Essay on Depression

Introduction to the Case

The case study involves an 8-year-old African American boy who presented to the ER with his mother. The client manifested signs of depression such as feeling sad; being withdrawn from peers in class; reduced appetite and sporadic periods of irritation. The client has reached all developmental landmarks at proper ages and the findings from the physical exam were normal. The client was referred to psychiatry for further assessment. The mental status exam (MSE) indicated that the client was alert and oriented to time, event, and place; his speech was clear and coherent, and he was also goal-directed and spontaneous. His self-reported mood was “sad” and he smiled normally several times during the clinical interview. The client’s affect was somewhat blunted. He denies any auditory or visual hallucinations. The assessment did not indicate any paranoid or delusional thought process and his insight and judgment appeared appropriate for his age. He denied any suicidal ideation but admitted that he often thinks of himself being dead and imagines what it would like to be dead. The client was administered with the Children’s Depression Rating Scale and scored 30, indicating significant depression. The client was thus diagnosed with depression. This assignment will discuss three treatment decisions for the client. The client is a pediatric patient and thus it will be good to select the medication with a good safety profile and few side effects/metabolic effects. The paper will also discuss the ethical issues likely to influence and affect the client’s treatment plan.

Decision Point One

The appropriate treatment decision is for the client to start Zoloft 25 mg orally. This decision was chosen because studies show that Zoloft is safe and effective in the treatment of depression in the pediatric population aged six years and above. The safety and tolerability of Zoloft in children have been established (Locher et al., 2017). The medication is an SSRI whose mechanism of action is by elevating the level of serotonin in the brain. The increased amount of serotonin in the brain will improve the client’s mood and thus help in improving the depressive symptoms.

Paxil 10 mg was not chosen since Paxil is associated with numerous side effects such as sleep problems, nausea, loss of appetite, blurred vision, shaking, among other symptoms. Additionally, the medication has been demonstrated to increase suicidal thoughts among children with depressive symptoms (Locher et al., 2017).

Wellbutrin was not chosen because it is also associated with numerous side effects such as reduced appetite, constipation, dizziness, drowsiness, sleep problems, seizures, headache, and dry mouth (Patel et al., 2016). Moreover, Locher et al (2017) explain that the tolerability, safety, and efficacy of Wellbutrin in the pediatric population have not been systematically studied.

Selection of Zoloft medication hoped that the client would respond to treatment as manifested by improved depressive symptoms such as improved mood, improved appetite, and increased interaction with his peers. It is also expected that the client will tolerate the drug and hence he will manifest few or no side effects. The efficacy of Zoloft in treating and improving depressive symptoms, safety, and tolerability in the pediatric population has been proved in various studies.

However, there was no symptom improvement as the client still manifested depressive symptoms. The lack of improvement is attributable to the low dosage of Zoloft that led to the low efficacy of the medication. Hieronymus et al (2016) explains that the efficacy of SSRI antidepressants such as Zoloft is characterized by a dose-response relationship.

Decision Point Two

The selected treatment decision is to increase the Zoloft dose to 50 mg orally. This decision was chosen because evidence demonstrates that the efficacy of SSRIs such as Zoloft is dose-dependent and hence higher doses of Zoloft have higher efficacy when compare to the lower doses (Hieronymus et al., 2016).

The decision to change the treatment regimen to Paxil was not chosen because of the many side effects associated with Paxil (Wang et al., 2018). Additionally, the maximum dose of Zoloft has not been administered, and hence there is no clinical reason to change the medication. The decision to increase the dose of Zoloft to 37.5 mg was not chosen since Zoloft treatment should start at a dose of 25 mg and the dose titrated upwards after a week to 50 mg (Santarsieri & Thomas, 2015).

By increasing the dose of Zoloft to 50 mg, the expectations were that the client would begin responding to treatment, as exhibited by reduced depressive symptoms. This is because studies demonstrate that the efficacy of SSRIs like Zoloft is dose-dependent and hence titration of Zoloft to 50 mg would have higher efficacy when compared to Zoloft 25 mg (Hieronymus et al, 2016). It is also expected that the client would tolerate the increased dose and thus he will have few or no side effects.

As was expected, the client manifested symptom improvement with the increased Zoloft dose (50 mg). There was a 50% symptom reduction with the Zoloft 50 mg and the client also tolerated the increased dose. The 50% symptom reduction is attributable to the improved efficacy of Zoloft with the upward titration of Zoloft (Hieronymus et al., 2016).

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Decision Point Three

The decision that was selected for decision three is to maintain the current dose. The decision to maintain Zoloft 50 mg was chosen because with this dose the client is responding to the treatment as manifested by symptom improvement. According to Carvalho et al (2016) when selecting antidepressants like Zoloft, it is important to consider both the potential benefits, treatment responsiveness as well as side effects (Kato et al., 2018). Therefore, it is important to maintain the minimum effective dose to avoid potential side effects with increased dose.

The decision to change the treatment regimen to SNRI was not chosen since there is no clinical reason as the client is already manifesting symptom remission. SSRIs are the first-line treatment choice when treating depression as they are effective and are associated with minimal side effects (Park & Zarate, 2019).

The decision to increase the Zoloft dose from 50 mg to 75 mg was not chosen since the client is already manifesting adequate response to Zoloft 50 mg as indicated by 50% symptoms improvement. Additionally, the client is tolerating Zoloft 50 mg as he did not report any side effects, and hence increasing the dose to 75 mg may lead to side effects (Carvalho et al., 2016).

Selecting the decision to maintain the current dose of Zoloft 50 mg expects that the client would continue exhibiting symptom improvement and finally achieve complete symptom remission. Additionally, it is expected that he would continue tolerating the medication, with few or no side effects.

Ethical Considerations

The ethical issues that may influence the treatment of this client include informed consent, confidentiality, and autonomy. The client in this case study is a minor and thus the decision of the parents will prevail. The client does not have the ability to make decisions about his treatment. Therefore, even if the client refuses to consent to treatment, the decision of his mother will prevail. The client has no autonomy. Secondly, it will be important to seek informed consent from the mother of the client before starting treatment (Belitz, 2018). The PMHNP should explain and educate the mother about the available treatment options, including all the side effects associated with the medications. This will ensure that the mother makes an informed treatment decision for the client. It is also important to seek assent from the client and involve him when developing the treatment plan in order to increase his treatment adherence. Moreover, it will be important for the PHMNP to ensure confidentiality of the client data and ensure the health information, including the diagnosis is only accessible to authorized individuals such as the parents (Hiriscau et al., 2016).

Conclusion

The first decision that was selected for the client is to start Zoloft 25 mg orally. This treatment decision was chosen because the efficacy and tolerability of Zoloft in the treatment of depression in the pediatric population aged 6 years and over has been demonstrated. The other decisions were not selected because Paxil and Wellbutrin are associated with many side effects and thus the client may not well tolerate these medications. The second decision was to increase the Zoloft dose from 25 mg to 50 mg. This decision was chosen because the efficacy of SSRIs like Zoloft is doe-dependent and thus higher doses are associated with increased efficacy. With this dose, the client manifested 50% symptom improvement and did not report any side effects. The decision to change treatment to Paxil was not chosen because Paxil is associated with numerous side effects. The decision to increase the dose to Zoloft 37.5 mg was not chosen since Zoloft treatment should start at a dose of 25 mg and the dose titrated upwards after a week to 50 mg.  As a result, the third dose was the maintenance of the current dose since with Zoloft 50 mg the client is already manifesting symptom improvement without any side effects. The decision to change to an SNRI was not chosen since there is no clinical reason as the client is already manifesting symptom remission while the decision to increase the dose to Zoloft 75 mg was not selected because the increased dose may lead to side effects. Ethical issues that may affect the treatment plan of this client include informed consent, autonomy, and confidentiality.

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.

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.

Hiriscau E, Nicola S, Wasserman D & Theil S. (2016). Identifying Ethical Issues in Mental Health Research with Minors Adolescents: Results of a Delphi Study. Int J Environ Res Public Health, 13(5), 489.

Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T., Fujise, N. (2018). Optimizing first- and second-line treatment strategies for the untreated major depressive disorder – the study: a pragmatic, multi-center, assessor-blinded randomized controlled trial. BMC medicine, 16(1), 103. https://doi.org/10.1186/s12916-018-1096-5

Locher C, Koechlin H, Zion S, Werener C, Pine D, Kirsch I, Kessler R & Joe K. (2017). Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents. JAMA Psychiatry, 74(10), 1011–1020.

Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. Reply. The New England journal of medicine, 380(23), 2279–2280. https://doi.org/10.1056/NEJMc1903259

Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic advances in psychopharmacology, 6(2), 99–144. https://doi.org/10.1177/2045125316629071

Santarsieri D & Thomas S. (2015). Antidepressant efficacy and side-effect burden: a quick guide for clinicians. Drugs Context, 2015(4).

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

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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

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.

You administer the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

Decision Point One

Select what you should do:

a.Begin Zoloft 25 mg orally daily

b.Begin Paxil 10 mg orally daily

c.Begin Wellbutrin 75 mg orally BID

Decision Point One A- Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

No change in depressive symptoms at all

Decision Point Two

Select what you should do next:

a.Increase dose to 37.5 mg orally daily

b.Increase dose to 50 mg orally daily

c.Change to Prozac 10 mg orally daily

Decision Point Two- Increase dose to 50 mg orally daily

 

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Depressive symptoms decrease by 50%. Cleint tolerating well

Decision Point Three

Select what you should do next:

 

a.Maintain current dose

b.Increase to 75 mg orally daily

c.Change to a SNRI

RESULTS OF DECISION POINT THREE

Guidance to Student

At this point, sufficient symptom reduction has been achieved. This is considered a “response” to therapy. Can continue with current dose for additional 4 week to see if any further reductions in depressive symptoms are noted. An increase in dose may be warranted since this is not “full” remission- Discuss pros/cons of increasing drug dose with client at this time and empower the client to be part of the decision. There is no indication that the drug therapy should be changed to an SNRI at this point as the client is clearly responding to this therapy.

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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.

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