Assessing A Treating A Child With Depression Essay Assignment

Assessing A Treating A Child With Depression Essay Assignment

Depression

Depression is the most common mood disorder among children and adolescents. It is characterized by sadness, anger outbursts, low mood, loss of concentration, sleep disturbances, guilt, and change in appetite. In children, depressive mood affects their social interactions, academic performance, and physical growth. Causes of depression in children are an unfriendly environment, stressful events, bereavement, medication, bullying, physical, social, and emotional abuse, alcohol, and family history of depression (DeFilippis, M. 2018). Studies conducted in 2019 show that the depression rate is at 4.4% among children aged of 3-17years old. The majority of these cases are due to ecological factors, quality of the child principle care-giver principle, and domestic violence. The diagnosis of depressive mood depends on the American psychiatric association DSM-V criteria and multiple assessment tools Assessing A Treating A Child With Depression Essay Assignment.

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Assessment tools are accurate in interviews, parent reporting, and self-reporting. The assessment determines the suicide risks in children with depressive moods. Patient health questionnaire-9, risk of suicide questionnaire, children depression inventory, ask suicide questionnaire, and beck depression scale has the highest sensitivity and specificity. The nurse should rule out other diseases through diagnostic tests like complete blood count, serum electrolytes, electroencephalography, and electrocardiography. The child presents with sadness, social withdrawal, reduced appetite, and irritability. The physical examination is unremarkable and all laboratory results are within the normal values. However, upon mental state examination, the child is in a sad mood and has a flat affect. The child meets the DSM-V criteria for diagnosis because he presents with sadness, irritability, loss of interest, and loss of appetite. Treatment methods for depressive mood involve the use of antidepressants and psychotherapy. In this paper, I will describe three decisions made and the impact of ethical considerations.

Decision #1

Which decision did you select?

Zoloft 25mg PO daily

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Zoloft is a selective serotonin reuptake inhibitor with a weak affinity for the alpha-adrenergic receptor. Therefore, it helps in relieving symptoms of depression, anxiety disorders, and obsessive-compulsive disorder. Zoloft taken orally with meals or without meals has a plasma peak time of 4 to 10 hours and has a plasma half-life of 32hours. Its dosage is adjusted to the child’s body weight to meet the proposed concentration for drug efficiency. It is FDA-approved in pediatric patients because the doses are well tolerated with no adverse effects (Sheftel, et al, 2020). This is the best choice for the patient because of its effectiveness and no side effects expected.

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.

Welbutrin is an atypical antidepressant with norepinephrine and dopamine reuptake inhibitors. It helps in conferring the cravings for cigarette smoking. It is approved for treating ADHD, schizoaffective disorder, and major depressive mood disorder. The dose is 150mg twice daily and has a plasma peak time of 6 hours and a half-life of 20 hours. Its effectiveness is established two weeks after the initial drug intake. I did not select this drug because it has a slow onset mode of action. Its effects are achieved two weeks after initiating treatment. It has adverse side effects on children like increasing the thresh hold of seizures and other cardiovascular events (Kharasch, et al, 2019). Paxil is a selective serotonin reuptake inhibitor, FDA-approved for depressive mood, panic attack, post-traumatic stress disorder, and anxiety disorders (Yang, et al, 2018). It helps in relieving vasomotor symptoms like sleep disturbances, irritability, mood disorders, and eating habits. It is readily absorbed within 2 to 8 hours with a plasma half-life of 21hours. However, I did not select Paxil because it is contraindicated in children less than 18 years. Studies show that sertraline has an increased risk of suicide among children Assessing A Treating A Child With Depression Essay Assignment.

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

The expectations of beginning Zoloft 25mg are to improve the moos, and appetite, and to reduce irritability. Its low affinity to muscarinic receptors helps in alleviating the mood.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Ethical principles enable nurses to use professional techniques when treating patients. The principle of justice and fairness ensures the nurse is kind and fair to all patients during assessment and examination.

Decision #2

Which decision did you select?

Increase Zoloft to 50mg.

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

During the visit, the patient reports that there was an improvement in the symptoms. Therefore, increasing the dose to 50 will help achieve the efficacy concentration of the drug. This will improve the symptoms by 50 percent.

Increasing the dosage to 37.5mg will slightly improve the symptoms. However, the recommendable dose increment to achieve the efficacy concentration is 25mg weekly, monitoring for tolerance and side effects. Prozac is a selective serotonin reuptake inhibitor approved for depression and anxiety disorders. It has immediate bioavailability after ingestion, goes through fast pass metabolism, and has a plasma half-life of 1-3days (Sadowsky, et al, 2021) I did not select the drug because it has adverse effects of suicidal ideation and GIT symptoms.

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

The expected outcome is to relieve the symptoms by 50% after a dosage increase. Zoloft has zero affinity to muscarinic receptors and alpha adrenergic receptors, thus improves mood, reduces irritation, and enhances sleep.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

During the second decision, the nurse considers the principle of non-maleficence. Non-maleficent is not harming a patient intentionally or unintentionally (Ventura, et al, 2021). The nurse adjusted to dosage to meet the patient’s requirements, protecting him from drug side effects.

Decision #3

Which decision did you select?

Maintain the current dose.

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Zoloft 50mg is the recommendable dose for children with a depressive mood disorder. It has proven to be effective in the previous visit because the patient reports improvement of the symptoms.

Zoloft 75mg is not a good decision because it is a higher dose than recommended by FDA. Increasing the dose increases the risk of hepatic diseases, dermatological events, and risk of suicide. Changing the drug to another SSRI is not a good choice because the Zoloft 50mg, has relieved the symptoms, and has been well-tolerated without side effects Assessing A Treating A Child With Depression Essay Assignment.

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

Maintaining Zoloft at 50mg gradually improves the patient’s symptoms over time. The expectation is to ensure the patient recovers from the depressive mood.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

At this decision point, the patients have recovered from the disease. The nurse recommends to the mother cognitive-based therapy to improve the child’s cognitive functions. The nurse considers autonomy at this point by allowing the guardian to make her medical decision.

Conclusion

Depression is the most common mood disorder among children and adolescents. It is characterized by sadness, anger outbursts, low mood, loss of concentration, sleep disturbances, guilt, and change in appetite. Treatment methods for depressive mood involve the use of antidepressants and psychotherapy. Selective serotonin reuptake inhibitors are the commonly used antidepressants because they are well tolerated and have few side effects. Zoloft is FDA approved for children because dose adjustments are made to fit the BMI. Antidepressants are prescribed to children with close monitoring of the symptoms of the suicidal watch. Nurses consider ethical principles at each decision point to ensure patient satisfaction and positive health outcome.

References

DeFilippis, M. (2018). Depression in children and adolescents with autism spectrum disorder. Children, 5(9), 112. https://doi.org/10.3390/children5090112

Kharasch, E. D., Neiner, A., Kraus, K., Blood, J., Stevens, A., Schweiger, J., … & Lenze, E. J. (2019). Bioequivalence and therapeutic equivalence of generic and brand bupropion in adults with major depression: a randomized clinical trial. Clinical Pharmacology & Therapeutics, 105(5), 1164-1174. https://doi.org/10.1002/cpt.1309

Sadowsky, J. Before and After Prozac: Psychiatry as Medicine, and the Historiography of Depression. Cult Med Psychiatry 45, 479–502 (2021). https://doi.org/10.1007/s11013-021-09729-2

Sheftel, C., Sartori, L. C., Manuel, R., Fricke, H., Bell, A., Mulvenna, E., & Hernandez, L. L. (2020). MON-001 Peripartum Sertraline (Zoloft®) Increases Pup Mortality Immediately Postpartum. Journal of the Endocrine Society, 4(Supplement_1), MON-001. https://doi.org/10.1210/jendso/bvaa046.1840

Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2021). Nursing care in mental health: Human rights and ethical issues. Nursing ethics, 28(4), 463-480.

https://doi.org/10.1177%2F0969733020952102

Yang, Y., Huang, Z., Zhang, X., Li, J., Huang, Y., Chen, W., … & Wu, C. (2018). Development of paroxetine hydrochloride single layer controlled-release tablets based on 32 factorial design. Pharmaceutics, 10(4), 243. https://doi.org/10.3390/pharmaceutics10040243

Decision point one	Decision point two	Decision point three
Begin Zoloft 25 mg Orally daily RESULTS OF DECISION POINT ONE -Client returns to clinic in four weeks -Slight increase in mood -No HAM-D results -No adverse events reported Assessing A Treating A Child With Depression Essay Assignment	Increase dose to 37.5 mg daily RESULTS OF DECISION POINT TWO -Client returns to clinic in four weeks Depressive symptoms decrease by 20%. Client reports feeling a little bit better	-Maintain current dose at this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate. -Increase to 50 mg orally daily At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate. -Change to a different SSRI At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.
	Increase dose to 50 mg orally daily RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Depressive symptoms decrease by 50%. Client tolerating well	-Maintain current dose At this point, sufficient symptom reduction has been achieved. It is considered a full response to therapy when symptoms are reduced by 50% or more on the HAM-D. Do not confuse this with full symptom resolution which would be a 100% reduction in symptoms as measured on the HAM-D. It would be in the best interest of the patient to continue with the current dose of medication and re-assess in 4 weeks. Remember, any change in dose resets the “clock” for a full assessment of therapy efficacy. Waiting an additional 4 weeks (8 weeks total from dose change) would allow additional benefit to be recognized. An increase in dose would not be warranted at this point in time as it would lead to an increased potential for adverse events. This could fracture the therapeutic alliance created with your patient and lead to loss to follow-up, loss of symptom control, and other negative consequences to the patient. 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.
		-Increase to 75 mg orally daily 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.
		-Change to a different SSRI 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.
	Change to Prozac 10 mg orally daily RESULTS OF DECISION POINT TWO – Client returns to clinic in four weeks No change at all in symptom	-Increase to 20 mg The client has been on a sub therapeutic dose of Prozac- low dosing is appropriate for up to the first week of therapy in an attempt to minimize side effects, but after that, a therapeutic dose should be achieved. Therefore, increasing to 20 mg orally daily is appropriate. There is no indication to change to another SSRI or SNRI as the client has not had an adequate trial of this medication at a therapeutic dose. – should stick with one antidepressant for a sufficient trial of therapy at optimized dose- frequent changes not recommended at sub-therapeutic doses
		-Attempt a different SSRI
		-Attempt SNRI therapy

Decision point one

Decision point two

Decision point three

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea Assessing A Treating A Child With Depression Essay Assignment

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

-Attempt to decrease dose for another 7 days then return to 10 mg dose Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, the PMHNP will need to select a different agent as these side effects are unfavorable to the client and may result in refusal to take treatment. Also, continuing to drop medication dose to subtherapeutic level will do minimal to treat depressive symptoms. Changing to a different SSRI would be the ideal choice as not all SSRIs have the same side effect profile in all clients. It would not be appropriate to increase the dose at this time as it would most likely result in increased intensity of side effects.

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-Change to a different SSRI

-Increase dose to overcome side effects

Increase dose to 20 orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Nausea, vomiting, and diarrhea has increased and client is refusing to take medication

-Discontinue Paxil and begin Prozac 10 mg orally daily

Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, the PMHNP will need to select a different agent as these side effects are unfavorable to the client and may result in continued refusal to take treatment. Changing to a different SSRI may be appropriate if the trial decrease of dose is unsuccessful and if the nausea, vomiting, and diarrhea return with reinitiation of 20 mg orally daily. Changing the medication may be appropriate as not all SSRIs have the same side effect profile in all clients.

-Continue same dose an encourage child to take medication

-Decrease dose to 10 mg orally daily x 7 days then increase dose back to 20 mg orally daily

Change to Prozac 10 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

There is a 25% reduction in symptoms, client’s side effects of nausea, vomiting, and diarrhea have resolved. Client reports that he is feeling a “little bit better”

-Continue current dose

The PMHNP has two equally compelling choices at this point. The client has only been taking the current drug at its current dose for 4 weeks. It would be appropriate to continue at current dose. Additionally, the PMHNP could also increase the dose to 20 mg orally daily. A discussion of risk/benefits should be had with the childs guardian regarding this and collaborative decision making should occur. There is no indication at this point that augmentation agents are required as the child is showing a partial response to therapy.

-Increase dose to 20 mg orally daily

-Augment with an atypical antipsychotic

Decision point one	Decision point two	Decision point three
Begin Wellbutrin 75 mg orally BID RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Child is unable to fall asleep at night	Change from immediate release to extended release 150 mg orally daily in the morning RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Child’s sleep patterns return to baseline. No change in depressive symptoms	-Change to SSRI The PMHNP can continue drug therapy for another 4 weeks, however, it is discouraging that there have been no changes in depressive symptomatology. Increasing the dose to 300 mg orally daily may be appropriate if the child is tolerating the medication well. Changing to an SSRI may also be appropriate, but it may be more prudent to give the Wellbutrin at an appropriate dose for an adequate duration of therapy before switching therapeutic classes.
		-Increase dose to 300 mg orally daily
		-Maintain current dose for another 4 weeks Assessing A Treating A Child With Depression Essay Assignment
	Give second dose of the day at 1:00 pm in the afternoon RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks No change in sleeping patterns, child is getting more difficult to wake for school	-Change to Wellbutrin XL 150 mg orally daily in the AM It is clear that the side effect after 4 weeks persists, the likelihood of it abating is quite low at this point, indicating that the PMHMP must do something. Administering both tablets of 75 mg in the morning may be an option, but then blood levels are not maintained throughout the day. There is also an increased risk of side effects (including seizure as this drug reduces seizure threshold). The correct answer would be to change the drug to an extended release formulation and administer in the morning.
		-Change administration to giving immediate release tablets in the morning
		-Counsel parent that the side effect will go away
	Change to Lexapro 10 mg orally daily RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms	-Continue current dose At this point, there is no indicating that the PMHNP should change back to Wellbutrin as the child is tolerating the current medication without mention of side effects. Also, the child is experiencing a reduction in symptoms. The PMHNP could also increase the dose to 15 mg orally daily, but the child has only been taking the drug for 4 weeks at this point. It may be more prudent to give the current therapy an additional 4 weeks before making any decisions to change current dose.
		– Increase dose to 15 mg orally daily
		– Re-attempt Wellbutrin XL 150 mg orally daily Assessing A Treating A Child With Depression Essay Assignment