Assessing and Treating Pediatric Patients With Mood Disorders Essay

Introduction to the Case  

The case study is about an 8-year-old African American male who came to the ER accompanied by his mother. The mother reported that the client manifested symptoms such as sadness, withdrawing from his peers, decreased appetite, and erratic periods of irritation. The assessment indicated that the client has achieved all the developmental landmarks appropriate for his age and the physical examination did not reveal any abnormality. The mental status exam (MSE) showed that he was oriented to person, event, time, and place and was alert. Additionally, his speech was coherent and clear, and he was spontaneous and goal-directed. The client’s self-reported mood was “sad” but he would smile numerous times during the interview. The client denied any visual or auditory hallucinations and also the assessment did not reveal any delusional thought process or paranoia. The client’s judgment and insight also appeared appropriate for his age. Even though the client denied any suicidal ideation, he reported that he often thought himself of being dead and often imagined how it would be like if he was dead. The client’s score for the Children’s Depression Rating Scale was 30, and this revealed that he had significant depression. The diagnosis was thus depression. Accordingly, this assignment discusses three treatment decisions that will be selected for the client. Since the client is a child, it will be appropriate to choose a medication with high tolerability, few side effects, and a good safety profile. The paper will conclude by discussing the ethical issues that could impact the treatment plan for this client.

Decision Point 1

The first decision is for the client to begin Zoloft 25 mg orally. The reason for selecting this decision is because Zoloft has been shown to be effective in the treatment of depressive symptoms in children six years and above and also the medication is well tolerated in the pediatric population (Garland et al., 2016). Zoloft is an SSRI and works by increasing the amount of serotonin within the brain. Serotonin is a chemical in the brain that controls moods and hence increasing serotonin levels within the brain will improve the client’s mood and consequently improve the depressive symptoms (Dwyer & Bloch, 2019).

The reason for not selecting Paxil 10 mg is because the medication has so many side effects that include nausea, appetite loss, sleep disturbances, shaking, blurred vision, and other associated symptoms. Moreover, Paxil has been shown to increase suicidal thoughts in the pediatric population with depression (Wang et al., 2018).

Similarly, the reason for not selecting Wellbutrin is due to the many side effects that include low appetite, dizziness, sleep disturbances, constipation, headache, dry mouth, and seizures. Additionally, evidence has not established the safety, tolerability, and efficacy of Wellbutrin in children (Yasin et al., 2019).

By selecting Zoloft, the expectations are that the client would start manifesting symptom reduction as manifested by improved mood, interacting with peers, improved appetite, and reduced irritability. It was also expected that the client would tolerate the mediation and thus will not experience any side effects.  This is due to the efficacy of the medication in the treatment of depression in children and also because the mediation has been shown to be well-tolerated and safe in the pediatric population (Dwyer & Bloch, 2019).

However, even though the client tolerated the medication and did not report any side effects as expected, the client did not show any symptom improvement. The lack of response to the treatment can be associated with the low start Zoloft dose that reduced the medication’s efficacy. This is because the efficacy of SSRIs such as Zoloft is dose-dependent and hence the higher the dose, the higher the efficacy (Feng et al., 2018).

Ethical Considerations

The ethical consideration in this decision is to seek informed consent. First, since the client is a minor, he might not be able to make any treatment decisions and hence his parents will make all his treatment decisions. Therefore, it is the parents who will consent to his treatment. The PMHNP should thus inform and educate the parents about all the available treatment choices, and provide all the information, including side effects associated with each medication. This will enable the parents to make an informed treatment decision (Belitz, 2018).

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Decision Point Two

The second treatment decision that was selected for this client is to increase the dose of Zoloft from 25 mg to 50 mg orally. This is because the efficacy of SSRIs like Zoloft depends on the amount of dose where higher doses of SSRIs have higher efficacy (Hieronymus et al., 2016). Therefore, with the increased dose of Zoloft, it is expected that the expected that medication will have higher efficacy and thus the client will show symptom improvement.

The decision to change the medication from Zoloft to Paxil was not selected because Paxil has so many side effects. Moreover, the maximum dose of Zoloft has not been used on the client and hence there is no clinical reason to change the treatment regimen. The decision to have the Zoloft dose increased to 37.5 mg was not selected because Zoloft is supposed to be started at 25 mg and titration of the dose done upwards to 50 mg, after one week.

Increasing the dose of Zoloft from 25 mg to 5o mg expected that the client would respond to treatment, and hence manifest symptom reduction. This is due to the fact that the efficacy of SSRIs like Zoloft depends on the dosage, where higher doses are more effective (Hieronymus et al., 2016). Therefore, increasing Zoloft dose to 50 mg would be more effective than Zoloft 25 mg. Secondly, it is expected that the client would tolerate the higher dose of Zoloft, without any side effects.

As was anticipated, the client started manifesting significant symptom improvement with a higher dose of Zoloft (50 mg). The findings indicated that the client’s symptoms reduced by 50%. The symptom reduction is due to the increased efficacy of higher Zoloft doses (Hieronymus et al., 2016). Additionally, as it was expected, the client tolerated the increased dose and he did not report any side effect.

Ethical Considerations

This decision involved increasing the dose of Zoloft for the client. Therefore, the PMHNP should seek informed consent from the mother before administering a higher Zoloft dose. The PMHNP should explain to the mother about the possible effects of the increased dose, such as the possibility of side effects due to the increased dose. Beneficence is another relevant ethical principle, where the PMHNP should act in the client’s best interest (Yip et al., 2016). The act of beneficence involved prescribing the medication to improve the patient’s symptoms and at the same time with minimal side effects.

Decision Point Three

The third decision for this client is maintaining the current dose of Zoloft 50 mg. This decision was selected because the client is already showing a significant response (50% response) to the current Zoloft dose of 50 mg. Evidence recommends that the selection of antidepressants such as Zoloft should take into consideration the treatment responsiveness, potential benefits, and also the side effects of the medication (Lewis et al., 2019). Therefore, the minimum effective dose of Zoloft should be selected to avoid any side effects due to an increased dose.

The reason why the decision to change medication to SNRI was not selected is because the client is already responding to the first-line treatment (SSRI) and thus there is no clinical decision to change to SNRI. SSRIs such as Zoloft are the first treatment choice during the treatment of depression due to the efficacy, better tolerability, and few side effects.

The decision to have the Zoloft dose increased from 50 mg to 75 mg was not selected because with the Zoloft 50 mg, the client is also showing adequate symptom improvement (50%). Moreover, with the Zoloft 50 mg, the client did not report any side effects, which indicates that he is tolerating the dose well. Increasing the dose of Zoloft to 75 mg can cause unwanted side effects for this client (Carvalho et al., 2016).

Maintaining the current Zoloft dose (50 mg) hopes that the client would continue responding to treatment by showing symptom improvement and eventually have complete symptom remission. This is due to the efficacy of the medication in treating depressive symptoms. It is also hoped that the client would not have any side effects because he will continue tolerating the current dose of Zoloft 50 mg.

Ethical Considerations

This decision involved maintaining the current Zoloft dose. The relevant ethical principle is beneficence where the PMHNP should act to the client’s best interests by ensuring that the prescribed dose does not lead to unwanted side effects. Moreover, it is important to ensure that the privacy and confidentiality of the client’s information are protected (Yip et al., 2016). This will be achieved by ensuring that the PMHNP does not reveal the patient information to third parties and ensuring that the information can only be accessed by the authorized people like his parents and the relevant healthcare providers.

Conclusion

The first decision chosen is for the client to start Zoloft 25 mg orally. This is because Zoloft has been demonstrated to be effective in treating depressive symptoms and the medication is also recommended for the treatment of depression in children aged 6 years and above. Additionally, Zoloft is well-tolerated and safe for the pediatric population. Wellbutrin and Paxil were not chosen because these medications have so many side effects and hence the client might not tolerate these medications. However, with the Zoloft 25 mg, the client did not show any symptom improvement and thus the second decision was to increase the Zoloft dose to 50 mg. the decision to increase the Zoloft dose was selected since the efficacy of SSRIs has been shown to increase with increased doses. Therefore, a higher dose of Zoloft is expected to have increased efficacy. As expected, with the increased dose of Zoloft the client started responding to the treatment as indicated by 50% symptom improvement. Moreover, the client did not experience any side effects with the increased Zoloft dose. Changing the treatment from Zoloft to Paxil was not selected since this medication is allowed to several side effects and hence the client would not tolerate an increased dose. On the other hand, the decision for not selecting the decision to have the Zoloft dose increased to Zoloft 37.5 mg is because the Zoloft dose is supposed to begin at 25 mg, followed by an upward titration to 50 mg, after one week. The third decision was maintaining the Zoloft dose of 50 mg since the client was already showing a significant response to this dose without any side effects. Changing to an SNRI was not chosen because the client is already showing significant symptom improvement with the first-line treatment of SSRIs. Additionally, the decision to have the dose increased to Zoloft 75mg was not selected since the client is already responding adequately to Zoloft 50 mg and to avoid the client experiencing side effects with the increased dose. The ethical issues that can influence the client’s treatment plan are confidentiality, informed consent, and autonomy.

References

Belitz, J. (2018). Ethics in assessing and treating children and adolescents. In J. N. Butcher & P. C. Kendall (Eds.), APA handbooks in psychology®. APA handbook of psychopathology: Child and adolescent psychopathology (p. 589–606). American Psychological Association.

Carvalho A, Sharma M, Brunoni A, Vieta E & Fava G. (2016). The Safety, Tolerability, and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychother Psychosom, 2016(85), 270–288.

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26–42F.

Feng, R., Wang, P., Gao, C., Yang, J., Chen, Z., Yang, Y., Jiao, J., Li, M., Fu, B., Li, L., Zhang, Z., & Wang, S. (2018). Effect of sertraline in the treatment and prevention of poststroke depression: A meta-analysis. Medicine, 97(49), e13453. https://doi.org/10.1097/MD.0000000000013453

Garland, E., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent, 25(1), 4–10.

Hieronymus F, Nilsson S & Eriksson E. (2016). A meta-analysis of fixed-dose trials reveals dose-dependency and rapid onset of action for the antidepressant effect of three selective serotonin reuptake inhibitors. Transl Psychiatry, 6(6), e834.

Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Gilbody, S. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomized trial. The Lancet Psychiatry, 6(11), 903-914.

Wang, S. M., Han, C., Bahk, W. M., Lee, S. J., Patkar, A. A., Masand, P. S., & Pae, C. U. (2018). Addressing the Side Effects of Contemporary Antidepressant Drugs: A Comprehensive Review. Chonnam medical journal, 54(2), 101–112. https://doi.org/10.4068/cmj.2018.54.2.101

Yasin, W., Ahmed, S. I., & Gouthro, R. V. (2019). Does Bupropion Impact More than Mood? A Case Report and Review of the Literature. Cureus, 11(3), e4277. https://doi.org/10.7759/cureus.4277

Yip, C., Han, N. R., & Sng, B. L. (2016). Legal and ethical issues in research. Indian journal of anesthesia, 60(9), 684–688. https://doi.org/10.4103/0019-5049.190627

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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.
https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_02/1.html

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