Pharmacological Approaches To Treatment-Resistant Depression Assignment

Pharmacological Approaches To Treatment-Resistant Depression Assignment

Assessing and Treating Pediatric Patients with Mood Disorders: Case Study of an 8 Year-Old African American Boy with a Mood Disorder 

According to the fifth version of the Diagnostic and Statistical Manual of Mental Disorders, depressive disorders are mood disorders (DSM-5). The defining aspects of the illnesses are a sense of sorrow, irritability, and desolation (APA, 2013). This is the account of an eight-year-old African-American child who is identified with major depression through using the Children’s Depression Rating Scale, or CDRS. The boy meets the DSM-5 diagnostic criteria for major depressive disorder (MDD) based on the history and mental state evaluation (MSE). He has expressed sadness, distancing himself from other students at school, and becoming frustrated. The DSM-5 criteria for this diagnosis include a considerably reduced interest/pleasure in everyday routines, persistent melancholy or emptiness as manifested in mood, feelings of worthlessness, psychomotor slowness or restlessness, inability to focus, and ideas about suicide (APA, 2013). The purpose of this paper is to outline the pharmacotherapy decisions taken at each of the three decision points presented in the case Pharmacological Approaches To Treatment-Resistant Depression Assignment.

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First Decision Point

The first choice is sertraline (Zoloft) at a starting dose of 25 mg orally every day (Rosenthal & Burchum, 2018; Stahl, 2017). Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant that is exclusively licensed by the FDA for the treatment of severe depression in adults. The FDA has only licensed it for treating obsessive-compulsive disorder in youngsters (Stahl, 2017). The decision to use it to treat depression in a child falls under the category of off-label prescription of antidepressants to children (Vijay et al., 2018; Allen et al., 2018; Mir & Geer, 2017). Since there is no risk assessment data on using sertraline (Zoloft) in minors to treat depression, it is considered to be as off-label use.

Sertraline was chosen because it has already been shown to be beneficial in combating juvenile depression when it is used off-label (Chon et al., 2017). The other two alternatives were not picked since sertraline (Zoloft) has been shown to be more successful in treating depression even in grownups (Chon et al., 2017). It has been proven to elicit symptom resolution during the first four weeks of therapy, with the impact being directly related to daily dosage. I decided to prescribe sertraline in the hopes of achieving symptom clearance, as indicated by the CDRS. If this were to be the case, the boy’s future CDRS test would result in a score of less than 30 points (Shanahan et al., 1987). This would imply that the intensity of the depressive episodes is decreasing.

Beneficence and nonmaleficence are two ethical concerns that would influence my plan of care (Haswell, 2019). Because there is no safety profile for the use of Zoloft in managing depression in children, the youngster must be continuously monitored to prevent causing harm in the spirit of nonmaleficence. However, the medicine will continue to be used because the expected benefits exceed the hazards. The boy admitted to having suicidal thoughts, implying that the prescription of sertraline (Zoloft) is potentially life-saving in this circumstance. This is beneficence Pharmacological Approaches To Treatment-Resistant Depression Assignment.

Second Decision Point

The follow-up visit allows the doctor to assess the complaint pattern and, if required, adapt or amend the prescription. When this patient’s parents revisited four weeks later, they stated that his anxiety and depression had not improved at all. According to Stahl (2017), the onset of sertraline’s therapeutic activity in the treatment of major depression normally takes two to four weeks. As a result, at this next decision point, the step performed was to raise the dose of sertraline (Zoloft) to 50 mg orally daily. This would boost the therapeutic benefit once it became obvious.

According to Stahl (2017), scientific proof literature indicates that if the starting dose of sertraline does not normally begin to alleviate symptoms within four to six weeks. As a result, the choice to increase the dose of sertraline rather than discontinue it was evidence-based practice (EBP). In comparison to the other alternatives, sertraline is the medicine most likely to continue having a meaningful therapeutic benefit for several years after therapy begins (Stahl, 2017). This is beneficial since it would prevent the child’s relapse of depressed episodes for a much prolonged period of time.

The other two choices were not taken since the optimal decision would still be to increase the dose of sertraline because there was evidence to support this step. An adjustment in sertraline dosage to 37.5 mg orally daily would have been too small to make a difference in the preferred result. A switch to fluoxetine (Prozac) 10 mg orally daily, on the other hand, would have been inappropriate because the off-label sertraline would have not had an opportunity to exhibit its full spectrum of therapeutic benefits within 4-6 weeks. This is notwithstanding the fact that fluoxetine is FDA-approved for the treatment of MDD in children as young as eight years old (Stahl, 2017). This decision is guided by evidence-based practice and not on FDA approval alone.

What I hoped to accomplish by increasing the sertraline dose by half to 50 mg orally per day was symptomatic resolution of at least 50%. This would be a substantial and acceptable treatment outcome. At this point, the ethical issues would be involving the parents and the boy in treatment decision making. This would be in accordance with relevant legislation and would also satisfy the bioethical autonomy of the patient (Haswell, 2019). The youngster will not be needed to take higher doses of sertraline in the future. They will be counselled alongside their parents, and an explanation will be provided as to why the amount was increased rather than changing the drug.

Third Decision Point

It has been eight weeks since I began taking sertraline (Zoloft) at 25 mg once daily and four weeks after I increased the dose to 50 mg once day. The parents report a considerable decrease in depression symptoms this time. They further indicate that the patient is tolerating the sertraline well and is not experiencing any negative side effects or reactions. The CDRS confirms this, indicating that depressed symptoms have decreased by 50% or half. Even if it is not yet full recovery, this is considered an excellent outcome in pharmacotherapy. This result demonstrated that the sertraline had finally begun to provide its therapeutic benefit as anticipated within 4-6 weeks. The conclusion was that the medication was progressing well with its effect and that the decision of off-label sertraline was a good one guided by EBP. At this point, and in light of the results obtained, the decision was made to increase the daily dose of sertraline to 75 mg orally daily Pharmacological Approaches To Treatment-Resistant Depression Assignment.

There were numerous reasons for increasing the dose to 75 mg. This medicine dose remains within the therapeutic window, and the increase was motivated by the patient’s positive response to the medication. Since the patient was already responsive to sertraline medication, the other two choices were not examined. It was hoped that the following visit in four weeks would result in an even greater reduction in symptoms of up to 75% (Stahl, 2017). The ethics remain the same at this stage: keep the boy safe from undesired side effects because the medicine is being used off-label.

Conclusion

In terms of pharmacotherapy, the management of major depression in minors presents numerous obstacles. The explanation for this is that there are not many pharmacological alternatives for treating this problem in minors. In this case study, an off-label sertraline alternative was helpful. Off-label sertraline was chosen in this circumstance due to its scholarly evidence of effectiveness. It was started with a 25 mg orally daily starting dose. When there was no reaction after four weeks, the dose was increased to 50 mg orally daily. The increase had an effect, as the boy’s symptoms were decreased by half by the next appointment. At the eight week mark, the decision was taken to raise the sertraline prescription to 75 mg orally once more.

 

BACKGROUND INFORMATION Case Study https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_02/index.html

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)

 

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

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)

My First Decision (Begin Paxil 10 mg orally daily)

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)
Decision Point Two

My Decision 2
Decrease dose for 7 days then return to previous 10 mg day dose
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose

PLACE YOUR ORDER HERE

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)
Decision Point Three

My Decision 3
Change to a different SSRI

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 Pharmacological Approaches To Treatment-Resistant Depression Assignment.

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.

 

RESOURCES: To be used Please

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/_Resources/Persistent/a97650fb538f47bb697c47873b0e58d493684a07/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

https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

https://www.tandfonline.com/doi/abs/10.2989/17280583.2014.938497

FOR MEDICATION LOOKUPS
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm 

References

Allen, H.C., Garbe, M.C., Lees, J., Aziz, N., Chaaban, H., Miller, J.L., Johnson, P., & DeLeon, S. (2018). Off-label medication use in children, more common than we think: A systematic review of the literature. The Journal of the Oklahoma State Medical Association, 111(8), 776–783. https://europepmc.org/article/pmc/pmc6677268

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Chon, M-W., Lee, J., Chung, S., Kim, Y., & Kim, H-W. (2017). Prescription pattern of antidepressants for children and adolescents in Korea based on nationwide data. Journal of Korean Medical Science, 32(10), 1694-1701. https://doi.org/10.3346/jkms.2017.32.10.1694

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Mir, A.N. & Geer, M.I. (2017). Off-label use of medicines in children. International Journal of Pharmaceutical Sciences and Research. https://ijpsr.com/bft-article/off-label-use-of-medicines-in-children/?view=fulltext

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for nurse practitioners and physician assistants. Elsevier.

Shanahan, K.M., Zolkowski-Wynne, J., Coury, D.L., Collins, E.W., & O’Shea, J.S. (1987). The Children’s Depression Rating Scale for normal and depressed outpatients. Clinical Pediatrics, 26(5), 245-247. https://doi.org/10.1177/000992288702600506

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press Pharmacological Approaches To Treatment-Resistant Depression Assignment.