Week 4: Therapy for Patients With Major Depressive Disorder (MDD)

Mood disorders can impact every facet of a human being’s life, making the most basic activities difficult for patients and their families. This was the case for 13-year-old Jeanette, who was struggling at home and at school. For more than 8 years, Jeanette suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues.

As a PNP working with pediatric patients, 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 three populations: pediatrics, adults, and geriatrics. The focus of your assessment tool, a decision tree, will specifically center on one of the most vulnerable populations, pediatrics. Please remember, you must also consider the ethical and legal implications of these therapies. You will also complete a Quiz on the concepts addressed throughout this module.
Learning Objectives
Students will:

Assess patient factors and history to develop personalized plans of antidepressant therapy across the lifespan
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric, adult, and geriatric patients requiring antidepressant therapy
Synthesize knowledge of providing care to pediatric, adult, and geriatric patients presenting for antidepressant therapy
Analyze ethical and legal implications related to prescribing antidepressant therapy to patients across the lifespan
Learning Resources
Required Readings (click to expand/reduce)

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/content/uploads/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

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex.

https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

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
Required Media (click to expand/reduce)

Case Study: An African American Child Suffering from Depression

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

Optional Resources (click to expand/reduce)

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. https://doi.org/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. https://doi.org/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. https://doi.org/10.2989/17280583.2014.938497

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)

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.All within 5yrs

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

BUY A PLAGIARISM-FREE PAPER HERE

Week4 Pyscopharm

Introduction

The patient in the provided case study presented to the ER while accompanied by his mother. The mother stated that the son was experiencing symptoms like lack of appetite, no longer interacting with his friends, sad mood, and increased irritability. The physical assessment indicated that the client did not have any abnormality and he had achieved the appropriate milestones for his age. The mental status exam revealed that he was oriented to time, place, and person and he was alert. He stated that his mood was sad, but did not report any audial/visual hallucinations. The assessment did not reveal a delusional thought process or paranoia. His insight and judgment were normal too. The client did not have any suicidal thoughts but admitted to thinking about being dead. The client scored 30 for the Children’s Depression Rating Scale. This confirmed that the diagnosis for the client was severe depression. The client manifested symptoms of depression such as irritability, sad mood, loss of appetite, reduced interactions, social withdrawal, poor sleep, etc. (Kadiyala, 2020). Therefore, this paper aims to analyze the provided case study and select suitable treatment decisions for this client. The client belongs to the pediatric population and therefore the selected medication should have a good safety profile and minimal side effects. The ethical principles that guided the selected decisions for this client.

Decision Point One

The appropriate prescription for this client is Zoloft 25 mg. The reason for prescribing Zoloft for the client is because the medication (Zoloft) has been used widely in the treatment of depressive symptoms and it is also approved by the FDA to treat depression in children (Garland et al., 2016). Zoloft improves depressive symptoms by preventing the intake of serotonin and hence elevating the level of serotonin in the brain (Li et al., 2020). The reason why both Wellbutrin and Paxil were not prescribed for the client is due to their associated side effects which the pediatric population like the client may not tolerate.

Zoloft was prescribed with the aim that the client will exhibit symptom improvements such as reduced sadness, increased social interactions, reduced irritability, and improved appetite. This is because evidence illustrates that Zoloft is effective in treating symptoms of depression (Li et al., 2020). The second aim was that the client would not experience adverse side effects from this medication.

However, after four weeks, there was not symptom improvement for this client. The lack of symptom improvement can be due to the lack of effectiveness for the low Zoloft start dose (25 mg). According to Holper (2020), higher doses of Zoloft are more effective in improving symptoms because higher doses avail a higher amount of serotonin within the brain and hence increased effectiveness.

Before prescribing Zoloft for the client, informed consent was sought from the client’s mother. This was done by explaining to the mother about the medications, pharmacology, as well as their side effects and appropriateness. This enabled the mother to make an informed decision. The ethical principle of beneficence was also used as this principle ensured that the medication likely to result in the best care outcomes for this client was selected (Vincer & Kaufman, 2017).

Decision Point Two

Zoloft 50 mg was prescribed for the client. This decision involved increasing the Zoloft dose from 25 mg to 50 mg. The rationale for prescribing Zoloft 50 mg for the client is because a higher Zoloft dose will avail more serotonin within the brain, and hence improve the medication’s effectiveness (Hamed & Hagag, 2020). It is also important to examine the effectiveness of a medication’s maximum dose before changing the first-line medication. Zoloft 37.5 mg was not prescribed because Zoloft ought to be titrated from 25 mg, 50 mg, to 75 mg. Paxil was not prescribed due to its numerous side effects and because it is recommended to examine the effectiveness of the first-line medication before prescribing another medication.

Prescription of Zoloft 50 mg hoped that the patient would show a good response to an increased Zoloft dose, leading to significant symptom improvement for the client. Higher doses of SSRIs like Zoloft are associated with a better response due to increased effectiveness (Hamed & Hagag, 2020). It was hoped that the client will tolerate the higher Zoloft dose.

As it was anticipated, the client showed a good response to Zoloft 50 mg as there was a 50% symptom decreased. This is attributable to the better efficacy of a higher Zoloft dose (Holper, 2020). It was noted that the client did not have any side effects even after the Zoloft dose was elevated from 25 mg to 50 mg.

The decision to increase the dose for the client was guided by the ethical principle of beneficence, non-maleficence, and informed consent. First, the decision likely to produce the best patient outcomes was chosen, while balancing the risks and benefits involved by increasing the dose. Moreover, the mother was informed about the possible effects of increasing the dose for the client such as the client experiencing unwanted side effects (McKenna, 2020).

Decision Point Three

The third decision involved maintaining the current dose of Zoloft (50 mg). This is because, with this dose, the client is exhibiting a good response, without any side effects. According to Furukawa et al (2019), it is important to maintain the minimum effective dose to avoid possible side effects associated with higher doses due to reduced tolerability. There was no reason to change from SSRI to SNRI as there is not a clinical reason to change from the first-line treatment choice (SSRIs) to second-line treatment (SNRIs) when treating depression. Zoloft 75 mg was not prescribed because a higher Zoloft dose may result in unwanted side effects for the client.

The treatment goal of maintaining the Zoloft dose at 50 mg is to ensure that the client continued exhibiting symptom improvement while tolerating this dose. It was also anticipated that the client will not have side effects as he is tolerating Zoloft 50 mg well. Zoloft is approved for children with depression due to its effectiveness in improving depression symptoms, with good tolerability (Holper, 2020).

Beneficence and non-maleficence guided the decision to maintain Zoloft 50 mg. This is because this decision was chosen due to the medication’s effectiveness and the minimal side effects associated with the medication. Moreover, Zoloft 50 mg was prescribed for the client as the benefits associated with the decision outdo the risks associated with the decision (McKenna, 2020).

Conclusion

Zoloft 25 mg was first prescribed for the client due to Zoloft’s effectiveness in treating depression. Zoloft has a good safety profile and hence approved to treat depression in children. Wellbutrin and Paxil were not prescribed to avoid any possible side effects. However, when the client came for evaluation after four weeks, there was no improvement due to the low Zoloft start dose. Therefore, the second decision included prescribing the client Zoloft 50 mg to improve the efficacy of the mediation. Higher doses of SSRIs avail more serotonin in the brain, leading to better symptom improvement. Paxil was not prescribed because it leads to undesirable side effects, while Zoloft 37.5 was not considered because that is not the recommended upward titration for Zoloft. With this decision, after four weeks the client manifested a 50% symptom reduction indicating a good response to Zoloft 50 mg. For the third decision, Zoloft 50 mg was maintained since the client is exhibiting a good response, without any side effects. An SNRI was not prescribed for the client because the first-line treatment choice is already effective. Zoloft 75 mg was not prescribed due to possible side effects after a higher dose due to reduced tolerability. The ethical considerations for the three treatment decisions were informed consent to ensure the client was well-informed before agreeing to the prescribed medication; beneficence to facilitate best care outcomes; and non-maleficence to ensure that the risks and benefits of each treatment decision were balanced before choosing a medication and dosage.

References

Furukawa, T. A., Cipriani, A., Cowen, P. J., Leucht, S., Egger, M., & Salanti, G. (2019). The optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis. The Lancet Psychiatry, 6(7), 601-609.

Garland, E., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent, 25(1), 4–10.

Hamed, M., & Hagag, R. S. (2020). The possible immunoregulatory and anti-inflammatory effects of selective serotonin reuptake inhibitors in coronavirus disease patients. Medical hypotheses, 144, 110140. https://doi.org/10.1016/j.mehy.2020.110140

Holper, L. (2020). Optimal doses of antidepressants in dependence on age: combined covariate actions in bayesian network meta-analysis. EClinicalMedicine, 18, 100219.

Kadiyala P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry, 33(3), e100109. https://doi.org/10.1136/gpsych-2019-100109

Li, W. H., Wei, Z. W., & Liu, X. F. (2020). Clinical efficacy of sertraline in the treatment of depression caused by Alzheimer’s disease: A protocol of systematic review. Medicine, 99(45).

McKenna H. (2020). Covid-19: Ethical issues for nurses. International journal of nursing studies, 110, 103673. https://doi.org/10.1016/j.ijnurstu.2020.103673

Vincer, K., & Kaufman, G. (2017). Balancing shared decision-making with ethical principles in optimizing medicines. Nurse Prescribing, 15(12), 594-599.