ASSIGNMENT#11F
TaniAlexis
INTERACTIVEMEDIA.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· Mother reports that teacher said child is withdrawn from peers in class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
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.
You administer 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
Select what you should do:
Begin Zoloft 25 mg orally dailyBegin Zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· No change in depressive symptoms at all
Begin Zoloft 25 mg orally daily
Decision Point Two
Select what you should do next:
Increase 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
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· Increase dose to 50 mg orally daily: Client returns to clinic in four weeks
· Depressive symptoms decrease by 50%. Cleint tolerating well: 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.
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· Change to Prozac 10 mg orally daily
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Increase dose to 50 mg orally daily
· Client returns to clinic in four weeks
· Depressive symptoms decrease by 50%. Cleint tolerating well
Change to Prozac 10 mg orally daily
· Client returns to clinic in four weeks
· No change at all in symptom: The client has been on a sub therapeutic dose of Prozac- low dosing is appropriate for up to the first week of therapy in an attempt to minimize side effects, but after that, a therapeutic dose should be achieved. Therefore, increasing to 20 mg orally daily is appropriate. There is no indication to change to another SSRI or SNRI as the client has not had an adequate trial of this medication at a therapeutic dose. - should stick with one antidepressant for a sufficient trial of therapy at optimized dose- frequent changes not recommended at sub-therapeutic doses.
Begin Wellbutrin 75 mg orally BIDBegin Wellbutrin 75 mg orally BID
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Child is unable to fall asleep at night
Decision Point Two
Select what you should do next:
· Change from immediate release to extended release 150 mg orally daily in the morning Client returns to clinic in four weeks
· Child’s sleep patterns return to baseline. No change in depressive symptoms: You 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. You 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. You 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.
Give second dose of the day at 1:00 pm in the afternoon:
o change in sleeping patterns, child is getting more difficult to wake for school: It is clear that the side effect after 4 weeks persists, the likelihood of it abating is quite low at this point, indicating that the PMHMP must do something. Administering both tablets of 75 mg in the morning may be an option, but then blood levels are not maintained throughout the day. There is also an increased risk of side effects (including seizure as this drug reduces seizure threshold). The correct answer would be to change the drug to an extended release formulation and administer in the morning.: It is clear that the side effect after 4 weeks persists, the likelihood of it abating is quite low at this point, indicating that the PMHMP must do something. Administering both tablets of 75 mg in the morning may be an option, but then blood levels are not maintained throughout the day. There is also an increased risk of side effects (including seizure as this drug reduces seizure threshold). The correct answer would be to change the drug to an extended release formulation and administer in the morning. It is clear that the side effect after 4 weeks persists, the likelihood of it abating is quite low at this point, indicating that the PMHMP must do something. Administering both tablets of 75 mg in the morning may be an option, but then blood levels are not maintained throughout the day. There is also an increased risk of side effects (including seizure as this drug reduces seizure threshold). The correct answer would be to change the drug to an extended release formulation and administer in the morning.
· 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. At this point, there is no indicating that you should change back to Wellbutrin as the child is tolerating the current medication without mention of side effects. Also, the child is experiencing a reduction in symptoms. You could also increase the dose to 15 mg orally daily, but the child has only been taking the drug for 4 weeks at this point. It may be more prudent to give the current therapy an additional 4 weeks before making any decisions to change current dose.: At this point, there is no indicating that you should change back to Wellbutrin as the child is tolerating the current medication without mention of side effects. Also, the child is experiencing a reduction in symptoms. You could also increase the dose to 15 mg orally daily, but the child has only been taking the drug for 4 weeks at this point. It may be more prudent to give the current therapy an additional 4 weeks before making any decisions to change current dose.
