Sample Answer for NURS 6630 Assessing and Treating Pediatric Patients With Mood Disorders Included After Question
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.
A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Pediatric Patients With Mood Disorders
Title: NURS 6630 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.
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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.
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