Feb 23, 2024 Foundational Neuroscience Psych Treatment Discussion
Foundational Neuroscience Psych Treatment Discussion
A Sample Answer For the Assignment: Foundational Neuroscience Psych Treatment Discussion
Depressive disorders are a source of considerable disease burden to the global population. The disorders affect productivity, lower the quality of life of the affected populations, and cause premature mortalities. Pharmacological interventions are the mainstream treatments for depressive disorders. Nurse practitioners should be aware of the safety, indications, and monitoring of different populations prescribed medications for depressive disorders. Therefore, this essay examines the medications used in treating major depression in children and adolescents, considerations, monitoring, follow-up, diagnosis, and its causes and symptoms.
Causes and Symptoms
Major depression in children and adolescents is an important public health concern since it affects 5% of 12-year-olds and 17% of 17-year-olds in America. Psychological, biological, and environmental factors cause major depression in children and adolescents. Some of the biological risk factors associated with major depression include overweight, female sex, having a family history of depression, early puberty in girls, chronic illness, and polymorphisms that affect dopamine, serotonin, or monoamine oxidase genes. Some of the psychological factors that cause major depression in this population include dysfunctional emotional regulation, body dissatisfaction, low self-esteem, negative thinking, and substance abuse (Boaden et al., 2020; Farley, 2020). Environmental causes of major depression among children and adolescents include bullying, victimization, exposure to traumatic events, parental rejection, and dysfunctional families.
Children and adolescents affected by major depression present to the hospital with a range of symptoms. They include hypersomnia or insomnia, weight gain or loss, difficulty concentrating, lack of interest and pleasure, easy irritability, and feeling sad or hopeless. Patients also report difficulties in making decisions, feeling guilty, and suicidal thoughts, plans, or attempts (Dwyer & Bloch, 2019; Selph & McDonagh, 2019). The symptoms affect the patient’s normal functioning in areas such as academic and social activities.
Diagnosing the Disorder and Why the Population is Considered Vulnerable
Screening tools such as PHQ-A are used in the diagnosis of major depression in children and adolescents. The screening tool helps healthcare providers rate the client’s depressive symptoms and rule out other potential causes such as generalized anxiety disorder and bipolar disorder. Major depression can present with symptoms that are seen in other conditions such as hypothyroidism. As a result, healthcare providers must perform laboratory investigations such as thyroid function tests to rule out other comorbidities. The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) also guides the diagnosis of major depression in children and adolescents. The DSM-5 manual sets the criteria that must be met for a diagnosis of major depression to be made (Selph & McDonagh, 2019). For example, patients should report symptoms such as being depressed almost every day most of the time, lack of interest and pleasure, changes in appetite and weight, being hopeless or guilty, having difficulties concentrating and making decisions, and symptoms affecting normal functioning.
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Children and adolescents are considered a vulnerable population. Firstly, children and adolescents are not mature enough to make safe decisions about issues that affect their health. Children and adolescents rely on others for decision-making and support. As a result, they are at risk of harm and practices that affect their health outcomes. Children and adolescents are also highly vulnerable to social, emotional, and physical changes. Exposure to negative experiences such as abuse, or violence can alter significantly their normal development and progression to adulthood. This makes them a vulnerable group to other health problems based on their environmental exposures. Children and adolescents also have immature body systems and organs. This means that, unlike adults, children and adolescents are prone to harm from medications used for different conditions. Their risk of developing side and adverse effects due to immature organs involved in drug metabolism and elimination is higher than in adults (Farley, 2020). Therefore, they are considered a vulnerable population and caution must be taken when treating mental health problems that affect them.
Medication Treatment Options and Examples
The Food and Drug Administration (FDA) has approved escitalopram and fluoxetine for use in treating major depression in children and adolescents. The guidelines recommend the use of fluoxetine in children who are aged eight years and older while escitalopram is used for patients who are aged 12 years and above. The other FDA-non-approved antidepressants used for treating major depression in this population include paroxetine, sertraline, citalopram, and fluvoxamine (Feeney et al., 2022). Bupropion and mirtazapine might also be considered despite the lack of adequate evidence that supports their use in the population.
Antidepressants have the benefit of managing the depressive symptoms of major depression. The improvement in symptoms results in enhanced functioning, well-being, and quality of life. Antidepressants also reduce the risk of symptom relapse among children and adolescents with major depression. However, practitioners should be aware of the risks associated with antidepressants. They include predisposing patients to suicidal thoughts, plans, or attempts. Patients might also suffer from a negative self-image from weight gain associated with antidepressants (Boaden et al., 2020; Dwyer & Bloch, 2019). Patients and their families should also be educated about anticipated side effects such as insomnia, sedation, sexual dysfunction, gastrointestinal upset, hyperhidrosis, and dry mouth.
Monitoring
Close patient monitoring should be done for children and adolescents prescribed antidepressants. Firstly, children and adolescents should be monitored for suicide risks. Antidepressants are associated with the adverse effect of increasing the risk of suicide in patients. Laboratory investigations such as a lipid panel and complete blood count should be performed periodically. Antidepressants are associated with side effects such as weight gain. Patients should be assessed for cardiovascular risks such as hyperlipidemia with weight gain (Hazell, 2022). Blood pressure and weight should also be assessed regularly, and patients advised on effective interventions to promote healthy weight gain.
Healthcare providers should also monitor children and adolescents for pediatric behavioral activation syndrome. The syndrome can be diagnosed based on symptoms such as mania, hyperactivity, and agitation. Patients should also be monitored for serotonin syndrome. Serotonin syndrome develops among patients with dual antidepressant therapy (Zhou et al., 2020). Patients with serotonin syndrome present to the hospital with symptoms that include hypertension, diarrhea, sweating, hyperthermia, and tachycardia.
Special Considerations
Several considerations influence drug therapy for children and adolescents diagnosed with major depression. Firstly, ethical considerations influence the selected treatments. Ethical principles such as autonomy and non-maleficence guide the practitioner’s decisions. Autonomy entails protecting a client’s right to self-determination. Healthcare providers ensure informed consent is obtained from the parents and legal custodians of the children and adolescents when treating major depression (Dwyer & Bloch, 2019). They also make decisions that are associated with optimum benefits such as a reduction in symptoms of major depression and minimum risk of patient harm.
Legal considerations also affect the treatment of major depression in children and adolescents. Healthcare providers must ensure data privacy and confidentiality when treating major depression in children and adolescents. They should ensure that unauthorized parties do not access the patient’s data. Informed consent should be obtained before sharing the information with other healthcare providers. Healthcare providers must also make decisions in the client’s best interest to prevent negligence in their practice. Nurse practitioners should also be aware of the effect of culture on treatment outcomes in children and adolescents with major depression. Cultural practices associated with mental health problems such as stigma and isolation lower treatment utilization and adherence (Zhou et al., 2020). Healthcare providers must advocate the adoption of strategies that address stereotypes related to mental health problems in their communities.
Social determinants of health also influence major depression among children and adolescents. Children and adolescents born to poor families are likely to experience barriers in accessing their needed mental healthcare services due to issues such as cost. Income and education levels also influence the access to and utilization of mental health services by this population (Sokol et al., 2019). Therefore, addressing social determinants of health would result in increased access to mental healthcare services for children and adolescents.
Follow-Up
Antidepressants take between two and six weeks to produce the desired effects in managing depressive symptoms. Therefore, patients should be followed up after two weeks to assess their response to treatment and identify any issues that should be addressed for optimum treatment outcomes. Patients should also be linked with social support groups for mental health problems to help them learn effective ways to cope with their conditions.
Examples of Proper Prescription
Name: L.L.
Age: 12 years
Diagnosis: Major depression
Treatment: Oral sertraline 25 mg OD for two weeks
Refills: none
Follow-up: after two weeks
Name of the prescriber and DEA number:
Name: Y.Y.
Age: 14 years
Diagnosis: Major depression
Treatment: Oral escitalopram 25 mg once daily for two weeks
Refills: none
Follow-up: two weeks
Name of the prescriber and DEA number:
Name: L.A.
Age: 17 years
Diagnosis: Major depression
Treatment: Oral Fluoxetine 25 mg once daily for two weeks
Refills: none
Follow-up: two weeks
Name of the prescriber and DEA number:
Conclusion
In summary, major depression in children and adolescents is the selected depressive disorder of focus in this assignment. FDA-approved and non-approved antidepressants are used in treating major depression in children and adolescents. Healthcare providers should weigh the benefits and risks of the available treatment. Legal, ethical, and cultural considerations and social determinants of health inform treatment decisions in children and adolescents diagnose with major depression.
References
Boaden, K., Tomlinson, A., Cortese, S., & Cipriani, A. (2020). Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment. Frontiers in Psychiatry, 11. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00717
Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26-42F.
Farley, H. R. (2020). Assessing mental health in vulnerable adolescents. Nursing2023, 50(10), 48. https://doi.org/10.1097/01.NURSE.0000697168.39814.93
Feeney, A., Hock, R. S., Fava, M., Hernández Ortiz, J. M., Iovieno, N., & Papakostas, G. I. (2022). Antidepressants in children and adolescents with major depressive disorder and the influence of placebo response: A meta-analysis. Journal of Affective Disorders, 305, 55–64. https://doi.org/10.1016/j.jad.2022.02.074
Hazell, P. (2022). Antidepressants in adolescence. Australian Prescriber, 45(2). https://doi.org/10.18773/austprescr.2022.011
Selph, S. S., & McDonagh, M. S. (2019). Depression in Children and Adolescents: Evaluation and Treatment. DEPRESSION IN CHILDREN AND ADOLESCENTS, 100(10).
Sokol, R., Austin, A., Chandler, C., Byrum, E., Bousquette, J., Lancaster, C., Doss, G., Dotson, A., Urbaeva, V., Singichetti, B., Brevard, K., Wright, S. T., Lanier, P., & Shanahan, M. (2019). Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics, 144(4), e20191622. https://doi.org/10.1542/peds.2019-1622
Zhou, X., Teng, T., Zhang, Y., Giovane, C. D., Furukawa, T. A., Weisz, J. R., Li, X., Cuijpers, P., Coghill, D., Xiang, Y., Hetrick, S. E., Leucht, S., Qin, M., Barth, J., Ravindran, A. V., Yang, L., Curry, J., Fan, L., Silva, S. G., … 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. https://doi.org/10.1016/S2215-0366(20)30137-1
1. Explain the agonist-to-antagonist spectrum of action of psychopharmacologic agents, including how partial and inverse agonist functionality may impact the efficacy of psychopharmacologic treatments.
The agonist spectrum can be explained best as a scale from agonist to inverse agonist; with natural neurotransmitters being an agonist or drugs that stimulate the receptors for that action. Partial agonist follows the agonist because of drugs that stimulate the same receptors on a lower gradation of the spectrum (Stahl, 2021). The next level on the spectrum is the antagonist blocking the action of the agonist (Stahl, 2021).
The final function is the inverse agonist has two behaviors: (1) block the agonist, and (2) lower the level of activity below the starting point in absence of an agonist (Stahl, 2021). The best way to explain a partial agonist is to present a medication used in the treatment of depression. Vilazodone is a serotonin reuptake inhibitor, which causes a rise in serotonin at the synaptic cleft by preventing the re-uptake of serotonin at the presynaptic axon terminal (Comprodon & Roffman, 2016).
However, Vilazodone also signals the 5HT1A presynaptic receptors and causes a decrease in the production of serotonin acting as a partial agonist (Baumgartnera et al., 2020). The outcome of partial and inverse agonists can be a marked increase or decrease in the concentration of a drug from the inhibition or excitation of the drug’s receptors (Comprodon & Roffman, 2016).
2. Compare and contrast the actions of g couple proteins and ion gated channels.
Two of the four methods of signal transduction involve neurotransmitters rather than hormones or neurotrophins (Stahl, 2021). G-coupled proteins and ion-gated channels are similar because they are stimulated by drugs that cause neurotransmitters to activate genes inside of the cell when a phosphate is added to the cAMP protein (Stahl, 2021).
Although they have similarities, the first, G-coupled proteins, cause a slow neuronal effect as a result of its action with cAMP and protein kinase A (Comprodon & Roffman, 2016). The second, ion-gated channels, cause a rapid neuronal effect on the membrane potential as a result of calcium and a kinase called CaMK (Comprodon & Roffman, 2016).
3. Explain how the role of epigenetics may contribute to pharmacologic action.
Epigenetics describes the heritable action of DNA when gene function changes from one
Foundational Neuroscience Psych Treatment Discussion
generation to the next because of the influence of the external milieu (Comprodon & Roffman, 2016). DNA can be affected by experiences triggering phenotype modifications rather than genotype changes medications (Quevedo et al., 2022). Stress, such as physical abuse in children, is positively correlated with the development of borderline personality disorder (Comprodon & Roffman, 2016; Quevedo et al., 2022).
The downstream effect of neuroplasticity can result in changes at the genetic level resulting in DNA sequencing variations (Quevedo et al., 2022). Once the chromatin’s structure is modified, the encoding of proteins may alter the original behavior of synaptic uptake of drugs causing changes of pharmacological action, such as enhanced or diminished responses to medications (Quevedo et al., 2022). The increased or decreased action at the receptor site may enhance or inhibit the action of a drug and cause an unexpected outcome.
4. Explain how this information may impact the way you prescribe medications to patients. Include a specific example of a situation or case with a patient in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.
Epigenetic changes are crucial to understand when prescribing medications to patients who have suffered trauma (child abuse, substance misuse, malnutrition, etc.) resulting in DNA silencing or activation (Comprodon & Roffman, 2016). The stress response to physical, emotional, or sexual abuse can cause increased DNA methylation in various tissues in the body, namely blood, saliva, and brain tissue (Quevedo et al., 2022). Therefore, the PMHNP should be well versed in the biomechanics of a medication for appropriate and effective prescribing.
One example is the higher reactivity of the HPA axis to adverse childhood experiences stimulating Corticotropin Releasing Hormone (CRH), which triggers the release of adrenocorticotropin hormone from the pituitary gland (Quevedo et al., 2022). A corticotropin releasing hormone antagonist may be ineffective if one’s mental health is severely affected by a history of abuse. Therefore, the PMHNP should consider an alternative medication to a CRH antagonist.
References
Baumgartnera, K., Doeringb, M., & Schwarz, E. (2020). Vilazodone poisoning: A systematic review. Clinical Toxicology, 58(5), 360–367. https://doi.org/10.1080/15563650.2019.1691221
Links to an external site.
Camprodon, J. A., & Roffman, J. L. (2016). Psychiatric neuroscience: Incorporating pathophysiology into clinical case formulation. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (pp. 1–19). Elsevier.
Quevedo, Y., Booij, L., Herrera, L., Hernández, C., & Jiménez, J. P. (2022). Potential epigenetic mechanisms in psychotherapy: A pilot study on DNA methylation and mentalization change in borderline personality disorder. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2022.955005
This is a detailed and exceptional work, Anitha. I have learned from your post that the ion-gated channels and g-coupled proteins are postsynaptic ion channels that ensure hyperpolarization and depolarization of postsynaptic neurons (Duncan et al., 2020). Epigenetics plays a role in pharmacological action by affecting the pharmacokinetics and pharmacodynamics of medication. The variability is associated with mutations and changes in the medication metabolizing enzymes and medication carriers programmed by numerous genes.
Understanding epigenetics is crucial for PMHNPs when prescribing medications to patients. Various conditions including neurodegenerative disorders are linked to epigenetic changes, and DNA methylation is a critical adjustment that causes disease (Kringel et al., 2021).
As such, it is advisable for PMHNPs to consider conducting epigenetic and genetic diagnostic testing to help in the recognition of molecular biomarkers linked to gene mutation and the application of medicines tailored to patient needs based on levels of proteins, RNA, and different metabolites. PMHNPs should also consider patient education and awareness about pharmacogenomics during the assessment.
References
Duncan, A. L., Song, W., & Sansom, M. S. (2020). Lipid-dependent regulation of ion channels and G protein–coupled receptors: insights from structures and simulations. Annual Review of Pharmacology and Toxicology, 60, 31-50. https://www.annualreviews.org/doi/abs/10.1146/annurev-pharmtox-010919-023411
Kringel, D., Malkusch, S., & Lötsch, J. (2021). Drugs and epigenetic molecular functions. A pharmacological data scientometric analysis. International Journal of Molecular Sciences, 22(14), 7250. https://doi.org/10.3390/ijms22147250
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Qestion Description
I’m working on a Nursing question and need guidance to help me study.
Agonist-to-Antagonist
When a drug works as an agonist, it binds to the receptors and copies the body’s molecules (Rosenthal & Burchum, 2020). This increases the effects of the neurotransmitter on the postsynaptic neuron of a cell (Rosenthal & Burchum, 2020). Lorazepam, a benzodiazepine, acts as an agonist at the specific receptor and assists the gamma-aminobutyric acid (GABA) (Kowalski et al., 2017).
An antagonist is a drug with an affinity for a particular receptor site but does not have intrinsic activity (Rosenthal & Burchum, 2020). Antagonists have no effect by themselves on receptor function. However, just because they do not cause activation, they still produce pharmacologic effects. Antagonists cause effects by preventing the activation of the receptors (Rosenthal & Burchum, 2020). Keep in mind, the response to an antagonist is determined by the amount of the agonist present.
Flumazenil is a benzodiazepine antagonist(Kowalski et al., 2017). Nothing happens unless a benzodiazepine is present. When a benzodiazepine is present, flumazenil reverses the activity and returns the cell’s ion channel to its resting state and why it is used in benzodiazepine overdose (Kowalski et al., 2017). Agonists can also be partial agonists which only have moderate intrinsic activity. This results in the maximum effect of a partial agonist are less than that of a full agonist, as one would expect (Rosenthal & Burchum, 2020).
Partial agonists can sometimes act as antagonists and are sometimes referred to as agonist-antagonists(Rosenthal & Burchum, 2020). Buspirone is a partial agonist on serotonin 1a receptors (Kowalski et al., 2017). An inverse agonist has the opposite effect of an agonist and depends on the receptor continuing to fire in the absence of an agonist (Kowalski et al., 2017). Kowalski et al. (2017) state that if an agonist opens a channel, an inverse agonist will close it. Naloxone is an example of an inverse agonist (Kowalski et al., 2017).
G Coupled Proteins and Ion Gated Channels
G-protein coupled receptors (GPCR) are the largest class of membrane protein receptors. GCPRs share a common architecture and sense molecules outside the cell and activate signal transduction inside the cell, which produced a cellular response (Alexander et al., 2019). They are made up of receptors for hormones such as calcitonin and neurotransmitters like serotonin and dopamine (Alexander et al., 2019).
They are the frequent target of medication. Ion gated channels regulate cellular excitability (McCance & Huether, 2019). They contain calcium, sodium, and potassium channels, which open and close depending on the action of the neurotransmitter, drug, or hormone (McCance & Huether, 2019).
Both GPCRs and ion gated channels are present in the plasma membrane and are essential in intracellular signaling. The most significant difference between the two is the amount of time it takes to produce the action onset (Stahl, 2013). Ion channel medications cause the ion to attach to the receptor triggering the ions’ movement, causing an immediate reaction to the drug (Stahl, 2013).
GCPR medications cause a chemical to bind to the receptor triggering changes altering which genes are expressed and which proteins are created (Stahl, 2013). This type of response occurs over time and have a more prolonged onset of action (Stahl, 2013).
Epigenetics
While epigenetics has various meanings, the overall idea is that gene function can be changed by an individual’s behavior and environment (CDC, 2020). Unlike genetic changes, epigenetic changes are reversible and do not affect the DNA sequence directly. However, they can change how your body reads a sequence of DNA (CDC, 2020).
Genetic changes alter how a protein is made, epigenetics change on/off switch of the way genes are expressed. Medications are one-way switch gets flipped or not (CDC, 2020). Changes caused by medications do not affect the receptor alone but can cause a widespread response to regulate the genes (CDC, 2020).
Impact
As healthcare providers, it is crucial to understand how a medication will affect the patient. There are many medications prescribed to treat psychiatric disord
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