Case Study: An African American Child Suffering From Depression
Case Study: An African American Child Suffering From Depression
Case Study: An African American Child Suffering From Depression
Pediatric depression has become common among children and adolescents with manifest debilitating effects on their academic, health, and social functioning. Thus, familiarity with the variables associated with initiating and then hastening the condition amongst pediatric populations can aid with the recognition of patients that may need to be subjected to screening instruments such as the Children’s Depression Rating Scale (Isa et al.¸2014). Accurately diagnosing the severity of the condition plays an important role in determining the nature of intervention that a psychiatric mental health nurse practitioner will prefer. Whereas therapy has always formed the first line of management of the condition, primary care physicians and PMNHPs also employ the usage of pharmacotherapy plan in conjunction with patients and their families. During the formulation of a psychopharmacological intervention, the PMHNP needs to consider factors such as safety and tolerability of a drug as affected by certain patient aspects including ethnicity (Stahl, 2014b). In the event that the abatement of depression symptomatology is not achieved within the first four weeks of pharmacotherapy, a review needs to be conducted and consideration given to options such as increasing dosage, changing to a new psychotropic medication or augmenting the existing medication with another one. The present paper will thus explore the above by examining the case of an 8-year old African-American who presents with significant depression according to his Children’s Depression Rating Scale score. In addition, while formulating an intervention for the patient, the PMNHP also needs to become cognizant of the ethical considerations so as not to expose themselves.
Decision Point One
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Selected Decision
Begin Zoloft 25 mg orally.
Reasons for the Selection
According to clinical guidelines and evidence-based care recommendations for the management of pediatric depression, sertraline (Zoloft), Fluoxetine (Prozac), and citalopram (Celexa) form the first line treatments for the management of pediatric depression (Zuckerbrot et al., 2018). Sertraline acts by selectively inhibiting the reuptake of central serotonin thus enhancing serotoninergic transmission. Studies reveal that Sertraline has selectivity as it does not possess significant affinity for certain receptors such as alpha1-adrenergic, muscarinic receptors and H1-histamine thus leading to lower incidences of adverse events including sedation, anticholinergic effects, and orthostatic hypotension. In addition, due to the genetic variations of the hepatic isoenzyme 2D6 of the cytochrome P450 system (CYP2D6) in the African-American child, the metabolism of sertraline takes significantly longer, which some studies have credited with the increased efficacy of Zoloft in the management of the pediatric depression symptoms (Sanchez, Reines, & Montgomery, 2014). Further, Sertraline reaches peak serum concentration at 4.5 hours, which positively impacts its efficacy.
However, Paxil and Wellbutrin could not be countenanced in the present situation because of safety and tolerability concerns. Scholarship on the usage of both drugs discounts them as they are not first line medications for the condition and they produce adverse events such as nausea, diarrhea, vomiting, and sleepless nights even at their starting doses. Specifically, Paxil cannot be approved because it leads to increased risk of suicidal ideation and suicidality in children as per a clinical trial conducted by its manufacturer in 2003, which revealed that 3.2% of those taking it demonstrated those tendencies as compared to 1.5% in the placebo (Nevels, Gontkovsky, & Williams, 2016). Consequently, the FDA has not approved the drug as an antidepressant intervention in children and this is relevant in the present case as the client does not interact with his peers or classmates, making it dangerous for him to be given such a drug. In addition, some studies have also revealed that the efficacy of Paxil in pediatric depression is questionable.
Similarly, Wellbutrin also has a black box label warning from the manufacturer encompassing increased suicidal behaviors and thoughts in pediatrics, adolescents and young adults (Monden et al., 2018). Moreover, bupropion causes strong epileptic seizures, which caused its recall from the market in the year 1986. Other evidence-based studies studies have found that Wellbutrin causes decrease in appetite and sleep disturbances particularly when administered late at night. The existence of these adverse effects disqualify Wellbutrin from consideration as a first line of treatment for pediatric depression. Therefore, the foregoing supports the decision to Select Zoloft 25 mg as the initial pharmacotherapy for the present case.
Expected Results
Experimental studies on the effectiveness of Zoloft in depression reveal that the pharmacological effect of the drug should be felt within the first two weeks (Cheung, Kozloff, & Sacks, 2013). Thus, by the fourth week when the patient visits the clinic for evaluation, he should demonstrate improved mood. Further, the nurse would expect the patient to show improved interest in activities and also interact well with his classmates. Lastly, the patient should also register some improvement in his appetite as well as become less irritated.
Differences between Expected Results and Actual Results
However, upon coming to the clinic for review, the patient did not show any signs of improvement in the symptoms of depression. Hence, the expectations of the nurse during the formulation of the therapy were not met as a consequence. The absence of resolution or improvement of the symptoms could be attributed to either underdosage or lack of response from the patient. Also, the patient did not show any adverse effects towards the drug, which was expected given the dosage that was used.
Decision Point Two
Selected Decision
Increase dosage to 50 mg orally
Reasons for the Selection
The 25 mg that was given at the commencement of the pharmacotherapy is the starting dose of Sertraline therapy. Guidelines and EBP-based recommendations have identified 50 mg as the effective dose of Zoloft wherein the therapeutic effect of the drug begins to occur (Cipriani et al., 2016). The option to increase the dosage to 37.5 mg is a non-starter as that is not the effective dose, thus applying it could still fail to improve the symptoms. Also, changing to Prozac 10 mg orally daily could expose the patient to withdrawal symptoms as children have a higher rate of drug metabolism compared to adults thus making them susceptible to this phenomenon as postulated by Cipriani et al. (2016). For these reasons, increasing the dosage to 50 mg is the best decision and is consistent with treatment guidelines.
The Expected Results
With the increase of Zoloft dosing to 50 mg, which is its effective dosage according to studies, the symptoms of depression in the child should decrease significantly. The 8-year-old African American clients should thus show improvements in mood, reduction in irritation, interest in activities and improved interactions with his peers at school, as well as improved appetite (Sanchez, Reines, & Montgomery, 2014). At 50 mg, Zoloft is anticipated to positively modulate the levels of neurotransmitters in the brain hence these results.
Differences between Expected Results and Actual Results
The pediatric client visited after four weeks and revealed that the symptoms had improved. The Children’s Depression Rating Scale buttressed these claims by revealing that indeed the symptoms had reduced by 50%. This was consistent with the anticipated results by the nurse at the point of reviewing the initial intervention. Further, the nurse expected certain side effects associated with Zoloft such as headaches, insomnia/sedation, and gastrointestinal upsets. Nevertheless, none of them appeared pointing to excellent tolerance by the client. Even then, the most important expectation, the improvement of depression symptoms, was achieved by this decision.
Decision Point Three
Selected Decision
Increase the dose to 75 mg orally daily.
Reasons for the Selection
The patient registered a 50% in the reduction of symptoms at 50 mg of the Zoloft dosage. Whereas this is a sufficient symptom reduction and response to therapy was demonstrated, a full remission has not been achieved. Given that the client has tolerated the drug well even at 50 mg, the nurse should consider increasing the dosage to 75 mg while instructing the client’s support system to monitor for adverse events (Kunitosha et al., 2018). Further, given that response to Zoloft has already been realized, the option to change the drug to SNRI cannot be adopted as this will raise complications including suicidal ideations by the client.
Expected Results
The administration of Zoloft at 75 mg orally daily is expected to lead to a full remission of the depression symptoms in the pediatric client. According to literature, the maximum dosage of Zoloft is 200 mg whole effective dosage is at 50 mg (Stahl, 2014b). Given that the client had already responded to the 50 mg dosage while registering a 50% improvement in symptoms, the nurse is expected to pursue full remission in consultation with the client and his parent (Zuckerbrot et al., 2018). Thus, four weeks after the introduction of the 75 mg dose, the client is expected to have a full resolution of sadness, fully interact with classmates and peers, demonstrate proper appetite and zero instances of irritation.
Differences between Expected Results and Actual Results
The decision to increase the dosage to 75 mg appears to be in line with the standard guideline for addressing depression symptoms in pediatric clients. It is advised that in the presence of excellent tolerance, the dosage can be increased in order to achieve full remission of symptoms instead of maintaining it at the effective dose. Whereas this increase may introduce some side effects, the psychiatric nurse practitioner is justified to pursue full remission as these adverse effects have not emerged yet.
Impact of Ethical Considerations on the Treatment Plan
The usage of antipsychotics in depression care plan exposes a client to many side effects irrespective of the chosen drug. These risks include the causation of suicidal tendencies in pediatric clients, especially when they do not interact with their peers or classmates. Thus, during the formulation of the therapy, the psychiatric nurse practitioner should inform the client and his family of the possible side effect associated with each drug option (Weihs et al., 2018). In the present scenario, the PMNHP should discuss the advantages and disadvantages of increasing the Zoloft dosage from the effective dose of 50 mg to 75 mg in order to achieve full resolution of the symptoms. By doing this, the clients would be empowered to make their decision regarding the direction of the therapy.
Conclusion
Depression in children and adolescents leaves significant and often debilitating imprints on multifarious functioning of their lives. However, with accurate diagnosis and appropriate pharmacological interventions, the symptomatology of the disease can undergo full resolution. During the administeration of a pharmacotherapy, a psychiatric nurse practitioner needs to consider few variables such as safety, tolerability and in some cases metabolism of a pharmacological agent. Further, during the formulation of such interventions, a nurse needs to be cognizant of their ethical responsibility towards a patient in order to increase compliance.
References
Cheung, A. H., Kozloff, N., & Sacks, D. (2013). Pediatric depression: an evidence-based update on treatment interventions. Current psychiatry reports, 15(8), 381.
Cipriani, A., Xinyu Zhou, Del Giovane, C., Hetrick, S. E., Bin Qin, Whittington, C., … Zhou, X. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet, 388(10047), 881–890. https://doi.org/10.1016/S0140-6736(16)30385-3
Isa, A., Bernstein, I., Trivedi, M., Mayes, T., Kennard, B., & Emslie, G. (2014). Childhood Depression Subscales Using Repeated Sessions on Children’s Depression Rating Scale – Revised (CDRS-R) Scores. Journal of Child & Adolescent Psychopharmacology, 24(6), 318–324. https://doi.org/10.1089/cap.2013.0127
Kunitoshi Kamijima, Mahito Kimura, Kazuo Kuwahara, Yuri Kitayama, & Yoshihiro Tadori. (2018). Randomized, double-blind comparison of aripiprazole/ sertraline combination and placebo/sertraline combination in patients with major depressive disorder. Psychiatry & Clinical Neurosciences, 72(8), 591–601. https://doi.org/10.1111/pcn.12663
Sanchez, C., Reines, E., & Montgomery, S. (2014). A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int. Clin Psychopharmacology, 29(4), 185-96.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Weihs, K. L., Murphy, W., Abbas, R., Chiles, D., England, R. D., Ramaker, S., & Wajsbrot, D. B. (2018). Desvenlafaxine Versus Placebo in a Fluoxetine-Referenced Study of Children and Adolescents with Major Depressive Disorder. Journal of Child & Adolescent Psychopharmacology, 28(1), 36–46. https://doi.org/10.1089/cap.2017.0100
Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., & Laraque, D. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part i. Practice preparation, identification, assessment, and initial management. American Academy of Pediatrics, 144(3), e1299.
Monden R., Roest, A.M., van Ravenzwaaij D., Wagenmakers E.J., Morey R., Wardenaar K.J., de Jonge, P. (2018). The comparative evidence basis for the efficacy of second-generation antidepressants in the treatment of depression in the US: A Bayesian meta-analysis of Food and Drug Administration reviews. Journal of Affective Disorders. 235: 393–398.
Nevels, R. M., Gontkovsky, S. T., & Williams, B. E. (2016). Paroxetine-The Antidepressant from Hell? Probably Not, But Caution Required. Psychopharmacology bulletin, 46(1), 77-104.
An African American Child Suffering From Depression
BACKGROUND INFORMATION
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
Case Study: An African American Child Suffering From Depression
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.
You administer 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.
Case Study: An African American Child Suffering From Depression
Decision Point One
Select what you should do:
Begin Zoloft 25 mg orally daily
Begin Paxil 10 mg orally daily
Begin Wellbutrin 75 mg orally BID
Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for
Case study: An African American child suffering from depression
clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, 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 pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.
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Case Study: An African American Child Suffering From Depression
When pediatric clients 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 Case study: An African American child suffering from depression clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Note: This Case Study: An African American Child Suffering From Depression Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
Case Study: An African American Child Suffering From Depression
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Case Study: An African American Child Suffering From Depression Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”
Chapter 7, “Antidepressants”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Review the following medications:
amitriptyline
bupropion
amitriptylinebupropioncitalopramclomipraminedesipraminedesvenlafaxinedoxepinduloxetineescitalopramfluoxetinefluvoxamineimipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
citalopram
clomipramine
Case Study: An African American Child Suffering From Depression
Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. Retrieved from http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. doi:10.1002/da.22171
Case Study: An African American Child Suffering From Depression
Note: Retrieved from Walden Library databases.
Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. In J. M. Rey (Ed.), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from http://iacapap.org/wp-content/uploads/A.7-PSYCHOPHARMACOLOGY-072012.pdf
Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.
Note: Retrieved from Walden Library databases.
Case Study: An African American Child Suffering From Depression Required Media
Laureate Education (2016e). Case study: An African American child suffering from depression [Interactive media file]. Baltimore, MD: Author.
Note: This case study will serve as the foundation for this week’s Assignment.
Case Study: An African American Child Suffering From Depression Optional Resources
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. doi: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. doi:10.1111/jpc.12655
Seedat, S. (2014)NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment . 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. doi:10.2989/17280583.2014.938497
To prepare for this Case Study: An African American Child Suffering From Depression Assignment:
Review this week’s Learning Resources. Consider how to assess and treat pediatric clients requiring antidepressant therapy.
The Case Study: An African American Child Suffering From Depression Assignment
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 client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
