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.

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.

1-Decision Point One

Select what the PMHNP should do:

1-Begin Zoloft 25 mg orally daily

Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· No change in depressive symptoms at all

egin Zoloft 25 mg orally daily

2Increase dose to 37.5 mg orally daily

· Client returns to clinic in four weeks

· Depressive symptoms decrease by 20%. Client reports feeling a little bit better

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.

/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-yellow.png-Begin Wellbutrin 75 mg orally BID

· 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

/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-red.pngDecrease dose for 7 days then return to previous 10 mg day dose

Guidance to Student

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.

2-RESULTS OF DECISION POINT TWO

Begin Paxil 10 mg orally daily

· 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

· /orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-red.pngDecrease dose for 7 days then return to previous 10 mg day dose

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

· Guidance to Student 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.

3-Begin Wellbutrin 75 mg orally BID/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-yellow.pngBegin Wellbutrin 75 mg orally BID

· Client returns to clinic in four weeks

· Child is unable to fall asleep at night

/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-red.pngChange from immediate release to extended release 150 mg orally daily in the morning

ive second dose of the day at 1:00 pm in the afternoon

· Client returns to clinic in four weeks

· Child’s sleep patterns return to baseline. No change in depressive symptoms

Change to SSRI

Guidance to Student 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.

hange to Lexapro 10 mg orally daily

Give second dose of the day at 1:00 pm in the afternoon

· Client returns to clinic in four weeks

· No change in sleeping patterns, child is getting more difficult to wake for school

3-Decision Point Three

· Begin Wellbutrin 75 mg orally BID Begin Wellbutrin 75 m

· Client returns to clinic in four weeks

· Child is unable to fall asleep at night

/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-yellow.pngChange to Lexapro 10 mg orally daily

· Client returns to clinic in four weeks

· Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms

Decrease dose for 7 days then return to previous 10 mg day dose

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

· /orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/02/mm/therapy_for_pediatric_clients_with_mood_disorders/img/pill-red.pngAttempt 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 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 client.

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2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

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Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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Assessing And Treating Pediatric Patients With Mood Disorders