Therapy for Pediatric Clients with Mood Disorders
An African American Child Suffering From Depression
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Mother reports that teacher said child is withdrawn from peers in class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
Begin Paxil 10 mg orally daily
Begin Wellbutrin 75 mg orally BID
Decision Point One
Begin Zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Slight increase in mood
No HAM-D results
No adverse events reported
Decision Point Two
Increase dose to 37.5 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Depressive symptoms decrease by 20%. Client reports feeling a little bit better
Decision Point Three
Maintain current dose
Guidance to Student
At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.
Assignment: Assessing and Treating Pediatric Patients With Mood Disorders
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.
Learning Resources
Required Readings (click to expand/reduce)
Baek, J. H., Nierenberg, A. A., & Fava, M. (2016). Pharmacological approaches to treatment-resistant depression. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 44–47). Elsevier.
Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 27–43). Elsevier.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Howland, R. H. (2008a). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21–24. https://doi.org/10.3928/02793695-20080901-06
Howland, R. H. (2008b). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21–24. https://doi.org/10.3928/02793695-20081001-05
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. https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf
Magellan Health. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf
Poznanski, E. O., & Mokros, H. B. (1996). Child depression rating scale—Revised. Western Psychological Services.
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. https://doi.org/10.1002/da.22171
Yasuda, S. U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
Medication Resources (click to expand/reduce)
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
Review the following medications:
amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
Required Media (click to expand/reduce)
Case Study: An African American Child Suffering from Depression
Note: This case study will serve as the foundation for this week’s Assignment.
Optional Resources (click to expand/reduce)
El Marroun, H., White, T., Verhulst, F., & Tiemeier, H. (2014). Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: A systematic review. European Child & Adolescent Psychiatry, 23(10), 973–992. https://doi.org/10.1007/s00787-014-0558-3
Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal? Journal of Pediatrics and Child Health, 50(11), 847–854. https://doi.org/10.1111/jpc.12655
Seedat, S. (2014). Controversies in the use of antidepressants in children and adolescents: A decade since the storm and where do we stand now? Journal of Child & Adolescent Mental Health, 26(2),
iii–v. https://doi.org/10.2989/17280583.2014.938497
3) Decision trees: I have posted guidance regarding the decision trees. Please read this announcement, and then read it again. There are some weeks when > 1 answer may be acceptable with rationale to back it up, and some weeks where there is one correct answer and multiple wrong answers. For example, if a patient has a genetic condition that prevents them from metabolizing a drug, and you choose to prescribe that drug , the grade you receive for the decision tree will be low as you clearly chose the incorrect answer. I expect you to state why you feel your choices are superior to the other choices available with evidence to back up your statements. I cannot emphasize that enough. Please also be sure to include ethical considerations as well as a minimum of 5 references.
Just to clear up any confusion that might exist – discussions require a minimum of 3 references, decision trees require a minimum of 5 references. You may use the book as 1 of the references for both discussions & decision trees.
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