Case study: An African American child suffering from depression

Therapy for Pediatric Clients With Mood Disorders

Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, 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 pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.

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Assignment: Assessing and Treating Pediatric Clients With Mood Disorders

When pediatric clients 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 clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.

Note: This Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.

Learning Objectives

Students will:

Assess client factors and history to develop personalized plans of antidepressant therapy for pediatric clients

Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric clients requiring antidepressant therapy

Evaluate efficacy of treatment plans

Analyze ethical and legal implications related to prescribing antidepressant therapy to pediatric clients

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 6, “Mood Disorders”

Chapter 7, “Antidepressants”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

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

Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. Retrieved from https://www.magellanprovider.com/media/11740/psychotropicdrugsinkids.pdf

Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. doi:10.1002/da.22171

Note: Retrieved from Walden Library databases.

Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. In J. M. Rey (Ed.), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from http://iacapap.org/wp-content/uploads/A.7-PSYCHOPHARMACOLOGY-072012.pdf

Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Note: Retrieved from Walden Library databases.

Required Media

Laureate Education (2016e). Case study: An African American child suffering from depression [Interactive media file]. Baltimore, MD: Author.

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources

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. doi: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. doi: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. doi:10.2989/17280583.2014.938497

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat pediatric clients requiring antidepressant therapy.

The Assignment

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 client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1

Which decision did you select?  See below.

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

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

Client seen by Psychiatric Nurse Practitioner

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.

The PMHNP administers the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

RESOURCES

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Decision Point One

Select what the PMHNP should do:

Begin Zoloft 25 mg orally daily

Begin Paxil 10 mg orally daily

Begin Wellbutrin 75 mg orally BID

Case Study of the above client

Decision Point One

I selected  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

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

Maintain current dose

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