NURS 6630 Module 2 Week 4 Assignment: Approaches to Treatments: Decision Tree in the Case of an 8 Year-Old African American Male Child Presenting with a DSM-5 Diagnosis of Depression

NURS 6630 Module 2 Week 4 Assignment: Approaches to Treatments: Decision Tree in the Case of an 8 Year-Old African American Male Child Presenting with a DSM-5 Diagnosis of Depression

NURS 6630 Module 2 Week 4 Assignment: Approaches to Treatments: Decision Tree in the Case of an 8 Year-Old African American Male Child Presenting with a DSM-5 Diagnosis of Depression

Module 2 Week 4
Mood disorders can impact every facet of a human being’s life, making the most basic activities difficult for patients and their families. This was the case for 13-year-old Jeanette, who was struggling at home and at school. For more than 8 years, Jeanette suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues.
As a PNP working with pediatric patients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.

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This week, as you examine antidepressant therapies, you explore the assessment and treatment of three populations: pediatrics, adults, and geriatrics. The focus of your assessment tool, a decision tree, will specifically center on one of the most vulnerable populations, pediatrics. Please remember, you must also consider the ethical and legal implications of these therapies. You will also complete a Quiz on the concepts addressed throughout this module.

Assignment- Decision tree

Required: media file within classroom
You will write a formal (APA formatted) paper no more than 5 pages long addressing the media file as directed in the classroom directions

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Approaches to Treatments: Decision Tree in the Case of an 8 Year-Old African American Male Child Presenting with a DSM-5 Diagnosis of Depression

The DSM-5 (fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) has the diagnostic criteria for the majority of mental disorders that have to be fulfilled for a diagnosis to be made. Conditions that are similar are grouped together under broad categories and one of these is the ‘Depressive Disorders’ under which depression falls. Other conditions in this category include persistent depressive disorder that is also known as dysthymia (APA, 2013; Sadock et al., 2015). Some of the criteria that these two diagnoses have to meet for instance are a depressed mood or sadness for most of the day most of the time, low self-esteem, insomnia, and a feeling of worthlessness amongst others. The purpose of this paper is to outline the pharmacotherapeutic choices that can be made amongst given options in a pediatric case of depression.

Background Information

The case is that of an 8 year-old African American boy presented by his mother and complaining of sadness and suicidality. From the subjective information, he has lately been isolating himself from his peers and no longer enjoys pleasurable activities that he previously enjoyed. He has scored 30 on the Children’s Depression Rating Scale or CDRS. This is an indication that he has moderate depression that requires treatment. During the mental status examination or MSE it emerges that he has suicidal thoughts but no homicidal thoughts, hallucination, or delusions. His self-reported mood is “sad” and the affect is blunt meaning that the two are congruent. There is no indication after investigations that the boy is suffering from any physical illness. He thus fits the diagnostic criteria of major depression in the DSM-5.

The First Decision Point (#1)

At this first decision point, three medication options are presented. These are paroxetine (Paxil), bupropion (Wellbutrin), and sertraline (Zoloft). Amongst these the decision is made to start the boy on the selective serotonin reuptake inhibitor sertraline off-label. This means that the drug is not FDA-approved to treat depression in children but only in adults. However, clinical evidence-based practice (EBP) has shown that the medication used off-label (it is only FDA-approved for the treatment of depression in adults) is effective and efficacious in children too (Allen et al., 2018; Mir & Geer, 2017; Vijay et al., 2018).

The drug regimen is commenced at an initial dose of 25 mg orally every day as monopharmacy. Because the drug has no safety studies in children, a lot of care is then taken in giving the mother health education to recognize and report early any adverse effects that may be observed. Two reasons inform the choice of off-label sertraline instead of the other two. The child’s life is in danger since he is clearly suicidal and the psychiatric-mental health nurse practitioner (PMHNP) has experience in using the medication efficaciously off-label. For this reason, the drug is chosen for use over the others without delay. The second reason is that there is no other medication with the same efficacy profile as off-label sertraline that is FDA-approved for treating depression in children. Invoking the bioethical principle of beneficence, the PMHNP then goes ahead to give the medication that she knows will bring the greatest benefit to the depressed child (Haswell, 2019). The benefits that the boy would derive from the off-label sertraline are more than the potential risks.

Sertraline (Zoloft) was selected in this case over the other two based on scholarly evidence for efficacy. According to Chon et al. (2017), sertraline is so efficacious that clinical manifestations of depression may start to reduce within the first four weeks of treatment. In treating this pediatric depression case with sertraline (Zoloft), the hope is that the symptoms will start to decline by the time the child is brought back for the next follow u appointment in four weeks. The baseline CDRS was a score of 30 and this is expected therefore to be less by the time the child is brought back for review and reassessment (Shanahan et al., 1987). The CDRS is both a diagnostic tool and an evaluation tool.

Beneficence and nonmaleficence are the two bioethical principles that are at play in this case (Haswell, 2019). The sertraline was chosen off-label because the clinician wanted the best for the boy, even if it meant using a non-FDA-approved medication. After starting the drug regime, the health education on side and adverse effects as well as the close evaluation of progress by the CDRS are aimed at guaranteeing no harm or nonmaleficence for the boy.

The Second Decision Point (#2)

After four weeks the boy is brought back for re-evaluation and assessment of the progress of the treatment with off-label sertraline (Zoloft). This time, the other reports that she has not experienced any change in the symptomatology of the condition in her son. In a way, it appeared that the 25 mg dose of sertraline was not being enough or just that the therapeutic effect of the drug had not yet set in. It is known from studies that sertraline begins its therapeutic action at between two and four weeks of treatment. This meant that the judgment could still not be made that the sertraline had failed in producing the desired effect.

According to Stahl (2017), it is advisable to increase the dose of sertraline (Zoloft) if for whatever reason its therapeutic effect does not begin to show after 4-6 weeks. The second decision taken at this decision point is therefore to double the dose of the drug to 50 mg orally every day. The other two options presented at this decision point were an increase in the sertraline dose to 37.5 mg, or a cessation of sertraline and introduction of fluoxetine (Prozac). However, increasing the dose of sertraline (Zoloft) to just 37.5 mg would have very minimal effect. Also, stopping sertraline would not be prudent at this juncture because it would not have been given the chance to commence its therapeutic effect. In other words, it was not yet time to say that sertraline had failed.

The hope in making the above decision of doubling the dose of sertraline was to reduce the boy’s psychiatric symptoms by half after a further four weeks of treatment. This would be determined by using follow up CDRS scores to monitor progress. If the reduction by half of the symptoms can be achieved by the next visit, that would qualify as a therapeutic response from sertraline. The cooperation and concurrence of the mother would be sought through education and reassurance. This will be in the spirit of autonomy as the other prevailing bioethical principle at this decision point. It is acknowledged here that there will be a need for a lot of reassurance and treatment counseling for both the mother and the boy. This is because it is expected that they will be reluctant to continue with a medication that has not produced any result after four weeks of use.

The Third Decision Point (#3)

After a further four weeks on the increased dose of sertraline (Zoloft) of 50 mg orally every day, the mother finally comes with the good news. She states this time that she has noticed considerable improvement in her son’s symptoms. It will now be a total of eight weeks that the boy will have been on the off-label sertraline for his depression. True to expectations, the CDRS assessment test shows a symptom reduction of 50% this time. This proves that the sertraline has now started to manifest its therapeutic effect. Due to this positive response and good news, it was decided at this third decision point to increase the dose of the sertraline again to 75 mg orally every day going forward. The rationale for this was that the therapeutic effect needed to be sustained and the best way to do this was to increase the pharmacodynamic capacity of the sertraline.

At this juncture, it was not even necessary to consider the other two options that were presented because the sertraline had already started showing promise. By taking the above decision of further increasing the sertraline dose to 75 mg orally daily, it was hoped that the therapeutic effect would be raised and boosted by anywhere between 20-30%. This would show again through the CDRS scores the next time they come back for re-evaluation and review. On the ethical principles that were at play at this decision point, beneficence and nonmaleficence still reigned supreme. The increase in the dose of sertraline (Zoloft) was meant to accord the boy the most therapeutic benefit (beneficence). Shunning the other two options meant that the spirit was not to experiment with the boy and cause unnecessary suffering and harm. This is what nonmaleficence is all about.

Conclusion

In any clinical scenario involving pharmacotherapy in treating mental illness, due diligence and critical decision making is supposed to take place. In this case, the client was a minor presenting with depression in the face of a lack of a superior FDA-approved medication for the same. The clinician had recourse to EBP informed by experience and evidence and used sertraline (Zoloft) off-label with very satisfying results.

References

Allen, H.C., Garbe, M.C., Lees, J., Aziz, N., Chaaban, H., Miller, J.L., Johnson, P., & DeLeon, S. (2018). Off-label medication use in children, more common than we think: A systematic review of the literature. The Journal of the Oklahoma State Medical Association, 111(8), 776–783. https://europepmc.org/article/pmc/pmc6677268

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Chon, M-W., Lee, J., Chung, S., Kim, Y., & Kim, H-W. (2017). Prescription pattern of antidepressants for children and adolescents in Korea based on nationwide data. Journal of Korean Medical Science, 32(10), 1694-1701. https://doi.org/10.3346/jkms.2017.32.10.1694

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Mir, A.N. & Geer, M.I. (2017). Off-label use of medicines in children. International Journal of Pharmaceutical Sciences and Research. https://ijpsr.com/bft-article/off-label-use-of-medicines-in-children/?view=fulltext

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Shanahan, K.M., Zolkowski-Wynne, J., Coury, D.L., Collins, E.W., & O’Shea, J.S. (1987). The Children’s Depression Rating Scale for normal and depressed outpatients. Clinical Pediatrics, 26(5), 245-247. https://doi.org/10.1177/000992288702600506

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Vijay, A., Becker, J.E., & Ross, J.S. (2018). Patterns and predictors of off-label prescription of psychiatric drugs. PLoS ONE 13(7): e0198363. https://doi.org/10.1371/journal.pone.0198363