and always thinks about being dead and how it would be like when he is dead. However, he does not approve of committing suicide and has no such ideas in mind. The patient is in a sad mood during the interview but at some points during the interview he smiles normally (Laureate Education, 2016). The purpose of this paper is to consider a proper plan for the treatment of the patient. The plan focuses on the decision tree with emphasis on proper communication with the patient and observance of all the related ethical standards to be met.
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Decision Point 1
Begin Zoloft 25 mg orally daily
Why Select Zoloft 25mg Oral Daily Dose?
The drug is classified as an anti-depressant that works on the principle of inhibition of the selective uptake of serotonin. It is the prescribed medication for major depressive disorder (MDD), obsessive compulsive disorder(OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder and premenstrual dysphoric disorder (PMDD). The 25mg daily dosage is the appropriate and recommended oral dose for children. Zoloft has proved to be effective in treatment of children with OCD for ages between six and seventeen years (Garland et al., 2016).
What is the expected outcome on making this decision?
This prescribed drug is aimed at reducing the patient’s sad mood, improving the patient’s appetite and boosting their feelings for self and social interactions (Neavin, Joyce & Swintak, 2018). The drug will also alleviate the feelings of death hence making the patient appreciate life and improve his general feeling about life. Additionally, Zoloft is appropriate for the age of the patient who is eight years old and there is less side effects expected on the patient.
Expected Vs. Actual Results
After a period of four weeks the patient returned to the health facility for follow up. The patient still had symptoms of depression. This was contrary from the expected outcome because the SSRIs have a slow action mechanism associated with late improvement of the depression symptoms.
Decision Point 2
Double up the dosage to 50mg daily
Why take this decision?
It is recommended to double up the dosage if the patient does not show any improvement within a period of four weeks (Garland et al., 2016). The use of Prozac 10mg daily dosage is not the appropriate decision at the moment because it is only recommended if there is no improvement of the patient’s condition after six weeks (Neavin et al., 2018).
What is the expected outcome on making this decision?
By doubling up the dosage I hope to improve the patient’s feelings on depression by half and make him feel better emotionally, improve his appetite and social interactions.
Expected Vs. Actual Results
On the second visit to the health facility after period of four weeks, the patient’s state has remarkably improved by half. The patient’s body has shown great tolerance to the drug and the expected and actual results are similar. This can also be attributed to the fact that Zoloft is associated with late improvement in depression patients.
Decision Point 3
Increase to 75 mg orally daily.
Why take this decision?
This decision was achieved at by checking on the patient’s progress. The patient had not achieved full recovery from depression and social withdrawal symptoms. This dosage will sustain the current dosage and improve on the patient’s recovery process. (Neavin et al., 2018).
Other options like the use of SSRI is not appropriate at the moment because the patient has exhibited good response to Zoloft in both treatment and the ability of the patient’s body to tolerate the drug. Additional SSRI has been associated with strong withdrawal symptoms especially when its use is discontinued and this like pose similar symptoms of the relapse to depression (Garland et al., 2016). The relapse of the withdrawal symptoms occurs after a period of between six and eight weeks after treatment with SSRI hence is not the outcome we need for this patient at the moment.
What is the expected outcome on making this decision?
By taking this decision, the aim is to achieve full recovery of the patient from depression and the related symptoms. It is expected after four weeks the patient’s mood would have changed and exhibit happiness coupled with euthymia (Dwyer & Bloch, 2019). Additionally, the patient is expected to have better appetite, proper sleeping patterns, improved social interactions and reduced or no feelings of death.
Expected Vs. Actual Results
After four weeks the patient returned with improved conditions. He was feeling happy and with improved social interactions. This actual results are similar to the expected results.
How Ethical Considerations Might Impact Your Treatment Plan Communication with Clients
One of the key ethical issue to be considered is the right to information and the independence of the client to make the decision that suits the needs. It is important to explain to the patient or the care giver the treatment plans available, their cost and the expected side effects (Katz et al., 2016). This will empower the client with knowledge and ensure that the client makes informed decisions. The case in point involves a child therefore the consent should be obtained from the mother who is the immediate care giver to the child. Therefore, the mother’s decision will have an impact on the patient’s treatment plan. Another ethical issue to consider is beneficence.
This will call upon the health practitioner to offer a treatment plan that is best suited to the patient and will deliver the best desired outcomes. I also allow the health practitioner to modify and improve the treatment plan if the existing one does not produce the desired outcomes. (Katz et al., 2016). Additionally, non-maleficence is another ethical issue that is likely to impact on the treatment plan, this allows the medical practitioner to modify the treatment plan in case the existing one has adverse effects to the patient. It is imperative for the healthcare practitioner to consider all the ethical issues before coming up with the treatment plan and modify it along the way with key emphasis being to ensure that the patient’s outcome is improved and patient satisfaction is met.
Conclusion
The case in point was an eight-year-old African-American boy with a depression disorder that exhibited various symptoms such as reduced appetite, social withdrawal and feelings of death. The boy is treated with Zoloft initial dosage of 25mg daily but after four weeks the symptoms had not improved is can be attributed to the late action of the Zoloft drug The dosage was doubled to 50mg daily and the symptoms improved by half after another four weeks. On further increase of the dosage to 75mg daily for another four weeks, the patient’s condition greatly improved and the patient exhibited happiness, improved appetite, better sleep and general feeling of euthymia. The treatment plan considered ethical factors such as patient’s autonomy, beneficence and non-maleficence as the key to better patient outcomes.
References
Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26–42F. PMC6738970/
Jane Garland, E., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie Canadienne de Psychiatrie de l’enfant et de l’adolescent, 25(1), 4–10. PMC4791100/
Katz, A. L., & Webb, S. A. (2016). Informed Consent in Decision-Making in Pediatric Practice. Pediatrics, 138(2), e20161485. https://doi.org/10.1542/peds.2016-1485
Neavin, D., Joyce, J., & Swintak, C. (2018). Treatment of Major Depressive Disorder in Pediatric Populations. Diseases, 6(2), 48. https://doi.org/10.3390/diseases6020048
When pediatric patients 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 patients with the same disorders, they also metabolize medications much differently. Yet, there may be times when the same psychopharmacologic treatments may be used in both pediatric and adult cases with major depressive disorders. As a result, psychiatric nurse practitioners must exercise caution when prescribing psychotropic medications to these patients. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat pediatric patients presenting with mood disorders.
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of pediatric patients requiring antidepressant therapy.
The Assignment: 5 pages
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 patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Pediatric depression is a common psychiatric mood disorder in children that usually persists episodically into adulthood. Children with the depressive disorder present with symptoms such as depressed or irritable mood; Reduced interest or loss of pleasure in most activities; Sleep disturbances; Appetite disturbance; Weight changes; Diminished concentration or indecisiveness; Fatigue; Suicidal ideation or thoughts (Patra, 2019). These symptoms cause significant distress or impairment in a child’s academic and social functioning. The purpose of this paper is to discuss a case of pediatric depression and describe the treatment approaches, including ethical considerations in treatment.
Case Overview
The case study is about an 8-year-old AA boy accompanied to the ER by his mother with complaints of feeling sad and having signs of depression. The mother states that the boy has peer withdrawal, has reduced appetite, and is sometimes irritable. However, his physical exam findings and laboratory results are unremarkable. On MSE, the patient has a sad mood and fairly blunted affect, but he smiles appropriately during the interview (Laureate Education, 2016). In addition, the child denies having active suicidal ideations but mentions that he regularly thinks about being dead. The patient scored 30 on the Children’s Depression Rating Scale, indicating significant depression.
Various patient factors influence the treatment decisions for pediatric depression. Specific factors that may influence decision-making when prescribing treatment for this patient include the severity of the depressive symptoms, age, number of previous depressive episodes, history of treatment adherence, and the patient’s and caregiver’s motivation for treatment (Patra, 2019). Since the patient has moderate depression, medication will be preferred over psychosocial interventions.
Decision #1
Initiate Zoloft 25 mg orally daily.
Reason for Selecting this Decision
Zoloft was selected because it has established safety and efficacy in children above six years. The recommended initial dose is 25 mg once daily. Zoloft was selected because it is an antidepressant under the class of SSRIs, which are the most preferred over other antidepressants owing to their less prominent adverse effects (Neavin et al., 2018). Besides, SSRIs are the recommended first-line antidepressants for pediatric populations. Thus, the few adverse effects of Zoloft might contribute to compliance with medication in the patient.
Why Other Options Were Not Selected
Paxil was not ideal since it has no established safety and efficacy in children. Dwyer and Bloch (2019) explain that discontinuation of Paxil causes a syndrome characterized by flu-like symptoms, fatigue, nausea, muscle pain, and dizziness. Wellbutrin was also inappropriate since minimal evidence supports its efficacy in children. Therefore, it should be prescribed only when first-line agents are ineffective.
What I Was Hoping To Achieve
The PMHNP hoped that Zoloft would alleviate the patient’s depressive symptoms, including thoughts about death, by 25%. The PMHNP also hoped the depression score would reduce to at least 15 within four weeks after initiating treatment. Zoloft alleviates depressive symptoms by blocking presynaptic serotonin reuptake resulting in decreased serotonin, which is usually involved in the pathogenesis of depression (Grover & Avasthi, 2019).
How Ethical Considerations May Impact the Treatment Plan
Ethical consideration may affect treatment since the PMHNP has to select an evidence-based intervention associated with the best outcomes and least adverse effects (Bipeta, 2019). For example, the PMHNP selected Zoloft because it promotes the best outcomes in children and has the least adverse effects compared to Paxil and Wellbutrin.
Decision #2
Increase Zoloft dose to 50 mg orally daily.
Reason for Selecting this Decision
The Zoloft dose was increased to 50 mg since the patient did not demonstrate any improvement with the initial 25 mg dose. Anvari et al. (2020) explain that the Zoloft dose should be titrated up if a patient shows no or has an insignificant improvement of depressive symptoms after four weeks.
Why Other Options Were Not Selected
Increasing Zoloft to 37.5 mg was not ideal since it is still a low dose, and the patient’s symptoms may fail to improve with this dose. Besides, the treatment was not changed to Prozac because it is not recommended to change the initial drug until six weeks of no improvement (Grover & Avasthi, 2019). Besides, SSRIs usually show a late improvement of symptoms, and the clinician should not be quick to change the drug.
What I Was Hoping To Achieve
The PMHNP hoped that increasing the dose would increase the drug’s effect in inhibiting the reuptake of serotonin in the presynaptic cleft resulting in suppression of depressive symptoms by 25% within four weeks. Grover and Avasthi (2019) explain that SSRIs like Zoloft have a comparatively flat dose-response curve meaning that a drug’s maximum clinical response is achieved at the lowest effective doses. Thus, clinicians must give adequate time for an SSRI to achieve the desired clinical response.
How Ethical Considerations May Impact the Treatment Plan
Ethical principles of beneficence and nonmaleficence may impact treatment since the clinician is mandated to promote better patient outcomes without compromising patient safety (Bipeta, 2019). In this case, beneficence and nonmaleficence impacted treatment as the PMHNP had to select an intervention to alleviate the patient’s symptoms without causing harm from adverse effects.
Decision #3
Increase Zoloft to 75 mg orally daily.
Reason for Selecting this Decision
The patient had not achieved a complete reduction of the depressive symptoms, which led to the decision to increase Zoloft from 50 to 75 mg. The 50 mg dose had reduced the symptoms by 50%, leading to increasing to 75 mg would result in complete remission. Anvari et al. (2020) explain that the dose can be increased if the patient tolerates the drugs and has good compliance to promote further improvement of symptoms.
Why Other Options Were Not Selected
Maintaining the current 50 mg dose was not ideal since the symptoms had only reduced by 50%, and the desired complete remission had not been achieved. Neavin et al. (2018) explain that maintaining the dose can delay achieving desired treatment outcomes. Changing to an SNRI was not ideal because the patient demonstrated a positive response to Zoloft, and there were no reported adverse effects warranting a change of treatment.
What I Was Hoping To Achieve
The PMHNP hoped that increasing Zoloft would help fully alleviate the depressive symptoms and suicidal thoughts in the next 4-6 weeks. Besides, the PMHNP hoped that increasing the dose would not have any adverse effects and the patient would comply with treatment. Grover and Avasthi (2019) assert that antidepressants in pediatrics should be started in low doses and increased gradually to a level where a balance is established between control of symptoms and avoidance of adverse effects.
How Ethical Considerations May Impact the Treatment Plan
Ethical principles of the right to autonomy may impact treatment since the PMHNP has to involve the patient or the guardian in making treatment decisions (Bipeta, 2019). For instance, the PMHNP had to explain to the patient’s mother the available treatment options, including their benefits and side effects, and implement the option the caregiver consented to.
Conclusion
The specific patient factors that would have impacted the treatment for this patient include the severity of depression, age, history of depression, previous adherence to treatment, and motivation for treatment. The first treatment intervention was to initiate Zoloft 25 mg per day. Zoloft was the ideal option because its efficacy and safety in pediatric populations is established, unlike Paxil and Wellbutrin, with minimal or no evidence supporting their effectiveness in treating pediatric depression (Neavin et al., 2018). However, after four weeks of treatment, the patient demonstrated no improvement in symptoms, which led to increasing the dose to 50 mg. Zoloft shows a late improvement of symptoms, which is why the treatment was not changed to Prozac.
Increasing Zoloft to 50 mg alleviated the patient’s depressive symptoms by 50% within four weeks. Since no adverse effects were reported, the dose was increased to 75 mg with the hope of achieving complete remission of symptoms. The treatment was not changed to an SNRI since the patient demonstrated a significant positive response to Zoloft (Grover & Avasthi, 2019). Furthermore, maintaining the dose at this point was not the ideal choice because it could have delayed the attainment of complete remission. The ethical principles of beneficence, nonmaleficence, and autonomy impacted the treatment plan (Bipeta, 2019). The PMHNP had to prescribe a medication associated with the best outcomes and no harm to the patient and involve the caregiver in decision-making.
References
Anvari, A. A., Carroll, M. P., & Klein, D. A. (2020). Primary Care Clinicians Can Effectively Treat Depression in Children and Adolescents. American family physician, 102(4), 198-199.
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26–42F.
Grover, S., & Avasthi, A. (2019). Clinical Practice Guidelines for the management of depression in children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 226–240. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_563_18
Laureate Education (2016). Case study: An African American child suffering from depression [Interactive media file]. Baltimore, MD: Author.
Neavin, D. R., Joyce, J., & Swintak, C. (2018). Treatment of Major Depressive Disorder in Pediatric Populations. Diseases (Basel, Switzerland), 6(2), 48. https://doi.org/10.3390/diseases6020048
Patra, S. (2019). Assessment and management of pediatric depression. Indian journal of psychiatry, 61(3), 300–306. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_446_18
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