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 Client complained of feeling “sad” Mother reports that teacher said child is withdrawn from peers in class Mother notes decreased appetite and occasional periods of irritation Client reached all developmental landmarks at appropriate ages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. Decision Point One 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 RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks No change in depressive symptoms at all Decision Point Two Increase dose to 50 mg orally daily RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Depressive symptoms decrease by 50%. Cleint tolerating well · Decision Point Three · · Increase to 75 mg orally daily · · Guidance to Student 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. 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: Decision #1 Which decision did you select? Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Decision #2 Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Decision #3 Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? Also include how ethical considerations might impact your treatment plan and communication with clients.
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Case Study: An African American child suffering from depression
Denesa Morgan
Walden University
Dr. Weiner
Psychopharmacologic approaches to treatment of psychopathology, NURS-6630N
June 9, 2019
Case Study: An African American child suffering from depression
Depression is a common and serious form of childhood mental illness and a leading cause of morbidity and mortalitiy in youngsters. Early identification and corresponding treatment is imperative in the reduction and prevention of future, prolonged and more severe depressive episodes (Rao, 2013). Untreated depression in childhood can pose risk of self harm by engagement in drug and alcohol use, as well as attempts of suicide. Timely recognition and proper treatment can prove life-saving by resolving depressive symptoms and reducing risk of relapse (Cheung, Kozloff and Sacks, 2013).
Childhood depression often has biological and social underpinnings necessitating the formulation of an individualized treatment plan that explores and addresses each aspect (Rao, 2013). Manifestation of the condition in childhood may differ than symptoms affecting the adult population. Common signs of depression in children and teens may include loss of interest in usual fun activites, withdrwal from social or pleasurable activities, occasional irritability, appetite or weight changes and frequent references to death or dying (Stahl, 2013).
Similar depressive symptoms were reported by an eight year old African Ameican child and his mother upon arrival to the emergency department. Following conduction of a comprehensive medical evaluation that ruled out underlying medical conditions and a mental status exam which excluded potential development of other psychiatric conditions, the diagnosis of depression was reached. Determination of severity was then attained by administration of the Children’s Depression Rating Scale which indicated significant depression.
The purpose of this paper is to analyze the symptoms presented by the client and his mother in addition to contributing factors to determine three optimal decisions concerning pharmacological treatment and management of the clients diagnosed depression. The decision itself, rationale, intentions and differences between expectations and actual results will be explored. Support for each will be offered in order to judge the effectiveness of the decisions made and evaluate plausible considerations for improvement.
Decision #1
Treatment options for children with depression may include a combination of psychotherapy and medication depending on severity and individual factors (Rao, 2013). As the psychiatric mental health nurse practitioner (PMHNP) designated to care for the presented patient in question, the first decision made was to begin Zoloft 25 mg orally daily.
Rationale for decision
The Children’s Depression Rating Scale (CDRS) was devised by Poznanski, Cook, and Carroll in 1979, to diagnose depression in 6-to12- year-olds (Mayes et al., 2010). The authors state a score of 30 indicates significant depression which was the score obtained by the client presented in the case study. In this case, medication is warranted because of a higher and more complete rate of relief from depressive symptoms than opting to not use medications at all. For moderate to severe depression, evidence-based guielines recommend the prescription of SSRI medications, also known as Selective Serotonin Re-uptake Inhibitors (Kozloff et al., 2013). This group of antidepressant are believed to inhibit serotonin reuptake thus increasing serotonin levels in the brain by blocking the action of the serotonin transporter. The AACP parameter on depression indicated that depressed patients treated with SSRIs have a relatively good response rate (40-70%). Zoloft, a type of SSRI, was selected due to relative safety of the drug for children aged 6 and older combined with favorable effectiveness (Kozloff et al., 2013).
Intent of decision
The decision to prescribe Zoloft to the client was made with hopes of stabilizing his mood resulting in a brighter affect and calmer demeanor. By intitiating an antidepressanat medication regimen, it was hoped that the child could regain his happiness and enjoyment in day to day activities. Although the child denied active suidial ideations, the concern for suicide remained present as it was revealed during the mental status exam he was experiencing frequent and recurrent thoughts surrounding his death. Although depression can’t always be prevented, steps can be implemented to improve the child’s mental health. When properly used, medications can have an important role in the treatment of children and adolescents with diagnosed depression (Rao, 2013). There is evidence that treatment with SSRIs can help not only manage symotoms, but also improve functioning and speed up recovery (Kozloff et al., 2013).
Expectation versus actual results
Starting of the antidepressant Zoloft was expected to achieve patient reports of reduced sadness and irritability. However, his follow up 4 weeks later, resulted in no change in depressive symptoms. The considerable difference between the expected and actual results is believed to have occurred from insufficient dosing.
Decision #2 Rationale
Upon return to the clinic 4 weeks later, the decision was made to increase the dose of Zoloft to 50 mg orally daily. The decision to titrate the childs medication in a 25 mg increment resulted from an inadequate response to the initial starting dose. According to Rao (2013), if no improvement is observed in the first 6 to 8 weeks, diagnosis and initial treatment should be reassessd and the low starting dose optimized. No adverse reactions or clincal worsening were reported however, indicating the child was tolerating the medication well. Thus, continuation of the medication at a higher dose was selected as the best decision.
Intent of decision
By making the decision to increase the dose of Zoloft from 25 mg to 50 mg orally daily, hopes were to achieve specific social and health goals that promoted the childs self-esteem, improved function and eliminated morbid thoughts about death. Higher rates of SSRI prescriptions are associated with lower rates of suicide in children with evidence showing that SSRI treatment decreases suicidal ideation and attempts (Kozloff et al., 2013). Goals should include improved functional status (school, home and peers) and lessening of depressive symptoms.
Expectation versus actual results
Despite the decision to increase the patients starting dose to 50 mg while waiting a total of 4 weeks for the response, symptoms were reported at only a 50% reduction.This fell below expectations to achieve a higher percentage of reduction in symptoms.
Decision #3
Once it was determined that resultant improvement in depressive symptoms were occurring and tolerance was maintained, the decision was made to continue the medication at the current dose. Reports of a 50% reduction in depressive symptoms signifided moderate effectiveness. With continued maintenance at the current dose, medication benefits were presumed to improve. According to Rao (2013), maintenance therapy with Zoloft is well tolerated and has significant efficacy in preventing recurrence or reemergence of depression in patients.
Intent of decision
It was hoped that by making the decision to maintain the current dose of medication, treatment of the clients depression to remission would be achieved. Remission is considered the standard of treatment for major depression (Mayes et al., 2010). It is noted that patients with residual depressive symptoms have more recurrences, faster relapse, and shorter intervals when they feel well (Rao, 2013). If the patient fails to reach full remission, relapse may be of concern.
Expectation versus actual results
Although the results of the decision to maintain the current dose of medication produced a 50% reduction in results, expectations to achieve full remission were not attained. Despite failure to attain full remission, sufficient symptom reduction was noted. This response to therapy is encouraging discrediting a change in medication at this point. Therapy with the current dose instead will be continued for an additional 4 weeks to gauge results.
Conclusion
When prescribed and monitored carefully, taking medication is a safe and effective treatment option for depression in selected youth. Zoloft is a selective serotonin reuptake inhibitor that is well-tested and a FDA-approved treatment for youth with major depressive disorder (Kozloff et al., 2013). The results of this case study have examined the effects of depression on a child’s thinking and behavior at home, in school, and with peers. Benefits of medication management were explored and effectiveness of treatment compared to potential risks. With comprehensive management and application of structured psychological treatments, remission of symptoms and return to health may be achieved.