Therapy for pediatric clients with mood disorders.It is still not known the reason for pediatric mood disorder. Some research has shown that neurotransmitters are in control of the regulation of the chemicals which affect temperaments in the brain. in the brain. Mood disorders are caused by chemical disproportion, in the brain that may be idiopathic or as result of a stressful life event. Mood disorder can be a result of genetics or environmental factors. In other words, it can be hereditary. (Magellan Health, 2013).
The Assignment is focused on the evaluation of a case study of an African American child suffering from depression. This is done in order to ensure that the PMHNP understands the precise medication therapy used in the treatment of pediatric mood disorder.
Although mood disorder is not gender specific it is more common in females as it is believed that about an average of 70% of females are expected to develop the disorder. There are numerous types of this condition. They can be diagnosed, as major depression, persistent depressive disorder, bipolar disorder, disruptive mood dysregulation disorder to mention a few. For children symptoms of mood disorders includes, low self-esteem, constant feeling of unhappiness, glum, appetite variation, hopeless and helpless feelings, listlessness, mounting hostility, insomnia and suicidal thoughts. (Magellan Health, 2013).
Diagnosis is based on the personal data presented by the child’s parent and the PMHNP assessment of children’s depression rating scale of 30, that validates the diagnosis of depression. At evaluation there was no medical or congenital abnormality detected which may be a hinderance to drug absorption, distribution, metabolism and excretion. Consequently, the necessity to further test the CYP450 enzymes (CYP3A4 and CYP2D6) that are done in pediatric patients for metabolism of psychotropic medications might be unnecessary. Pharmacodynamics deals with the effect of psychotropic drugs in the body. It comprises the receptor binding and the chemical exchanges, mostly with the neurotransmitters that undergoes changes all through a child’s developing phases. This should be the base for coming up with the client’s plan of care by the PMHNP. (Vitiello, B 2012).
Point 1 Decision
One of the he first line treatment for depression in children is Zoloft. Treatment should begin at the lowest dosage of 25mg daily by mouth. Even though it is not approved by the food and drug administration (FDA) to be used in children younger than 12 years of age but based on research findings, some of the doctors use it as “off- label” bases on this age groups.(Southammakosane, & Schmitz, 2015).). This is because it has been proven to be harmless and effective with little adverse effects. All antidepressants have a boxed warning for an increased risk of suicide; therefore, close monitoring is recommended. This can be in the form of weekly telephone calls, scheduled visits for the first month of therapy to assess for suicidality and other adverse effects, such as gastrointestinal effects, nervousness, headache, and restlessness Mechanism of action: Inhibition of the CNS neuronal uptake of serotonin After the initial sequence of randomized controlled trials based on “IACAPAP” guideline it is put to use and is . easily absorbed in the system. The treatment plan should be tailored towards the child’s developmental age, psycho education, family participation and the child’s health. Possible side effects and treatment results should be reviewed with parents or guardians so as to get an informed consent before beginning medication. (Vitiello, B 2012). For the PMHNP following the International Association for Child and adolescent Psychiatric Allied Professions (IACAPAP) guidelines is vital. It highlights the overall method of initiating a selective serotonin reuptake inhibitor (SSRI) for the treatment of mood disorder. It is important to find out if the child can benefit from psychosocial intervention, if not possible a base line blood work, should be done for short- and long-term treatment. The performance of a comprehensive diagnostic assessment offers the opportunity of deciding the need for this medication.
In taking this decision, the PMHNP anticipates an improvement in the child within four weeks evidenced by a noticeable reduction in depressive symptoms, such as a reduced amount of agitation, better appetite and increased interactions with peers.
Rationale for not choosing Paxil
Paxil is one of the most effective selective serotonin reuptake inhibitors, used in the treatment of panic, obsessive compulsive disorders and depression. It has a higher affinity to the serotonin receptor site, thereby increasing the discharge of serotonin level and its concentration in the “synaptic cleft”. (Kondro & Sibbold, 2014). The Medicine and Health product Regulatory Agents (MHRA) is of the opinion that the use of Paxil should be discouraged in the treatment of child and adolescent depression because of heightened risk of suicidal ideation and behavior. It is believed that suicidal ideation is elevated to 3.5 times more before the start of medication. Consequently, the FDA does not approve the use of Paxil.
Rationale for not choosing Wellbutrin
Wellbutrin is an anti-depressed, under the classification of Aminoketones. It is used in the treatment of major depressive disorder. The dosages ranges from 75-200mg, with side effect that includes seizure, suicidal thoughts in children and adolescents, hypertension, psychosis, mania and hypomania. It is not known to impede monoamine oxidase or serotonin reuptake but is a dopamine and norepinephrine reuptake inhibitor. Wellbutrin is not considered the best choice of treatment currently because of the numerous side effect, like seizures and health complications associated with this drug. The FDA has not approved the use of this medication for the treatment of mood disorders in children and adolescents. (Stahl, 2014).
Point 2 Decision
At a scheduled four week follow up visit, assessment does not show any improvement on depression which was unexpected by the PMHNP. Some of the question should be, asking the parent of any side effect or unusual changes on the child, and compliance with the ordered medication. The parents or guardian should be encouraged to monitor the child to avoid checking of the medication. Reevaluation of the child is important to ensure the previous diagnosis and to rule out new disorder. The PMHNP should not forget that the patient is still actively being treated since getting a therapeutic level of treatment with Zoloft takes up to 6-8weeks (Vitiello, 2012). The plan of care is to increase Zoloft to 50mg daily by mouth. Reassess patient and the family understanding of the disease and the medication. Assess their knowledge of possible side effects and result of the of the treatment. Encourage the parents in making sure of the child’s compliance with the medication by observing them swallow the medication. Because of the increased dosage, the treatment goals are to attain a therapeutic level and improved mood shown by less depressive symptoms, increased appetite, energy and sleep.
Point 3 Decision
After four weeks of starting the new medication dosage, visit, revealed a noticeable decrease in the depression as much as 50%. This shows a positive response to the treatment, with no reported side effect. The American Academy of child and Adolescent psychiatrist (AACAP) guideline, states that prescribing psychopharmacological treatment for children and adolescent with mood disorder necessitates usage of an acceptable dose for an acceptable period of time. (Magellan Health, 2013). Due to this, it is recommended to keep the child on the current daily dose of Zoloft 50mg, based on the patients’ response to treatment and the mothers report. (Vitiello, 2012). During this time, the focus of the PMHNP will be on long term treatment plan, of gathering numerous data from diverse sources. This will include information from preceding research on the effectiveness, pharmacokinetic and pharmacodynamics of the medicine on the pediatric population, that will serve as an indication for continuied care, and family education. The need for follow up care should be emphasized to the parent or guardian.
The PMHNP should remember that is ethically important to give a comprehensive explanation of the patient’s condition, treatment choice to parents, guardian and the child, making it easy for them to understand. An informed consent is mandatory from the legal guardian after a proper explanation of the benefits, and side effects of such drug use on the child. Where possible the parents or guardians should be given literature on the medications and be allowed to read and ask questions before deciding. Parents or the legal guardians should be educated on the significance of consistency and medication adherance throughout the treatment phase. Another important consideration for the PMHNP is the FDA guidelines on the use selective serotonin reuptake inhibitor in managing mood disorders in children particularly on “off- label” bases, to ensure parents full understanding of what they are consenting for. (Southammakosane, ; Schmitz, 2015). The parents should be cognizant of the black box warning and the heightened risk of suicidal thoughts on children younger than 18 years. Parents or guardian should be knowledgeable on being on the lookout for any unexpected variations at the beginning of the first two weeks of treatment and make a prompt report to the PMHNP for instant action. (Gordon, 2014).
In conclusion the assignment offers the vital use of correct choice of medicine in treating depression in pediatric populations. It broadens the understanding of PMHNP on the necessity for appropriate assessment and clinical evaluation of an individual patient before beginning treatment with psychotropic medication and the continuous monitoring, throughout the treatment period. It ensures continuous instruction and the usage of evidenced based practice. Furthermore, the management of a patient by a PMHNP will be dependent on the therapeutic values of the chosen psychotropic medications after the consideration of treatment options. The PMHNP should be aware of the legal and ethical implications in the treating of pediatric patients with psychotropic medications and be conversant with the innovations of psychiatric management in this group.
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Stahl, S.M (2014). The prescriber’s guide (5th Ed). New York: Cambridge University press.
Vitiello, B (2012). Principles in using psychotropic medication in children and adolescents.
In J.M. Rey (Ed.) IACAPAP. E. text of child and adolescent mental health. Geneva
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