Depression: Parents’ Medication Guide

Case study analysis of 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• Mother reports that teacher said child is withdrawn from peers in class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

Mental status examination

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.

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You administer the Children\’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression

Decision point one.

Select what you should do?

1-Begin Zoloft 25mg orally daily

2-Begin paxil 10mg orally

3-Begin Wellbutrin 75mg orally BID

QUESTIONS

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. Depression: Parents’ Medication Guide

Decision #3 (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.

Conclusion (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

Case Study Analysis

Introduction to the Case

The client involved in this case is an 8-year-old boy, who presented with complaints about sadness. The mother stated that the boy exhibited other symptoms such as withdrawal from peers, lack of appetite, irritation, and sadness. The findings from the assessment showed that the client had appropriately attained all the developmental milestones suitable for his age. Additionally, the physical examination showed that he did not have any abnormality. The mental status exam (MSE) indicated that the client was alert and appropriately oriented. The client’s speech was clear and coherent. The MSE also showed that he was goal-directed and spontaneous. Even though the client would smile during the interview, his self-reported mood was sad. He denied any auditory/visual hallucinations, paranoia, or any delusional thought process. His insight and judgment were suitable for his age. The client denied any suicidal thoughts but reported that he would think of himself being dead and would often envisage how it is to be dead. The client scored 30 for the Children’s Depression Rating Scale, showing that he was having severe depression. The client’s diagnosis is therefore depression. Therefore, this assignment will discuss and select three treatment choices for the client. The client is a minor and thus the treatment choice with a good safety profile and minimum side effects will be selected for the client. Moreover, the paper will discuss all ethical issues that are likely to influence the client’s treatment plan.

Decision Point One

The appropriate decision is that the client should start Zoloft 25 mg orally. Zoloft was chosen due to its efficacy in treating depressive symptoms for the pediatric population and also the medication has few side effects (Zhou et al., 2020). The medication is an SSRI and it increases the serotonin level in the brain and thus improves the mood, and in turn treats depressive symptoms (Dwyer & Bloch, 2019).

Paxil 10 mg was not chosen due to its numerous side effects such as loss of appetite, vomiting, nausea, sleep problems, blurred vision, shakiness, among other symptoms. Paxil is also associated with suicidal ideation among children manifesting depressive symptoms (Wang et al., 2018). Wellbutrin was not chosen for the client because it is not well tolerated among children due to its numerous side effects (Patel et al., 2016).

Selection of Zoloft 25 mg for this client hoped that the client would respond to the medication and thus manifest improved symptoms for instance by manifesting improved mood, decreased irritability, interactions with peers, and better appetite. Zoloft is effective in treating depressive symptoms among children and also the medication has a good safety profile. Secondly, it is expected that the client would not have side effects.

However, the client did not respond to the administered treatment as expected. The lack of symptom improvement is attributable to the low start dose which led to low efficacy and thus the inability of the medication to improve the depressive symptoms (Kato et al., 2018). However, as anticipated, the client tolerated the medication as he did not experience any side effects.

Decision Point Two

Decision point two for this client is to have the Zoloft dose increased to 50 mg. The reason for choosing this decision is because evidence shows that the efficacy of SSRIs such as Zoloft is dose-dependent where higher doses are associated with increased efficacy (Kato et al., 2018). Accordingly, a higher dose of Zoloft will have an increased efficacy for this client. Changing the treatment regimen to Paxil was not chosen since evidence shows that this medication is associated with many side effects (Wang et al., 2018). Additionally, the efficacy of the maximum dose of the first-line treatment choice (Zoloft) has not been evaluated and thus it would be inappropriate to change the medication. The reason for not choosing to increase the Zoloft dose to 37.5 mg is because the first Zoloft dose is at 25 mg and the dose is then titrated up to 50 mg, then 75 mg, in that order.

By selecting Zoloft 50 mg for the client, the expectations ate that the client would start showing symptom improvement. This is because increased doses of SSRIs like Zoloft have better and higher efficacy (Kato et al., 2018). It is also hoped that the dose increment would not lead to unwanted side effects for the client.

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Just like it was expected with this decision, the client started showing response to the medication, as manifested by symptom improvement. During the review, the findings showed that the depressive symptoms had decreased by 50%. The symptom improvement is attributable to increased efficacy with an increased dose of Zoloft (50 mg). Moreover, as per expectations, the client did not have any side effects, indicating he tolerated the higher Zoloft dose.

Decision Point Three

Decision point three is to maintain the current Zoloft dose (50 mg). The rationale for this decision is because he is manifesting significant symptom reduction with the current dose of Zoloft. The minimum effective dose ought to be administered to ensure tolerability and prevent unwanted side effects (Hashimoto, 2020). The decision of changing to an SNRI is because SSRIs such as Zoloft are the first-line treatment choices and the maximum effective dose should be evaluated before changing the medication. First-line treatments have a better safety profile, few side effects, and well-tolerated (Hashimoto, 2020). The decision of increasing the Zoloft dose to 75 mg is not appropriate because the client is manifesting an adequate response to Zoloft 50 mg. Increasing the dose could result in the client experiencing side effects.

Maintaining Zoloft 50 mg expects that the client will continue responding to the treatment and finally have all symptoms clear. This is attributable to the efficacy of Zoloft in treating depressive symptoms. It is also expected that he will not experience any side effects.

Ethical Considerations

Ethical issues likely to impact the client’s treatment plan are confidentiality and informed consent. The PMHNP should educate the mother about the medications, including their side effects. This will enable the mother to make an informed treatment choice. It is also important to make sure that the confidentiality and privacy of the patient’s health information, including the diagnosis is protected (Yip et al., 2016).

Conclusion

The first decision includes the client starting Zoloft 25 mg orally. Zoloft was selected due to its efficacy, tolerability, and good safety profile when treating children with depressive symptoms. The medication is also approved by the FDA to treat depression in children aged 6 years and over. Paxil and Wellbutrin were not selected because of the many side effects. With Zoloft 25 mg, the client’s depressive symptoms did not improve and thus the second decision was to have the Zoloft dose increased to 50 mg in order to increase the medication’s efficacy. After increasing the dose to 50 mg, the client had a 50% symptom decrease, indicating that he was responding to the medication. He also tolerated the increased dose and thus the third decision was to maintain the current Zoloft dose of 50 mg. The decision to change to Paxil was not chosen because there is no clinical reason to change the first-line medication. Additionally, the decision to have the Zoloft dose increased to 75 mg was not selected because the minimum effective dose should be administered to avoid unwanted side effects. It is expected that the client will continue responding to the Zoloft 50 mg and ultimately achieve complete symptom remission. The relevant ethical issues during the treatment of this client are the issue of confidentiality and seeking informed consent from the mother before starting any treatment.

References

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26–42F.

Hashimoto K. (2020). Impact of age on the optimal dose of antidepressants. EClinicalMedicine, 18, 100233. https://doi.org/10.1016/j.eclinm.2019.12.003

Kato, T., Furukawa, T. A., Mantani, A., Kurata, K. I., Kubouchi, H., Hirota, S., … & Ikeda, Y. (2018). Optimizing first-and second-line treatment strategies for the untreated major depressive disorder—the study: a pragmatic, multicentre, assessor-blinded randomized controlled trial. BMC medicine, 16(1), 103.

Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic advances in psychopharmacology, 6(2), 99–144. https://doi.org/10.1177/2045125316629071

Wang, S. M., Han, C., Bahk, W. M., Lee, S. J., Patkar, A. A., Masand, P. S., & Pae, C. U. (2018). Addressing the Side Effects of Contemporary Antidepressant Drugs: A Comprehensive Review. Chonnam medical journal, 54(2), 101–112. https://doi.org/10.4068/cmj.2018.54.2.101

Yip, C., Han, N. R., & Sng, B. L. (2016). Legal and ethical issues in research. Indian journal of anesthesia, 60(9), 684–688. https://doi.org/10.4103/0019-5049.190627

Zhou, X., Teng, T., Zhang, Y., Del Giovane, C., Furukawa, T. A., Weisz, J. R., … & Hetrick, S. E. (2020). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive Depression: Parents’ Medication Guide