NURS 6630 Assessing and Treating Pediatric Patients With Mood Disorders

Sample Answer for NURS 6630 Assessing and Treating Pediatric Patients With Mood Disorders Included After Question

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.

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Pediatric Patients With Mood Disorders

According to theNational Institute of Mental Health,approximately 9% of teenagers from the age of 12 to 17 years have depression disorder in the United States.Ghandour et al., (2019) reported that about 3.2% of African American adolescents presented with suicidal thoughtsin 2018as 1.4%tried to commit. Despite the burden associated with this mental disorder, several treatment options are available to help manage the symptoms and promote the quality of life of children and adolescents with this disorder.

The assigned case study demonstrates an African American boy child diagnosed with depression. The patient reports symptoms such as irritability, feeling sad, decreased appetite, and withdrawalfrom social gatherings like school. The conducted mental status examination revealed that the patient is suicidal, but has never tried to kill himself. The patient however denies hallucinations and delirium among other psychotic symptoms. Based on clinical practice guidelines and DSM-5 diagnostic criteria,together with a score of 30 on theChildren’s Depression Rating Scale,the patient’s primary diagnosis is depression.

The patient’s age, African American race, and anxiety diagnosis are some of the factors which might affect the choice of drugs for the management of the patient’s symptoms. For instance, most antipsychotic agents are associated with suicidal attempts, among other side effects hence must be monitored closely when use among children and adolescents. Additionally, a study conducted by (Leichsenring et al., 2021) reported that African Americans are more likely tocarry alleles that slow down the metabolism of most antidepressants such as tricyclic antidepressants (TCA), leading to a ‘slowmetabolizer’ phenotype hence higher blood TCA plasma level, in addition to more rapid response. The purpose of this paper is to demonstrate the decision-making process of the most effective medication to include in the patient’s treatment plan, while observing pharmacokinetic and pharmacodynamic factors, in addition to ethical considerations which might impact this care process.

Decision #1 Top of Form

Selected Decision and Rationale

The initial intervention is to start the patient on Zoloft 25 mg orally once daily. Sertraline belongs to the class of selective serotonin reuptake inhibitors (SSRIs), recommended in national clinical guidelines as the first-line for the management of depression in children and adults (Walkup, 2017).

Considering the patient’s specific factors, Zoloft is the best choice of drug for the management of depressive symptoms displayed by the patient. anxiety symptoms. For instance,most studies recommend the use of sertraline among children as a result of its great effectiveness and desirable safety profile reported by the few conducted clinical trials. The drug acts by inhibiting the central nervous system (CNS) neuronal uptake of serotonin(5HT) (Pile et al., 2020). Among children, the recommended starting dose is 25mg.

The drug is absorbed slowly in the GIT with a peak plasma level being attained after 6 to 8 hours, necessary to elicit optimal therapeutic action. Studies have also identified several polymorphisms in genes encoding P-450 isoenzymes (2D6 and 2C19) among African Americans which affect the metabolism of the drug. However, when used in low disease, the drugs have displayed great effectiveness with an appealing safety profile. 

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Wellbutrin on the other hand is not recommended for children less than 18 years due to evidence deficits in its safety and effectiveness (Ghandour et al., 2019). The drug is also associated with high suicidal incidence, hence not appropriate for this patient as he already displayed symptoms of suicidal ideation. Paxil is also not appropriate for this patient as it is also associated with high suicide incidences as the FDA issued a black box warning for use of the drug among this vulnerable population (Leichsenring et al., 2021). It should only be considered in case there is no other suitable option which in this case is Zoloft as described above.

Expected Outcome

The drug is expected to display at least 50% remission of the patient’s depression symptoms within the next 4 to 8 weeks. As a result, theChildren’s Depression Rating Scalescores are expected to decrease to less than 10 from 30. Only common self-limiting side effects such as dry mouth increased sweating and headache might be expected(Walkup, 2017).

Ethical Considerations

Given that the patient is under the age of 18 years, it will be necessary for the PMHNP to adequately inform the patient’s parents about the available treatment options and their benefits and risks to involve them in decision making concerning the health of their child(Pile et al., 2020).  Parents and guardians have legal authority in making healthcare decisions for their children.

Decision #2

Selected Decision and Rationale

The second decision is to increase the Zoloft dose from 25mg to 50mg PO daily. Studies show that the dose of Zoloft should be increased at intervals of 25mg to 50 mg per day once weekly when the desired therapeutic response has not been attained among children, while closely monitoring the patient’s symptoms(Ghandour et al., 2019).

            This decision was based on the treatment outcome as the patient reported no changes in his depressive symptoms after four weeks of therapy. Increasing the dose of Zoloft to 50 mg is the best decision at this point, and evaluate the patient outcome after another 4 weeks. Studies show t that it takes between 8 to 12 weeks for sertraline to attain optimum therapeutic action in completely managing depression symptoms(Leichsenring et al., 2021).  However, the dose must be increased gradually, while monitoring patient symptoms to attain an optimum dose. The patient also displayed no adverse effects, indicating great tolerance to the medication, hence no reason to alter the medication.

Increasing the dose to 37.5mg is not appropriate as this would only display similar results, as that titration rate is not recommended in several clinical guidelines(Walkup, 2017). Consequently, this will only prolong the period of use of the drug to the point where optimum dose will be attained.  Discontinuing the use of sertraline, is also not necessary at this point, as studies only recommend it in case the maximum dose has been reached with no effect or the patient displays adverse effects(Pile et al., 2020). Consequently, studies recommend that the dose be reduced gradually first before switching to another drug like Prozac which is associated with several adverse effects as described above.

Expected Outcome

With the dose increment of Zoloft to 50mg, the patient is expected to display atleast 50% remission of symptoms this time round unlike within the first 4 weeks(Ghandour et al., 2019). His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10. No side effects are expected since the patient already displayed great tolerance to the drug.

Ethical Considerations

The PMHNP has a legal obligation of preventing harm and promoting the health of the patient (Dawson, 2018). As such, considering a dose increment of the drug was the best choice in managing the patient’s symptoms, with limited side effects (Walkup, 2017). This decision promotes ethical principles such as beneficence and non-maleficence.

Decision #3

Selected Decision and Rationale

The last decision is to maintain the dose of Zoloft at 50mg once daily and continue evaluating the progress of the patient. The evidence-based practice recommends dose maintenance once the optimum level has been maintained until the patient’s symptoms have been resolved completely (Pile et al., 2020).

This decision was supported by the outcome the patient displayed in the last four weeks with a 50% reduction in depressive symptoms. The outcome shows great effectiveness and adherence to the medication by the patient, hence the need to maintain the dose. Studies show that it may take the drug another 4 to 8 weeks for Zoloft to completely manage symptoms of depression once the optimum dose has been achieved (Leichsenring et al., 2021). Additionally, this dose is still low hence limiting the possibility of side effects or toxicity. 

Increasing the dose of Zoloft is not necessary as this will only lead to increased risks of adverse effects and toxicity due to increased plasma levels(Dawson, 2018). Additionally, the patient’s age does not allow a higher dose of the drug, as this could lead to increased suicidal ideation. Changing the treatment regimen to another drug, is also not appropriate as this will only lead to new complications (Walkup, 2017). This will also affect the patient compliance with the treatment regimen.

Expected Outcome

The patient is expected to display completely managed depression symptoms within the next four weeks. His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10(Dawson, 2018). The patient’s quality of life will improve within this time, with no side effects reported as a result of the displayed tolerance and adherence to the treatment.

Ethical Considerations

At this point, the PMHNP is required to consider the ethical principle of nonmaleficence. Out of all the available options, maintaining the dose is the only choice that will benefit the patient with no harm (Pile et al., 2020). The patient’s parents must however be informed of the red flags like suicidal ideation and the importance of sticking to the treatment regimen to enhance optimal care outcomes.

Conclusion

Depression is a common mental problem among children below the age of 17 years. It affects both their social and academic life with additional mental and physical health burdens. Researchers have however been able to confirm the effectiveness of several treatment options for the management of depression among this vulnerable population (Ghandour et al., 2019). For the African American child with depression, factors such as his race and age were considered in choosing the best drug in the management of his symptoms.  T

he first choice was Zoloft 25 mg once daily, which is an SSRI recommended by most clinical guidelines as a first-line for the management of depression among children due to its great effectiveness reported in most studies (Pile et al., 2020). Other alternatives such as Paxil and Wellbutrin were not appropriate due to their increased risk of suicide.

The second decision was to increase the dose to 50mg given the lack of effectiveness within the first 4 weeks. Increasing the dose to 37.5mg or replacing the drug with Prozac is not necessary as the former will lead to a similar outcome as the latter will compromise the patient’s tolerance (Walkup, 2017). The last decision was to maintain the dose at 50mg and monitor patient outcome for the next 4 weeks. The patient displayed great effectiveness and tolerance of the second intervention hence the need to maintain the dose. Increasing the dose to 75 or replacing the drug was not necessary as a result of the increased risk of toxicity and adverse events (Leichsenring et al., 2021). On the other hand, the PMHNP had to observe several legal and ethical considerations given that the patient is a minor such as the right to information, beneficence, and non-maleficence (Dawson, 2018).

References

Dawson, R. S. (July 01, 2018). Depression in children and adolescents: The pediatrician at the front lines. Pediatric Annals, 47, 7.)https://doi.org/10.3928/19382359-20180618-01

Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (January 01, 2019). Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. The Journal of Pediatrics, 206, 256-267.https://doi.org/10.1016/j.jpeds.2018.09.021

Leichsenring, F., Luyten, P., Abbass, A., Rabung, S., & Steinert, C. (January 01, 2021). Treatment of depression in children and adolescents. The Lancet. Psychiatry, 8, 2, 96-97.DOI:https://doi.org/10.1016/S2215-0366(20)30492-2

Pile, V., Shammas, D., & Smith, P. (January 01, 2020). Assessment and treatment of depression in children and young people in the United Kingdom: Comparison of access to services and provision at two-time points. Clinical Child Psychology and Psychiatry, 25, 1, 119-132.https://doi.org/10.1177/1359104519858112

Walkup, J. T. (May 01, 2017). Antidepressant efficacy for depression in children and adolescents: Industry- and NIMH-funded studies. American Journal of Psychiatry, 174, 5, 430-437.https://doi.org/10.1176/appi.ajp.2017.16091059

According to theNational Institute of Mental Health,approximately 9% of teenagers from the age of 12 to 17 years have depression disorder in the United States.Ghandour et al., (2019) reported that about 3.2% of African American adolescents presented with suicidal thoughtsin 2018as 1.4%tried to commit. Despite the burden associated with this mental disorder, several treatment options are available to help manage the symptoms and promote the quality of life of children and adolescents with this disorder.

The assigned case study demonstrates an African American boy child diagnosed with depression. The patient reports symptoms such as irritability, feeling sad, decreased appetite, and withdrawalfrom social gatherings like school. The conducted mental status examination revealed that the patient is suicidal, but has never tried to kill himself. The patient however denies hallucinations and delirium among other psychotic symptoms. Based on clinical practice guidelines and DSM-5 diagnostic criteria,together with a score of 30 on theChildren’s Depression Rating Scale,the patient’s primary diagnosis is depression.

The patient’s age, African American race, and anxiety diagnosis are some of the factors which might affect the choice of drugs for the management of the patient’s symptoms. For instance, most antipsychotic agents are associated with suicidal attempts, among other side effects hence must be monitored closely when use among children and adolescents. Additionally, a study conducted by (Leichsenring et al., 2021) reported that African Americans are more likely tocarry alleles that slow down the metabolism of most antidepressants such as tricyclic antidepressants (TCA), leading to a ‘slowmetabolizer’ phenotype hence higher blood TCA plasma level, in addition to more rapid response. The purpose of this paper is to demonstrate the decision-making process of the most effective medication to include in the patient’s treatment plan, while observing pharmacokinetic and pharmacodynamic factors, in addition to ethical considerations which might impact this care process.

Decision #1 Top of Form

Selected Decision and Rationale

The initial intervention is to start the patient on Zoloft 25 mg orally once daily. Sertraline belongs to the class of selective serotonin reuptake inhibitors (SSRIs), recommended in national clinical guidelines as the first-line for the management of depression in children and adults (Walkup, 2017).

Considering the patient’s specific factors, Zoloft is the best choice of drug for the management of depressive symptoms displayed by the patient. anxiety symptoms. For instance,most studies recommend the use of sertraline among children as a result of its great effectiveness and desirable safety profile reported by the few conducted clinical trials. The drug acts by inhibiting the central nervous system (CNS) neuronal uptake of serotonin(5HT) (Pile et al., 2020).

Among children, the recommended starting dose is 25mg. The drug is absorbed slowly in the GIT with a peak plasma level being attained after 6 to 8 hours, necessary to elicit optimal therapeutic action. Studies have also identified several polymorphisms in genes encoding P-450 isoenzymes (2D6 and 2C19) among African Americans which affect the metabolism of the drug. However, when used in low disease, the drugs have displayed great effectiveness with an appealing safety profile. 

Wellbutrin on the other hand is not recommended for children less than 18 years due to evidence deficits in its safety and effectiveness (Ghandour et al., 2019). The drug is also associated with high suicidal incidence, hence not appropriate for this patient as he already displayed symptoms of suicidal ideation. Paxil is also not appropriate for this patient as it is also associated with high suicide incidences as the FDA issued a black box warning for use of the drug among this vulnerable population (Leichsenring et al., 2021). It should only be considered in case there is no other suitable option which in this case is Zoloft as described above.

Expected Outcome

The drug is expected to display at least 50% remission of the patient’s depression symptoms within the next 4 to 8 weeks. As a result, theChildren’s Depression Rating Scalescores are expected to decrease to less than 10 from 30. Only common self-limiting side effects such as dry mouth increased sweating and headache might be expected(Walkup, 2017).

Ethical Considerations

Given that the patient is under the age of 18 years, it will be necessary for the PMHNP to adequately inform the patient’s parents about the available treatment options and their benefits and risks to involve them in decision making concerning the health of their child(Pile et al., 2020).  Parents and guardians have legal authority in making healthcare decisions for their children.

Decision #2

Selected Decision and Rationale

The second decision is to increase the Zoloft dose from 25mg to 50mg PO daily. Studies show that the dose of Zoloft should be increased at intervals of 25mg to 50 mg per day once weekly when the desired therapeutic response has not been attained among children, while closely monitoring the patient’s symptoms(Ghandour et al., 2019).

This decision was based on the treatment outcome as the patient reported no changes in his depressive symptoms after four weeks of therapy. Increasing the dose of Zoloft to 50 mg is the best decision at this point, and evaluate the patient outcome after another 4 weeks. Studies show t that it takes between 8 to 12 weeks for sertraline to attain optimum therapeutic action in completely managing depression symptoms(Leichsenring et al., 2021).  However, the dose must be increased gradually, while monitoring patient symptoms to attain an optimum dose. The patient also displayed no adverse effects, indicating great tolerance to the medication, hence no reason to alter the medication.

Increasing the dose to 37.5mg is not appropriate as this would only display similar results, as that titration rate is not recommended in several clinical guidelines(Walkup, 2017). Consequently, this will only prolong the period of use of the drug to the point where optimum dose will be attained.  Discontinuing the use of sertraline, is also not necessary at this point, as studies only recommend it in case the maximum dose has been reached with no effect or the patient displays adverse effects(Pile et al., 2020). Consequently, studies recommend that the dose be reduced gradually first before switching to another drug like Prozac which is associated with several adverse effects as described above.

Expected Outcome

With the dose increment of Zoloft to 50mg, the patient is expected to display atleast 50% remission of symptoms this time round unlike within the first 4 weeks(Ghandour et al., 2019). His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10. No side effects are expected since the patient already displayed great tolerance to the drug.

Ethical Considerations

The PMHNP has a legal obligation of preventing harm and promoting the health of the patient (Dawson, 2018). As such, considering a dose increment of the drug was the best choice in managing the patient’s symptoms, with limited side effects (Walkup, 2017). This decision promotes ethical principles such as beneficence and non-maleficence.

Decision #3

Selected Decision and Rationale

The last decision is to maintain the dose of Zoloft at 50mg once daily and continue evaluating the progress of the patient. The evidence-based practice recommends dose maintenance once the optimum level has been maintained until the patient’s symptoms have been resolved completely (Pile et al., 2020).

This decision was supported by the outcome the patient displayed in the last four weeks with a 50% reduction in depressive symptoms. The outcome shows great effectiveness and adherence to the medication by the patient, hence the need to maintain the dose. Studies show that it may take the drug another 4 to 8 weeks for Zoloft to completely manage symptoms of depression once the optimum dose has been achieved (Leichsenring et al., 2021). Additionally, this dose is still low hence limiting the possibility of side effects or toxicity. 

Increasing the dose of Zoloft is not necessary as this will only lead to increased risks of adverse effects and toxicity due to increased plasma levels(Dawson, 2018). Additionally, the patient’s age does not allow a higher dose of the drug, as this could lead to increased suicidal ideation. Changing the treatment regimen to another drug, is also not appropriate as this will only lead to new complications (Walkup, 2017). This will also affect the patient compliance with the treatment regimen.

Expected Outcome

The patient is expected to display completely managed depression symptoms within the next four weeks. His score on the Children’s Depression Rating Scalescores is also expected to decrease to less than 10(Dawson, 2018). The patient’s quality of life will improve within this time, with no side effects reported as a result of the displayed tolerance and adherence to the treatment.

Ethical Considerations

At this point, the PMHNP is required to consider the ethical principle of nonmaleficence. Out of all the available options, maintaining the dose is the only choice that will benefit the patient with no harm (Pile et al., 2020). The patient’s parents must however be informed of the red flags like suicidal ideation and the importance of sticking to the treatment regimen to enhance optimal care outcomes.

Conclusion

Depression is a common mental problem among children below the age of 17 years. It affects both their social and academic life with additional mental and physical health burdens. Researchers have however been able to confirm the effectiveness of several treatment options for the management of depression among this vulnerable population (Ghandour et al., 2019). For the African American child with depression, factors such as his race and age were considered in choosing the best drug in the management of his symptoms.  The first choice was Zoloft 25 mg once daily, which is an SSRI recommended by most clinical guidelines as a first-line for the management of depression among children due to its great effectiveness reported in most studies (Pile et al., 2020). Other alternatives such as Paxil and Wellbutrin were not appropriate due to their increased risk of suicide.

The second decision was to increase the dose to 50mg given the lack of effectiveness within the first 4 weeks. Increasing the dose to 37.5mg or replacing the drug with Prozac is not necessary as the former will lead to a similar outcome as the latter will compromise the patient’s tolerance (Walkup, 2017). The last decision was to maintain the dose at 50mg and monitor patient outcome for the next 4 weeks. The patient displayed great effectiveness and tolerance of the second intervention hence the need to maintain the dose. Increasing the dose to 75 or replacing the drug was not necessary as a result of the increased risk of toxicity and adverse events (Leichsenring et al., 2021). On the other hand, the PMHNP had to observe several legal and ethical considerations given that the patient is a minor such as the right to information, beneficence, and non-maleficence (Dawson, 2018).

References

Dawson, R. S. (July 01, 2018). Depression in children and adolescents: The pediatrician at the front lines. Pediatric Annals, 47, 7.)https://doi.org/10.3928/19382359-20180618-01

Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (January 01, 2019). Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. The Journal of Pediatrics, 206, 256-267.https://doi.org/10.1016/j.jpeds.2018.09.021

Leichsenring, F., Luyten, P., Abbass, A., Rabung, S., & Steinert, C. (January 01, 2021). Treatment of depression in children and adolescents. The Lancet. Psychiatry, 8, 2, 96-97.DOI:https://doi.org/10.1016/S2215-0366(20)30492-2

Pile, V., Shammas, D., & Smith, P. (January 01, 2020). Assessment and treatment of depression in children and young people in the United Kingdom: Comparison of access to services and provision at two-time points. Clinical Child Psychology and Psychiatry, 25, 1, 119-132.https://doi.org/10.1177/1359104519858112

Walkup, J. T. (May 01, 2017). Antidepressant efficacy for depression in children and adolescents: Industry- and NIMH-funded studies. American Journal of Psychiatry, 174, 5, 430-437.https://doi.org/10.1176/appi.ajp.2017.16091059