Assignment#2
TaniAlexis
CASESTUDY.docxTherapy for Pediatric Clients with Mood Disorders 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· Mother reports that teacher said child is withdrawn from peers in class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
· 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.
1-Decision Point One
Select what the PMHNP should do:
1-Begin Zoloft 25 mg orally daily
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
egin Zoloft 25 mg orally daily
2Increase dose to 37.5 mg orally daily
· Client returns to clinic in four weeks
· Depressive symptoms decrease by 20%. Client reports feeling a little bit better
At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.
-Begin Wellbutrin 75 mg orally BID
· Client returns to clinic in four weeks
· Reduction in The Children's Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea
Decrease dose for 7 days then return to previous 10 mg day dose
Guidance to Student
Guidance to Student
The PMHNP has two equally compelling choices at this point. The client has only been taking the current drug at its current dose for 4 weeks. It would be appropriate to continue at current dose. Additionally, the PMHNP could also increase the dose to 20 mg orally daily. A discussion of risk/benefits should be had with the childs guardian regarding this and collaborative decision making should occur. There is no indication at this point that augmentation agents are required as the child is showing a partial response to therapy.
2-RESULTS OF DECISION POINT TWO
Begin Paxil 10 mg orally daily
Begin Paxil 10 mg orally daily
· Client returns to clinic in four weeks
· Reduction in The Children's Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea
·
Decrease dose for 7 days then return to previous 10 mg day dose
Client returns to clinic in four weeks
· Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose
·
· Attempt to decrease dose for another 7 days then return to 10 mg dose
3-Begin Wellbutrin 75 mg orally BIDBegin Wellbutrin 75 mg orally BID
· Client returns to clinic in four weeks
· Child is unable to fall asleep at night
Change from immediate release to extended release 150 mg orally daily in the morning
ive second dose of the day at 1:00 pm in the afternoon
· Client returns to clinic in four weeks
· Child’s sleep patterns return to baseline. No change in depressive symptoms
Change to SSRI
Guidance to Student The PMHNP can continue drug therapy for another 4 weeks, however, it is discouraging that there have been no changes in depressive symptomatology. Increasing the dose to 300 mg orally daily may be appropriate if the child is tolerating the medication well. Changing to an SSRI may also be appropriate, but it may be more prudent to give the Wellbutrin at an appropriate dose for an adequate duration of therapy before switching therapeutic classes.
hange to Lexapro 10 mg orally daily
Give second dose of the day at 1:00 pm in the afternoon
· Client returns to clinic in four weeks
· No change in sleeping patterns, child is getting more difficult to wake for school
3-Decision Point Three
· Begin Wellbutrin 75 mg orally BID Begin Wellbutrin 75 m
· Client returns to clinic in four weeks
· Child is unable to fall asleep at night
Change to Lexapro 10 mg orally daily
· Client returns to clinic in four weeks
· Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms
Decrease dose for 7 days then return to previous 10 mg day dose
· Client returns to clinic in four weeks Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose
·
Attempt to decrease dose for another 7 days then return to 10 mg dose
·
Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, the PMHNP will need to select a different agent as these side effects are unfavorable to the client and may result in continued refusal to take treatment. Changing to a different SSRI may be appropriate if the trial decrease of dose is unsuccessful and if the nausea, vomiting, and diarrhea return with reinitiation of 20 mg orally daily. Changing the medication may be appropriate as not all SSRIs have the same side effect profile in all client.
