NURS 6630 Week 4: Therapy for Patients with Major Depressive Disorder (MDD)
Assessing and Treating Pediatric Patients with Mood Disorders
Mood disorders are known to negatively impact numerous aspects of individuals, children, and adults alike. For instance, these disorders complicate the processes of performing the basic and day-to-day life activities, which is hence a challenge for patients and their families. One of such disorders is a major depressive disorder. Patients experiencing major depressive disorder present with various common symptoms such as loss of interest in normal life activities and a persistent depressed mood which consequently impairs the individual’s life (“American Psychiatric Association,” 2013). As such, it is key to closely monitor such patients for better outcomes. The implication is that nurse specialists such as PMHNP should be able to assess such patients to find out if the prevailing symptoms are resulting from developmental, underlying growth, social or psychological issues. Accurate assessment leads to an appropriate prescription and treatment of the patient. The purpose of this assignment is to evaluate the case of patients presenting with symptoms of major depressive disorder and decision points on pharmacological management of the patient.
Introduction to the Case
The case under consideration is the case of Jeanette, a thirteen-year-old patient who has been showing signs of struggling both at school and at home. For close to ten years, eight years to be precise, the patient has been suffering from various issues such as sleep issues, difficulty in judgment, inappropriate behavior, impulsiveness, and temper tantrums. This patient came to the clinic accompanied by her mother, who indicated that her daughter seemed depressed. The patient indicates that she has been feeling sad, while her mother also indicated that the report from the teachers in the school was that the girl is always withdrawn from her peers in the class.
The mother also states that Jeanette has been exhibiting lowered appetite and, in some instances, irritation. It is worth noting that the patients had obtained every developmental landmark at the expected ages; in addition, the physical examination conducted was unremarkable. The mental status exams revealed a spontaneous individual, goal-directed, with a coherent and clear speech. The patient also appears alert. She self-report her mood as sad even though she was able to smile at times during the assessment. There was a visible paranoid or delusional thought process, while there were also no hallucinations observed. The patient’s insight seemed age-appropriate. Even though there is no clear indication of suicidal thoughts or ideation, the client indicates that she sometimes thinks of death and how it can be like when someone dies. An assessment using the Children’s Depression Rating Scale showed a score of thirty, which pointed to a major depressive disorder.
Decision #1
The Selected Decision
The first decision made at the first point is to start the patient on 25 mg of Sertraline which the patient has to take on a daily basis orally. Sertraline belongs to the class of selective serotonin reuptake inhibitors and has been used widely as an antidepressant. Indeed, it is considered the first line of treatment in a case where a patient presents with symptoms connected to a major depressive disorder (Clevenger et al., 2018). This medication is effective in treating mood disorders as it inhibits the serotonin uptake by the brain hence regulating an individual’s moods. The end result is improved symptoms.
Why the Other Two Decisions were Not Selected
The other two options were to use paroxetine 10 mg to be orally taken daily or begin using Bupropion to be taken 75 mg orally as needed. Paroxetine was ignored due to the patient’s age. The patient is only thirteen years old, which is not appropriate to manage the potential side effects of the medications (Naguy, 2018). The patient also needed to recover as fast as possible to resume normal school attendance and activities. Paroxetine’s efficacy is known to be lower than Sertraline. Therefore, its impact or benefits may be delayed since the patient may have to be given up to one month to start realizing positive outcomes, hence making it inappropriate for treating the major depressive disorder. Bupropion has limited data on use among children (Kweon & Kim, 2019)
What I was hoping to Achieve
I was hoping to achieve various positive outcomes by prescribing Sertraline. For example, the dosage is expected to help in improving the patient’s mood and alleviate the feeling of sadness, improve energy level, improve appetite and sleep and brighten the mood (Clevenger et al., 2018). Therefore, the patient will be able to be active in school once again and interact with her peers. It is also expected that the unwanted thoughts would reduce.
How the Ethical Consideration May Impact Treatment Plan
Even though treatment plans usually focus on improving a patient’s symptoms, in most cases, the choice of these treatment plans and options are impacted by ethical principles. For example, nonideality, debriefing, anonymity, and informed consent will considerably impact the communications with the patient and the treatment plan. It is key to ensuring that the patient’s information remains private and confidential and not shared unless the patient consents. It is also important not to reveal the identity of the patient to any third party without their consent.
Decision #2
The decision at this point is to increase the Dosage of Sertraline to 50 mg daily.
Reasons For Selecting the Decision
When the patient visited the hospital one month later, there was no notable improvement in the symptoms previously exhibited. Since the symptoms seem to be persistent and not improving, it important to increase the Sertraline dosage for possible improvement instead of going for another medication. It was not prudent to start with a higher dose as it has been shown that such a situation can lead to a higher risk of self-harm among adolescents (Clevenger et al., 2018). Therefore, it is recommended that a lower dosage should be the first line before gradually increasing to find the right dosage. The right dosage can then be obtained through titration.
Why the Other Two Options Were Not Selected
In the management of illnesses such as mood disorders, in the case where a child fails to respond to the first line of treatment, then, it is key to find out if the dosage used was appropriate and if the right duration was given. This medication is available in different doses; hence it is key to start from the lowest in the case of a child and gradually increase the dosage as necessary. There are high chances that the patient would have positive outcomes, and it is even better if side effects are diminished even at higher doses. Fluoxetine was not chosen since the guideline are the Sertraline dosage should be gradually brought down before completely eliminating it and introducing another medication (Yan & Goldman, 2018)
What I was hoping to Achieve
One of the expectations is that the patient will present with at least a fifty percent improvement in the symptoms connected to the major depression. Indeed, current data indicate that Sertraline may not be able to lower the depressive symptoms in a patient within one month, though other symptoms may improve (Clevenger et al., 2018). Therefore, using the medication for the next weeks added to the previous weeks may eventually improve outcomes.
How the Ethical Consideration May Impact Treatment Plan
One of the central ethical considerations, in this case, is informed consent from the accompanying mother to allow the increase of the medication’s dosage as required (“American Psychiatric Association,” 2013). However, the possible side effects of a higher dosage of the medication have to be considered. The patient is also to be educated on adherence for better outcomes.
Decision #3
The decision at this point is to increase the Sertraline medication dosage to 75 mg.
Reasons For Selecting the Decision
The patient visits the clinic and indicates a considerable improvement of up to fifty percent in the symptoms of depression. Therefore it is important to increase the dosage by a small amount again (Clevenger et al., 2018). Indeed, it is advised that when a patient does not fully respond to the lower dosage of the medication, then it is important to slightly increase the dosage; therefore, the next dosage of the medication was chosen
Why the Other Two Options Were Not Selected.
The patients showed some improvement, and there is no reason why the therapy should be changed as the patient is already responding. In addition, when using an antidepressant to treat a child it is key to titrate it as guided by the possible adverse impacts, concomitant medication, other disorders, and the patient’s age (Clevenger et al., 2018). In case of adverse impacts, then lower doses are indicated. However, an acute treatment phase need not be prematurely closed if a patient doesn’t fully respond (“American Psychiatric Association,” 2013). The risk of relapse should be eliminated by continuing the medication for up to 4 months.
What I Expected To Achieve.
It is expected that the patient will experience near full relief of the symptoms. This is because there has been an increased dosage of the medication. In addition, the impact of this class of medication may not start immediately but after some time (“American Psychiatric Association,” 2013).
The Ethical Considerations and Treatment Plan
One of the ethical considerations is informed consent to again increase the dosage of the medication to 75 mg. Since the patient is a child, informed consent will have to be given by the mother to enable the treatment plan to continue. Autonomy also impacts this treatment plan as the patient and the mother has the right to choose whether to continue with the medication at raised dosage, and such a decision should be respected (“American Psychiatric Association,” 2013).
Conclusion
The case study explored here is of Jeanette, a thirteen-year-old patient who has been showing signs of struggling both at school and at home. For close to ten years, eight years to be precise, the patient has been suffering from various issues such as sleep issues, difficulty in judgment, inappropriate behavior, impulsiveness, and temper tantrums. Therefore, it was important to prescribe possible step-wise management of this condition for better patient outcomes. As such, Sertraline 25 mg was selected as the first treatment option, which the patient had to take orally daily. The major ethical consideration in this first decision point was informed consent, where the parent needed an informed consent for the start of the plan as well as to keep the patient’s status confidential. The second decision was to increase the dosage to 50 mg as the patient failed to respond to the initial dose. Having responded at this point but not fully, the decision was to increase the dosage to 75 mg, with the major ethical consideration still to obtain informed consent to increase the dosage.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.
Clevenger, S. S., Malhotra, D., Dang, J., Vanle, B., & IsHak, W. W. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Therapeutic Advances in Psychopharmacology, 8(1), 49-58. https://doi.org/10.1177%2F2045125317737264.
Kweon, K., & Kim, H. W. (2019). Effectiveness and safety of Bupropion in children and adolescents with depressive disorders: a retrospective chart review. Clinical Psychopharmacology and Neuroscience, 17(4), 537. https://doi.org/10.9758%2Fcpn.2019.17.4.537
Naguy, A. (2019). Paroxetine: Into Oblivion? Well, Guess Not. The Primary Care Companion for CNS Disorders, 21(2), 27079. https://doi.org/10.4088/PCC.17l02113.
Yan, T., & Goldman, R. D. (2019). Time-to-effect of fluoxetine in children with depression. Canadian Family Physician, 65(8), 549-551. https://europepmc.org/article/pmc/6693597
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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.