Week 4: Therapy for Patients With Major Depressive Disorder (MDD)

Introduction

The patient in the provided case study presented to the ER while accompanied by his mother. The mother stated that the son was experiencing symptoms like lack of appetite, no longer interacting with his friends, sad mood, and increased irritability. The physical assessment indicated that the client did not have any abnormality and he had achieved the appropriate milestones for his age. The mental status exam revealed that he was oriented to time, place, and person and he was alert. He stated that his mood was sad, but did not report any audial/visual hallucinations. The assessment did not reveal a delusional thought process or paranoia. His insight and judgment were normal too. The client did not have any suicidal thoughts but admitted to thinking about being dead. The client scored 30 for the Children’s Depression Rating Scale. This confirmed that the diagnosis for the client was severe depression. The client manifested symptoms of depression such as irritability, sad mood, loss of appetite, reduced interactions, social withdrawal, poor sleep, etc. (Kadiyala, 2020). Therefore, this paper aims to analyze the provided case study and select suitable treatment decisions for this client. The client belongs to the pediatric population and therefore the selected medication should have a good safety profile and minimal side effects. The ethical principles that guided the selected decisions for this client.

Decision Point One

The appropriate prescription for this client is Zoloft 25 mg. The reason for prescribing Zoloft for the client is because the medication (Zoloft) has been used widely in the treatment of depressive symptoms and it is also approved by the FDA to treat depression in children (Garland et al., 2016). Zoloft improves depressive symptoms by preventing the intake of serotonin and hence elevating the level of serotonin in the brain (Li et al., 2020). The reason why both Wellbutrin and Paxil were not prescribed for the client is due to their associated side effects which the pediatric population like the client may not tolerate.

Zoloft was prescribed with the aim that the client will exhibit symptom improvements such as reduced sadness, increased social interactions, reduced irritability, and improved appetite. This is because evidence illustrates that Zoloft is effective in treating symptoms of depression (Li et al., 2020). The second aim was that the client would not experience adverse side effects from this medication.

However, after four weeks, there was not symptom improvement for this client. The lack of symptom improvement can be due to the lack of effectiveness for the low Zoloft start dose (25 mg). According to Holper (2020), higher doses of Zoloft are more effective in improving symptoms because higher doses avail a higher amount of serotonin within the brain and hence increased effectiveness.

Before prescribing Zoloft for the client, informed consent was sought from the client’s mother. This was done by explaining to the mother about the medications, pharmacology, as well as their side effects and appropriateness. This enabled the mother to make an informed decision. The ethical principle of beneficence was also used as this principle ensured that the medication likely to result in the best care outcomes for this client was selected (Vincer & Kaufman, 2017).

Decision Point Two

Zoloft 50 mg was prescribed for the client. This decision involved increasing the Zoloft dose from 25 mg to 50 mg. The rationale for prescribing Zoloft 50 mg for the client is because a higher Zoloft dose will avail more serotonin within the brain, and hence improve the medication’s effectiveness (Hamed & Hagag, 2020). It is also important to examine the effectiveness of a medication’s maximum dose before changing the first-line medication. Zoloft 37.5 mg was not prescribed because Zoloft ought to be titrated from 25 mg, 50 mg, to 75 mg. Paxil was not prescribed due to its numerous side effects and because it is recommended to examine the effectiveness of the first-line medication before prescribing another medication.

Prescription of Zoloft 50 mg hoped that the patient would show a good response to an increased Zoloft dose, leading to significant symptom improvement for the client. Higher doses of SSRIs like Zoloft are associated with a better response due to increased effectiveness (Hamed & Hagag, 2020). It was hoped that the client will tolerate the higher Zoloft dose.

As it was anticipated, the client showed a good response to Zoloft 50 mg as there was a 50% symptom decreased. This is attributable to the better efficacy of a higher Zoloft dose (Holper, 2020). It was noted that the client did not have any side effects even after the Zoloft dose was elevated from 25 mg to 50 mg.

The decision to increase the dose for the client was guided by the ethical principle of beneficence, non-maleficence, and informed consent. First, the decision likely to produce the best patient outcomes was chosen, while balancing the risks and benefits involved by increasing the dose. Moreover, the mother was informed about the possible effects of increasing the dose for the client such as the client experiencing unwanted side effects (McKenna, 2020).

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Decision Point Three

The third decision involved maintaining the current dose of Zoloft (50 mg). This is because, with this dose, the client is exhibiting a good response, without any side effects. According to Furukawa et al (2019), it is important to maintain the minimum effective dose to avoid possible side effects associated with higher doses due to reduced tolerability. There was no reason to change from SSRI to SNRI as there is not a clinical reason to change from the first-line treatment choice (SSRIs) to second-line treatment (SNRIs) when treating depression. Zoloft 75 mg was not prescribed because a higher Zoloft dose may result in unwanted side effects for the client.

The treatment goal of maintaining the Zoloft dose at 50 mg is to ensure that the client continued exhibiting symptom improvement while tolerating this dose. It was also anticipated that the client will not have side effects as he is tolerating Zoloft 50 mg well. Zoloft is approved for children with depression due to its effectiveness in improving depression symptoms, with good tolerability (Holper, 2020).

Beneficence and non-maleficence guided the decision to maintain Zoloft 50 mg. This is because this decision was chosen due to the medication’s effectiveness and the minimal side effects associated with the medication. Moreover, Zoloft 50 mg was prescribed for the client as the benefits associated with the decision outdo the risks associated with the decision (McKenna, 2020).

Conclusion

Zoloft 25 mg was first prescribed for the client due to Zoloft’s effectiveness in treating depression. Zoloft has a good safety profile and hence approved to treat depression in children. Wellbutrin and Paxil were not prescribed to avoid any possible side effects. However, when the client came for evaluation after four weeks, there was no improvement due to the low Zoloft start dose. Therefore, the second decision included prescribing the client Zoloft 50 mg to improve the efficacy of the mediation. Higher doses of SSRIs avail more serotonin in the brain, leading to better symptom improvement.  Paxil was not prescribed because it leads to undesirable side effects, while Zoloft 37.5 was not considered because that is not the recommended upward titration for Zoloft. With this decision, after four weeks the client manifested a 50% symptom reduction indicating a good response to Zoloft 50 mg. For the third decision, Zoloft 50 mg was maintained since the client is exhibiting a good response, without any side effects. An SNRI was not prescribed for the client because the first-line treatment choice is already effective. Zoloft 75 mg was not prescribed due to possible side effects after a higher dose due to reduced tolerability. The ethical considerations for the three treatment decisions were informed consent to ensure the client was well-informed before agreeing to the prescribed medication; beneficence to facilitate best care outcomes; and non-maleficence to ensure that the risks and benefits of each treatment decision were balanced before choosing a medication and dosage.

References

Furukawa, T. A., Cipriani, A., Cowen, P. J., Leucht, S., Egger, M., & Salanti, G. (2019). The optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis. The Lancet Psychiatry, 6(7), 601-609.

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.

Hamed, M., & Hagag, R. S. (2020). The possible immunoregulatory and anti-inflammatory effects of selective serotonin reuptake inhibitors in coronavirus disease patients. Medical hypotheses, 144, 110140. https://doi.org/10.1016/j.mehy.2020.110140

Holper, L. (2020). Optimal doses of antidepressants in dependence on age: combined covariate actions in bayesian network meta-analysis. EClinicalMedicine, 18, 100219.

Kadiyala P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry, 33(3), e100109. https://doi.org/10.1136/gpsych-2019-100109

Li, W. H., Wei, Z. W., & Liu, X. F. (2020). Clinical efficacy of sertraline in the treatment of depression caused by Alzheimer’s disease: A protocol of systematic review. Medicine, 99(45).

McKenna H. (2020). Covid-19: Ethical issues for nurses. International journal of nursing studies, 110, 103673. https://doi.org/10.1016/j.ijnurstu.2020.103673

Vincer, K., & Kaufman, G. (2017). Balancing shared decision-making with ethical principles in optimizing medicines. Nurse Prescribing, 15(12), 594-599.

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Mood disorders can impact every facet of a human being’s life, making the most basic activities difficult for patients and their families. This was the case for 13-year-old Jeanette, who was struggling at home and at school. For more than 8 years, Jeanette suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues.

As a PNP working with pediatric patients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.
This week, as you examine antidepressant therapies, you explore the assessment and treatment of three populations: pediatrics, adults, and geriatrics. The focus of your assessment tool, a decision tree, will specifically center on one of the most vulnerable populations, pediatrics. Please remember, you must also consider the ethical and legal implications of these therapies. You will also complete a Quiz on the concepts addressed throughout this module.
Learning Objectives
Students will:

Assess patient factors and history to develop personalized plans of antidepressant therapy across the lifespan
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric, adult, and geriatric patients requiring antidepressant therapy
Synthesize knowledge of providing care to pediatric, adult, and geriatric patients presenting for antidepressant therapy
Analyze ethical and legal implications related to prescribing antidepressant therapy to patients across the lifespan
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)

IBM Corporation. (2020). IBM Micromedex.

https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, 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)

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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

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.All within 5yrs

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

Decision Tree Assignments

 

Please read these instructions VERY carefully…please ask questions if you have any difficulties understanding the information below. My goal is to provide you with very detailed instructions so you understand the assignment instructions.

 

You will have your first interactive case study assignment (decision tree) in week 2 A case study is included in the reading assignment and you will face three different decision points. There may not be a “right” answer and you are not expected to answer with the “right” answer at each scenario. You will need to describe your answer and provide your rationale and evidence supporting your decision at each decision point. Please review the information below. I feel like it is important to share with you exactly what I am looking for in the assignments.

 

You will find the case studies listed in the course reading list under “required media” each week you have a decision tree assignment.

 

Here is a general framework for what I am looking for on the decision tree assignments.

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Provide an introduction to the disease state discussed in the case. I am looking for a high-level summary that briefly describes the key aspects of that disease state. I do not want several pages of information related to the diagnosis of the disease state.

 

Provide a high-level summary of the important pieces of information from the case-study that is presented. I do not want the entire case study presented. The goal is that you would be able to give your essay to someone that does not know anything about the assignment and for that individual to be able to understand the purpose of your essay. Again….focus on the important pieces of information that will help you make your decision.

You also want to mention the purpose of the assignment. This can be brief. Decision Point 1, 2, and 3.

At each decision point, list the options that are presented and describe your rationale for choosing the option you chose.

 

I do not want general answers….”I chose sertraline because sertraline is an SSRI and SSRIs are approved for depression/anxiety”. I want VERY SPECIFIC reasons you chose the option you chose. These reasons must be backed by good evidence. Feel free to include studies comparing

 

agents, side effects, dosing, patient considerations, therapeutic practice guidelines, comorbid conditions, etc………………….. You will also need to explain your rationale for not choosing the other two

options. This is very important in your learning. Please remember that you will have

MANY more medications to choose from than three in clinical practice. When you make your choice, you also need to describe your goals of treatment. What do you want to achieve by initiating the therapy you picked. Again….be specific. Defend your choices like you are in a courtroom.

 

After each decision, you will be presented with the outcome of that decision. You need to discuss how that outcome was what you expected or if it was different than what you expected and why.

 

You will do the above for all three decision points.

 

You need to use evidence to support your rationale. [Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. Credible reference material only will be accepted. Sites such as WebMD and drugs.com (among others) will not be counted.]

 

How to move through the case study…..

 

You will be presented with three options at the bottom of the case for decision point one. You must click on one of these options to move to decision point 2.

 

You will then be presented with the outcome of the decision you chose for decision point 1. The outcome is different for each of the three options (see below).

 

You will then choose the option for decision point 2 which will take you to the outcome of the decision you made for decision point 2. You will then be presented with decision point 3.

 

Analogy:

Where would you like to go on vacation?

 

You would want to describe WHY you would want to go to the location of your choosing and NOT the other two. You do not need to describe what the beach, theme park, and mountains are.

 

Decision 1:

Beach Theme Park Mountains

 

Let’s assume you choose beach…..

 

What will you do at the beach once you get there?

 

Again….describe why you picked the option you did and NOT the other two.

 

Decision 2:

Build a sandcastle Swim in the ocean Play frisbee

 

Let’s assume you chose to build a sandcastle… What type of sandcastle will you build?

Decision 3:

A large sculpture

A small sandcastle with a moat

A detailed sand castle decorated with seashells

 

 

Note about providing evidence……..

 

Please note that you need to be VERY SPECIFIC when describing the reason you chose the decision you made for each decision point. I cannot stress this enough.

 

Here are some examples of what I do NOT want:

  • I chose sertraline (ZOLOFT) because it is an SSRI that treats

 

  • Paroxetine (PAXIL) was chosen because paroxetine increases the levels of serotonin in the brain.

 

  • I decided to prescribe bupropion (Wellbutrin) because data supports the use of bupropion in……

 

  • Think about the patient you are treating. I have had students discuss concerns with erectile dysfunction in pediatric patients and female patients on multiple You want to consider the patient you are treating.

 

Here are some examples of what I DO want:

  • “As the PMHNP caring for this client, Zoloft 25 mg daily would be the first choice of therapy for this patient. Selective Serotonin Reuptake Inhibitors (SSRIs) are known to be the first line of treatment for children with depression (DeFilippis & Wagner, 2014). While sertraline and paroxetine are both SSRIs, sertraline is FDA approved when treating children whereas paroxetine has been found to be affective when treating children with depression, it is not specifically approved by the FDA at this point in time (Stahl, 2014b).”

 

  • “Paroxetine is not recommended in use for children due to its short half-life which can lead to withdrawal when the medication is stopped abruptly (Nathan & Gorman, 2015).”

 

  • Evidence supporting the effectiveness of one agent over another. How did one agent perform when compared to another medication in clinical trials. I really like seeing these types of

 

  • What do the guidelines recommend? You can typically find the reason for their recommendation in the body of the

 

  • What side effects are the most concerning for the patient case study? For example: you wouldn’t want to prescribe a medication that causes excessive sedation in a patient that operates heavy machinery or drives transport trucks across the

 

  • Consider genetics and the role genetics have in drug

 

  • Evaluate for the potential for drug-drug interactions.

 

The main point is to be very specific regarding the reason you made your choice. I have posted the essay requirements as a checklist. I would strongly recommend using the checklist prior to submitting your decision tree assignments to make sure you included the required information.

 

Don’t forget to include information related to the ethical considerations and how they might impact yourtreatment plan and communication with your clients.

 

In summary: What needs to be in your essay. Use this as a checklist prior to submitting each decision tree essay.

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Introduction regarding disease state High-level summary of patient case Purpose of the essay statement

Decision 1

·         What options were listed

  • What option did you choose?

·         Why did you select that option?

  • Why didn’t you select the other two options?

·         What was your goal of treatment

  • Was the outcome what you expected? Why? Decision 2

·         What options were listed

  • What option did you choose?

·         Why did you select that option?

  • Why didn’t you select the other two options?

·         What was your goal of treatment

  • Was the outcome what you expected? Why?

 

Decision 3

  • What options were listed

·         What option did you choose?

  • Why did you select that option?

 

·         Why didn’t you select the other two options?

  • What was your goal of treatment

·         Was the outcome what you expected? Why?

 

Conclusion with Ethical considerations

***Do not use the start over button and complete several different times. That is not the point. If you do use the START OVER button, I do not want your paper to reflect this. I have had students do it multiple times and address incorrect outcomes in their paper. I have also had students submit a paper that defends using all three options presented at decision point number one. You will need to click the option to move to the next screen which will provide you with the outcome and the options for the next decision point. You will receive a ZERO on the assignment if you do not follow the instructions correctly. I had a handful of students last semester complete the assignment incorrectly. Please ask questions if you do not understand.

*** Plagiarism and cheating***

It will not be tolerated. As soon as I discover it, I will send you an email requesting an explanation and will copy Academic Integrity, the PMHNP program coordinator, and the Dean of Nursing. It places all the patients you may someday see in harm’s way and I will not allow that to happen. As an FYI, I read the SafeAssign documents very carefully. I pull all papers that match your paper and read each. I also run your paper through all the assistive websites (such as Course hero, etc) and cross reference all former students in my sections along with the other professors for this course. As you can probably gather, I take these matters very seriously. I am here to make sure you learn the material and not copy it from some other student. Do not use other papers for your research (I had a handful of students try that in the past). This is also considered plagiarism.

Do not upload your papers, once written, to “assistive sites”. If I discover it, I will turn it in to Walden.

I hope I am being crystal clear on my thoughts of plagiarism and my reactions to any that is discovered. You should be reading your SafeAssign report and making adjustments to your papers before turning it in to me. Remember, if you turn it in to SafeAssign after you make adjustments, it will match at near 100% because your prior paper will match against the new submission. That is OK.

In summary, I want to see your original, genuine work and not some other person’s work.

The information I provided above were things that arose during other semesters of teaching this class.

I think you will enjoy the interactive case studies! Please let me know if you have any questions!

Matthew Bledsoe, PharmD, BCPS

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