Assessing and Treating Paediatric Patients with Mood Disorders Discussion

Introduction to the case

This case study involves an 8-year-old African American child suffering from depression. He reported to E.R. with his mother while exhibiting signs of depression. He appeared sad. The mother said that her son is withdrawn from peers in class, has decreased appetite, and has occasional episodes of feeling irritated. Upon assessment of data and physical examination, the child had normal developmental milestones, a remarkable physical exam, and lab results were WNL. The child was seen by a psychiatric nurse and referred for physiatry evaluation.

This paper explores the assessment and management of a child with depression. Three decisions regarding the medication to factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes shall be discussed. A child exposed to recent undesirable life events should be assessed for symptoms and risk factors for depression. The assessment should consider the potential child maltreatment, self-harm, and history of alcohol and drug (Lawton & Moghraby, 2016). Depressive disorders are frequent, chronic and recurrent, and chronic and need management. Depression in children contributes to other problems such as personal distress, reduced friends and sources of support, emerging somatic symptoms such as stomachaches and headaches, dwindling educational and job opportunities, an elevated five-fold risk of suicide attempts, reduced social functioning, declining school performance (Dawson,2018). Symptomatic review and current drug targets depression severity, such as suicidal tendencies (Kupfer,2022). The focus of treatment is the rapid resolution of depression during an acute phase, followed by continuation. Maintenance therapy is needed when the exposure to recurrence is high (Kupfer,2022). Depression medications are used based on the benefit/risk ratio. Depression affects all ages, but contestation exists in the context of the children population. Interpersonal therapy works to resolve interpersonal problems may cause.  Assessing and Treating Paediatric Patients with Mood Disorders Discussion

ORDER HERE A PLAGIARISM-FREE PAPER 

Decision 1: prescribe Sertraline

Sertraline (Zoloft) can be started at 25 mg daily and increased to 37.5 mg., then 50mg as a maintenance dose. Its age-related aspect is that 25–200 mg daily of Sertraline is recommended for children and adolescents (Tini et al.,2022). Depressive symptoms will reduce by 50%, and the client will tolerate them well. With the achievement of a 50 % symptomatic reduction in depression, Sertraline (Zoloft) 50 maintenance dose would consider the best option but can be altered if no changes after four weeks or if the client reports the need for a different drug, such as Prozac.

Paxil 10 mg orally daily is not recommended based on its pronounced side effects such as nausea, vomiting, and diarrhea. Equally, Wellbutrin 75 mg orally BID has not been considered the best decision due to the influence of Wellbutrin on sleep patterns. It is expected that Zoloft will slightly enhance mood, have no adverse events reported, and the client will return to the clinic after four weeks. The ethical consideration involves seeking consent from the client and ensuring engaging communication between the client, provider, and caregiver. Studies show that Sertraline is an effective antidepressant among children. Sertraline can be combined with non-pharmacological interventions such as counseling and cognitive behavioral therapy to optimize outcomes.

According to Melton et al. (2016), Sertraline substantially enhances depressive symptoms compared with placebo. Sertraline is an antidepressant. It acts by primarily inhibiting presynaptic serotonin reuptake, thus, leading to increased accumulation of serotonin. Serotonin regulates mood, personality, and wakefulness; thus, it can help in reducing symptoms of depression. Assessing and Treating Paediatric Patients with Mood Disorders Discussion

Sertraline is SSRI. However, despite its prevalent use and clinical benefits, the pharmacokinetics, efficacy, pharmacodynamics, and tolerability of Sertraline in children are not fully understood. It is a well-tolerated short-term treatment for children with depression and mood-related disorders. However, it should be monitored for adverse effects. Sertraline-induced adverse outcomes include Stevens-Johnson Syndrome and reversible hepatic injury, and toxic epidermal necrolysis (Huddart et al.,2020). Other adverse outcomes that should be monitored include syncope, lightheadedness, diarrhea, sweating, nausea, dizziness, xerostomia, hallucinations, confusion tremor, somnolence, fatigue, and rhinitis .When compared to other medications such as Venlafaxine and paroxetine that increase the risk of suicidal behavior/ideation, Sertraline could reduce such risks (Boaden et al.,2020). Sertraline is linked to first-pass metabolism. Sertraline is better tolerated than monoamine oxidase inhibitors or tricyclic antidepressants. It is metabolized to N-desmethyl sertraline, where multiple cytochrome P450 (CYP) mediates its biotransformation. Sertraline is gradually absorbed, with peak concentrations happening between 4–10 hours, and taking Sertraline with food may raise the peak concentration (Huddart et al.,2020).

Decision 2: prescribe Fluoxetine

If there the eight-year-old American boy returns to the clinic in four weeks with no change at all in symptoms, the medication can be changed to Prozac (fluoxetine)10mg orally. 10 mg of fluoxetine a day in the morning can be started and adjusted to 20 mg daily. 20 mg P.O. daily of fluoxetine dose as a maintenance dose can delay the time of relapse of depressive symptoms. The client is now on a sub-therapeutic dose of Prozac- a low regimen suitable up the first week of therapy to minimize side effects. This dosage will be changed to 20 mg orally so that a therapeutic dose is achieved. Therefore, increasing to 20 mg orally daily is appropriate. At this stage, there is no indication to change to another SSRI or SNRI. This reason results from the fact that the client has had no adequate trial of this medication at a therapeutic dose. Thus, the client in this case study should stick with one antidepressant for adequate therapy at optimized dosing. Assessing and Treating Paediatric Patients with Mood Disorders Discussion

However, if a satisfactory response has not been achieved or maintained, the dosing regimen can be reviewed. The decision, in this case, involves client’s return to the clinic in four weeks, feeling a little bit better and depressive symptoms declining by 20%.  One of the most frequent treatments that are used to manage depression in children and adults is fluoxetine. Fluoxetine belongs to the selective serotonin reuptake inhibitors (SSRIs) class. The use of antidepressants in children and adolescents has raised uncertainties about the safety and efficacy of these antidepressant medications. Fluoxetine and escitalopram are the primary antidepressants that are approved by the U.S. FDA for treating depression in children and adolescents.

Fluoxetine can be used by children above eight years, such as the one in this case. SSRIs such as Fluoxetine may improve response and functional status. However, SSRIs are linked to a higher risk of serious adverse events and an increased risk of withdrawal. FDA has cautioned against the potential risk of arrhythmias, such as Q.T. interval prolongation and ventricular arrhythmia associated with the use of fluoxetine. Patients with existing cardiovascular conditions hypomagnesemia, hypokalemia, or who show an increased risk of prolonged Q.T. interval should be discouraged from using fluoxetine. Any medication that prolongs Q.T. interval will negate the potential use of fluoxetine. Furthermore, fluoxetine should be applied with caution in children/patients with recent myocardial infarctions/ congenital long Q.T. syndrome /uncompensated heart failure, hypokalemia, bradycardia, or hypomagnesemia. Assessing and Treating Paediatric Patients with Mood Disorders Discussion

Decision 3: No change of medication

Since sufficient symptom reduction has been achieved as a “response” to therapy, the client will continue with the current therapy. Discussing the benefits and risks of increasing drug doses will be important. Thus, there is a need to empower the client to be part of the decision. Changing therapy to SNRI is unwarranted. The client in this case study should stick with one antidepressant for adequate therapy at optimized dosing, which is either a 20mg maintenance dose of Prozac or Zoloft 50mg daily. The evidenced-based practice supports interventions that combine cognitive-behavioral therapy (CBT), counseling, and pharmacotherapy, such as maintenance therapy of Prozac as a multifaceted approach to holistic management of depression not only in adults but also in children (Rao, 2013).

It is essential to assess each medication and balance the pros and cons while examining its safety and efficacy standards. In the increasingly growing evidence-based practice, health practitioners must carefully assess the risk and benefits of using psychological and pharmacological therapies in children while resolving grave concerns of overdiagnosis and overtreatment (Magellan Health,2013). The ethical consideration involves seeking consent from the client and ensuring engaging communication between the client, provider, and caregiver.

Conclusion

Management of depression across all age groups requires a multifaceted approach. Both non-pharmacological and pharmacological psychotherapy is needed to manage depression. However, in the case of children, caution must be held to reduce the risk of adverse effects and to improve outcomes through adopting interventional options that have optimal efficacy and safety.

Treatment is designed to resolve a patient’s interpersonal problems to enhance interpersonal functioning and mood by allowing Patients to identify interpersonal problem areas and modifying communication patterns. Regular telephone calls, supportive problem-based counseling visits, and face-to-face visits are some of the non-pharmacological approaches to managing depression amongst children and adults. When psychotic symptoms or suicidal intent is present, fluoxetine remains the single best intervention, with fluoxetine plus CBT as an optimal approach. Assessing and Treating Paediatric Patients with Mood Disorders Discussion Psychotherapy may not be adequate to mitigate the emotional difficulties that some patients face, which necessitates psychopharmacologic intervention. Thus, more often, a multifaced approach is required to manage depression. Healthcare practitioners are expected to adopt various principles to ensure the effective use of pharmacotherapies. Before starting pharmacotherapy, a psychiatric evaluation is completed, a medical history is obtained, medical evaluation is considered when appropriate, plus effective communication with other professionals. It also involves developing a psychosocial and Psychopharmacological treatment plan based on EBP, proper monitoring plan, documentation, and follow-ups. Assessing and Treating Paediatric Patients with Mood Disorders Discussion

ORDER HERE NOW

References

Boaden, K., Tomlinson, A., Cortese, S., & Cipriani, A. (2020). Antidepressants in children and adolescents: meta-review of efficacy, tolerability and suicidality in acute treatment. Frontiers in psychiatry, 717.

Dawson, R. S. (2018). Depression in children and adolescents: the pediatrician at the front lines. Pediatric annals, 47(7), e261-e265.

Huddart, R., Hicks, J. K., Ramsey, L. B., Strawn, J. R., Smith, D. M., Bobonis Babilonia, M., Altman, R. B., & Klein, T. E. (2020). PharmGKB summary: sertraline pathway, pharmacokinetics. Pharmacogenetics and genomics, 30(2), 26–33. https://doi.org/10.1097/FPC.0000000000000392

Lawton, A., & Moghraby, O. S. (2016). Depression in children and young people: identification and management in primary, community and secondary care (NICE guideline CG28). Archives of Disease in Childhood-Education and Practice, 101(4), 206-209.

Kupfer, D. J. (2022). The pharmacological management of depression. Dialogues in clinical neuroscience.

Melton, T. H., Croarkin, P. E., Strawn, J. R., & Mcclintock, S. M. (2016). Comorbid anxiety and depressive symptoms in children and adolescents: a systematic review and analysis. Journal of psychiatric practice, 22(2), 84.

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

Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. https://doi.org/10.1002/da.22171

Tini, E., Smigielski, L., Romanos, M., Wewetzer, C., Karwautz, A., Reitzle, K., … & Walitza, S. (2022). Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Comprehensive psychiatry, 115, 152301.

Sukhatme, V. P., Reiersen, A. M., Vayttaden, S. J., & Sukhatme, V. V. (2021). Fluvoxamine: a review of its mechanism of action and its role in COVID-19. Frontiers in Pharmacology, 763. Assessing and Treating Paediatric Patients with Mood Disorders Discussion