Examine Case Study: An African American Child Suffering From Depression An

Examine Case Study: An African American Child Suffering From Depression

An African American Child Suffering From Depression Case Study

Therapy for Pediatric Clients with Mood Disorders

Childhood mood disorders including depression have been discovered to have a high prevalence amongst children and adolescents. According to the scholarship on the matter, such disorders have characteristic behavioral, interpersonal, and emotional dysfunction that can result into impairments

NURS 6630 Week 2: Therapy for Pediatric Clients With Mood Disorders

across multifarious areas of functioning such as social and academic arenas. The diagnosis of various mood disorders such as depression in children present with certain challenges associated with developmental overlap and variations as well as the manner in which pertinent symptoms present. However, adapting significant screening questions when undertaking psychiatric evaluation through the interview technique leads to accurate diagnosis of mood disorders, specifically depression, in children. According to Stahl (2014), whereas psychiatric mental health nurse practitioners can manage mood disorders, the establishment of relevant therapies should be preceded by an accurate diagnosis of a condition. Fundamentally, PMNHPs may prefer the psychopharmacologic therapy using psychotropic drugs in severe conditions, which depends on certain pharmacokinetic and pharmacodynamics processes such as drug metabolism. Even then, the response of a patient to the prescribed regimen as well as the effectiveness of the same may influence whether a nurse may explore the usage of a different drug in addition to interpersonal therapy. Therefore, the purpose of the present paper entails examination of the potential pharmacotherapeutic interventions concerning Kara, a 13-year-old African-American child, who presents with symptoms of significant depression, by evaluating the efficacy of the chosen pharmacological agent at various decision points.

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Decision Point One

Selected Decision

Begin Zoloft 25 mg orally daily

Reasons for the Selection

            Studies have revealed that the administration of Selective serotonin reuptake inhibitors (SSRIs) has proven efficacious in the management of major depressive disorders. Zoloft, also referred to as Sertraline, acts as the first line of treatment when a psychopharmacologic therapy is preferred by a PMNHP (Stahl, 2013). When the Children’s Depression Rating Scale was administered to Kara, a score of 30 was indicated implying that the child was suffering from significant depression. From the given list, Zoloft 25 mg will be prescribed to the patient since it is a first line medication and has proven efficacious in previous studies. A Cochrane review discovered that children from 6 years have expressed high tolerance to Zoloft and the side effects associated with the drug are minimal. In addition, studies such as Murphy et al. (2013), have revealed that African-Americans, because of their genetic makeup, have a poor metabolism of Sertraline, which offers a greater therapeutic effect hence benefits to a patient of this origin.

An African American Child Suffering From Depression Case Stdy

Moreover, Paxil 10 mg has also proven effective in the pharmacotherapeutic management of major depression yet its associated side effects, particularly its propensity to heighten suicidal thoughts in children, and the age of the patient disqualify it from consideration (Gordon & Melvin, 2014; Seedat, 2014). Similarly, Wellbutrin 75 mg is not preferred because of its adverse reactions such as increased suicidal behaviors and thoughts in young adults and adolescents. Further, Stahl (2013) posits that Wellbutrin 75 mg can only be prescribed after the first line medications fail to resolve the depressive symptoms and also when affect is not overly pronounced. Also, the PMNHP should not countenance a combination therapy involving Zoloft and Paxil since they have the same mechanism of action, implying that a possibility of a higher SSRI dosage exists, which may predispose the client to Serotonin Syndrome. Having considered all these factors, administering Zoloft 25 mg using oral administration is the best option for the client.

Expected Results

            Antidepressants normally produce their desired effects within the first six weeks of administration as they prove effective in the management of long term depression. Studies have revealed that certain symptoms of depression should resolve within two weeks of using Zoloft (Sanchez, Reines, & Montgomery, 2014). However, the reduction of some of these symptoms to close to normal depends on the correct administration of the medication. Thus, within two weeks, the client is expected to show improvement in sadness and more interaction with classmates. Also, within the first three weeks, Kara should demonstrate improvement in appetite and irritation. Therefore, a majority of the symptoms of depression presented by Kara should have improved by the fourth week.

Difference between Expected Results and Actual Results

Upon returning to the clinic after four weeks of Zoloft therapy, the patient displayed unresolved depression symptoms. This was inconsistent with the objective of the formulated care plan as well as the expectations by the PMNH. While Zoloft has a few side effects, the PMNHP expected it to have resolved some of the symptoms displayed by Kara. The symptomatology of depression was anticipated to have improved within four weeks before the patient came in for evaluation. The actual result could be attributed to nonconformity to the dosage regimen, non-responsiveness as well as underdosage. For this reason, the outcome of the Zoloft pharmacotherapy was diametrically opposite to the anticipated results the PMNHP had during the drawing of the care plan.

Decision Point Two

Selected Decision

Increase dose to 50 mg orally daily

Reasons for the Selection

            The primary reason for administering SSRIs is to influence the remission of depression symptoms. Since they had not resolved within the expected four weeks, it would be assumed that Kara either did not strictly adhere to the dosage instructions or the patient did not respond to the drug. Thus, the PMNHP would be advised to either change the drug or increase the dosage to maximum while observing the therapeutic limits with respect to the patient’s age (Walkup, 2017). However, given that a clearer picture regarding the cause of the situation does not exist, the best decision would be to increase the dosage of Zoloft to 50 mg orally daily, which is recommended for children from 6 years of age. Further, this is in line with recommendations made by various studies, which reveal that the effectiveness of Zoloft is felt at 50 mg as opposed to 25 mg (Miller et al., 2015). The reason for the increase of dosage is thus found in the fact that higher levels of Sertraline trigger the release of serotonin, which modulates the reduction of the symptoms associated with depression.

Expected Results

The increased dosage from 25 mg to 50 mg is expected to increase the levels of serotonin within the central nervous system. As a consequence, the PMNHP expects Zoloft to induce the desired effects at this level since 50 mg is the maximum dosage for children of this age while 25 mg is the starting dose (Carvalho et al., 2016). This implies that the therapeutic effect of Zoloft is expected within four weeks of administration of this dosage since it falls within the therapeutic range of the drug. As such, by the eighth week of using Zoloft, Kara is expected to show improved appetite, reduced sadness, and have more willingness to engage classmates.

Difference between Expected Results and Actual Results  

            When the patient visited the facility in week eight of the Zoloft pharmacotherapy, the PMNHP expected him to show remission of depression symptoms. When Kara was evaluated, the symptoms had decreased by 20%, which was in conformity with the expected results to an extent. Due to the therapeutic effect of Zoloft, the client reported improved feelings, thus indicating reduced depressive symptoms. However, at this dose, the nurse also expected the presence of some adverse effects of the drug yet this did not occur. The absence of side effects could be attributed to better tolerance by Kara. Thus, the increased dosage produced expected results even when the percentage was lower.

Decision Point Three

Selected Decision

Change to a different SSRI

Reasons for the Selection

After eight weeks of using Zoloft for Kara’s depression, it was expected that the symptoms would have reduced by more than 40%. However, given that only 20% of the symptoms have improved, it implies that the patient suffers from a difficult to treat depression. Further, the responsiveness of the patient to Zoloft may also play a role in the lower percentage of reduced symptoms registered so far. Ciprian, Zhou and Del Giovane (2016) posit that in a scenario such as this one, a PMNHP should consider to either introduce another antidepressant to the active drug or change from Sertraline to a different molecule. Maintaining the current dose as well as increasing the dosage of Zoloft cannot be countenanced as the former has proven ineffective while the latter will introduce dangerous side-effects to the patient. As such, given that the first assertion by Ciprian, Zhou and Del Giovane (2016) does not exist, the present PMNHP will have to introduce a different SSRI while withdrawing Zoloft.

Expected Outcomes

            According to Walkup (2017), the introduction of a different SSRI, which may be stronger that Zoloft, is expected to resolve more than 30% of the depressive symptoms affecting Kara.  The resolution of these symptoms is expected to occur within the first four weeks, which is by week 12 of the pharmacotherapy, after the PMNHP has prescribed a different SSRI. It is hoped that the introduction of the new drug will enhance the confidence of the patient in the therapy, further aiding Kara’s adherence to the medication regimen.

Difference between Expected Outcomes and Actual Results      

            According to treatment guidelines for childhood depression, upon the administration of maximum therapeutic dosage of a pharmacological agent without results, a PMNHP should consider withdrawing the drug in question and introduce a new molecule. For this reason, the decision to change from Zoloft to another SSRI conformed to the standard pharmacotherapy intervention for depression. Scholarship on the matter has revealed that each individual responds uniquely to a given psychopharmacological intervention and in cases where one proves ineffective, the introduction of a more efficacious drug becomes necessary.

Impact of Ethical Considerations on Treatment Plan

The Food and Drug Administration has warned that most antidepressants heighten suicidal tendencies in childhood depression. As a consequence, whereas some of these drugs may effectively manage symptoms, it becomes incumbent upon a nurse practitioner to discuss the side effects associated with a client (Breggin, 2016). Given that Kara was a 13-year-old and was accompanied by the mother, the PMNHP was supposed to discuss the possibility of increased suicidal thoughts with the parent. A full disclosure of the benefits and dangers of Zoloft and the other SSRI to the mother is necessary in order to allow her to green light or reject the therapy. The disclosure is particularly important in this case given that the patient demonstrates withdrawal from classmates and thus may require close monitoring. Also, based on this fact, the PMNHP may consider a different treatment regimen with less adverse events. Therefore, ethical considerations in this pharmacotherapeutic intervention is integral in determining the safest drug to utilize as part of the care plan.

Conclusion: An African American Child Suffering From Depression Case Study

            Therefore, a psychopharmacological intervention has proven to be more effective in the management of significant depression in children. To this end, a PMHNP needs to formulate an intervention therapy based on aspects such as tolerance, safety, and metabolism of a drug. During the ensuing evaluations, the PMHNP needs to observe the response of the patient and make necessary adjustments to the therapy including increasing the dosage, changing the molecule or introducing a combination therapy. Even then, PMHNPs need to communicate the benefits and side effects of a pharmacological agent to a client or their parent so as to ensure all ethical points are covered.

References: An African American Child Suffering From Depression Case Study

Breggin, P. (2016). Rational principles of Psychopharmacology for therapists, Healthcare providers and clients. Journal of Contemporary Psychotherapy, 46(1), 1-13.

Carvalho, A., Sharma, M., Brunoni, A., Vieta, E., & Fava, G. (2016). The safety, Tolerability and risks associated with the use of newer generation antidepressant drugs: A critical review of the literature. Psychotherapy and Psychomatics, 25(5), 270-288.

Ciprian, A., Zhou, X., & Del Giovane, C. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: A network Meta-analysis. The Lancet, 388, 881-890.

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

Miller, S., McTeague, L. M., Gyurak, A., Patenaude, B., Williams, L. M., Grieve, S. M., … Etkin, A. (2015). Cognition-childhood maltreatment interactions in the prediction of antidepressant outcomes in major depressive disorder patients: results from the ispot-d trial. Depression & Anxiety (1091-4269), 32(8), 594–604. https://doi.org/10.1002/da.22368

Murphy, E., Hou, L., Maher, B. S., Woldehawariat, G., Kassem, L., Akula, N., Laje, G., … McMahon, F. J. (2013). Race, genetic ancestry and response to antidepressant treatment for major depression. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology, 38(13), 2598-606.

Sanchez, C., Reines, E. H., & Montgomery, S. A. (2014). A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike?. International clinical psychopharmacology, 29(4), 185-96.

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. doi:10.2989/17280583.2014.938497

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Walkup, J. (2017). Antidepressant efficacy for depression in children and adolescents: Industry- And NIMH-funded studies. Am J Psychiatry, 174, 430-437.