Feb 23, 2024 Week 4: Assessing and Treating Pediatric Patients With Mood Disorders NURS 6630
Week 4: Assessing and Treating Pediatric Patients With Mood Disorders NURS 6630
Week 4: 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 The patient is positive for loss of appetite, feeling sad, being irritable and withdrawn, even from his peers at school.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.
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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
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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