Week 4: Therapy for Patients With Major Depressive Disorder (MDD)

Week 4: Therapy for Patients With Major Depressive Disorder (MDD)

Week 4: Therapy for Patients With Major Depressive Disorder (MDD)

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.

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.

Learning Objectives

Students will:

  • Assess patient factors and history to develop personalized plans of antidepressant therapy across the lifespan
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric, adult, and geriatric patients requiring antidepressant therapy
  • Synthesize knowledge of providing care to pediatric, adult, and geriatric patients presenting for antidepressant therapy
  • Analyze ethical and legal implications related to prescribing antidepressant therapy to patients across the lifespan

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Learning Resources

Required Readings (click to expand/reduce)

Baek, J. H., Nierenberg, A. A., & Fava, M. (2016). Pharmacological approaches to treatment-resistant depression. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 44–47). Elsevier.

Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 27–43). Elsevier.

Medication Resources (click to expand/reduce)

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

Review the following medications:

 

  • amitriptyline
  • bupropion
  • citalopram
  • clomipramine
  • desipramine
  • desvenlafaxine
  • doxepin
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • imipramine
  • ketamine
  • mirtazapine
  • nortriptyline
  • paroxetine
  • selegiline
  • sertraline
  • trazodone
  • venlafaxine
  • vilazodone
  • vortioxetine

 

Required Media (click to expand/reduce)

Case Study: An African American Child Suffering from Depression
Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources (click to expand/reduce)

Assignment: Assessing and Treating Pediatric Patients With Mood Disorders

When pediatric patients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult patients with the same disorders, they also metabolize medications much differently. Yet, there may be times when the same psychopharmacologic treatments may be used in both pediatric and adult cases with major depressive disorders. As a result, psychiatric nurse practitioners must exercise caution when prescribing psychotropic medications to these patients. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat pediatric patients presenting with mood disorders.

To prepare for this Assignment:

  • Review this week’s Learning Resources, including the Medication Resources indicated for this week.
  • Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of pediatric patients requiring antidepressant therapy.

The Assignment: 5 pages

Examine Case Study: An African American Child Suffering From Depression. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

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.

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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

By Day 7

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK4Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 4 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 4 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.
Grading Criteria

To access your rubric:

Week 4 Assignment Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 4 Assignment draft and review the originality report.

Submit Your Assignment by Day 7 of Week 4

To participate in this Assignment:

Week 4 Assignment

What’s Coming Up in Week 5?Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will build on your assessment and treatment skills as you examine patients presenting with bipolar disorders.

Next Week

Examine Case Study: An African American Child Suffering From Depression.

Therapy for Pediatric Clients with Mood Disorders

Pediatric depression has become common among children and adolescents with manifest debilitating effects on their academic, health, and social functioning. Thus, familiarity with the variables associated with initiating and then hastening the condition amongst pediatric populations can aid with the recognition of patients that may need to be subjected to screening instruments such as the Children’s Depression Rating Scale (Isa et al.¸2014). Accurately diagnosing the severity of the condition plays an important role in determining the nature of intervention that a psychiatric mental health nurse practitioner will prefer. Whereas therapy has always formed the first line of management of the condition, primary care physicians and PMNHPs also employ the usage of pharmacotherapy plan in conjunction with patients and their families. During the formulation of a psychopharmacological intervention, the PMHNP needs to consider factors such as safety and tolerability of a drug as affected by certain patient aspects including ethnicity (Stahl, 2014b). In the event that the abatement of depression symptomatology is not achieved within the first four weeks of pharmacotherapy, a review needs to be conducted and consideration given to options such as increasing dosage, changing to a new psychotropic medication or augmenting the existing medication with another one. The present paper will thus explore the above by examining the case of an 8-year old African-American who presents with significant depression according to his Children’s Depression Rating Scale score. In addition, while formulating an intervention for the patient, the PMNHP also needs to become cognizant of the ethical considerations so as not to expose themselves.

Decision Point One

Selected Decision

Begin Zoloft 25 mg orally.

Reasons for the Selection

            According to clinical guidelines and evidence-based care recommendations for the management of pediatric depression, sertraline (Zoloft), Fluoxetine (Prozac), and citalopram (Celexa) form the first line treatments for the management of pediatric depression (Zuckerbrot et al., 2018). Sertraline acts by selectively inhibiting the reuptake of central serotonin thus enhancing serotoninergic transmission. Studies reveal that Sertraline has selectivity as it does not possess significant affinity for certain receptors such as alpha1-adrenergic, muscarinic receptors and H1-histamine thus leading to lower incidences of adverse events including sedation, anticholinergic effects, and orthostatic hypotension. In addition, due to the genetic variations of the hepatic isoenzyme 2D6 of the cytochrome P450 system (CYP2D6) in the African-American child, the metabolism of sertraline takes significantly longer, which some studies have credited with the increased efficacy of Zoloft in the management of the pediatric depression symptoms (Sanchez, Reines, & Montgomery, 2014). Further, Sertraline reaches peak serum concentration at 4.5 hours, which positively impacts its efficacy.

However, Paxil and Wellbutrin could not be countenanced in the present situation because of safety and tolerability concerns. Scholarship on the usage of both drugs discounts them as they are not first line medications for the condition and they produce adverse events such as nausea, diarrhea, vomiting, and sleepless nights even at their starting doses. Specifically, Paxil cannot be approved because it leads to increased risk of suicidal ideation and suicidality in children as per a clinical trial conducted by its manufacturer in 2003, which revealed that 3.2% of those taking it demonstrated those tendencies as compared to 1.5% in the placebo (Nevels, Gontkovsky, & Williams, 2016). Consequently, the FDA has not approved the drug as an antidepressant intervention in children and this is relevant in the present case as the client does not interact with his peers or classmates, making it dangerous for him to be given such a drug. In addition, some studies have also revealed that the efficacy of Paxil in pediatric depression is questionable. Week 2: Therapy for Pediatric Clients With Mood Disorders.

Similarly, Wellbutrin also has a black box label warning from the manufacturer encompassing increased suicidal behaviors and thoughts in pediatrics, adolescents and young adults (Monden et al., 2018). Moreover, bupropion causes strong epileptic seizures, which caused its recall from the market in the year 1986. Other evidence-based studies studies have found that Wellbutrin causes decrease in appetite and sleep disturbances particularly when administered late at night. The existence of these adverse effects disqualify Wellbutrin from consideration as a first line of treatment for pediatric depression. Therefore, the foregoing supports the decision to Select Zoloft 25 mg as the initial pharmacotherapy for the present case.

Expected Results

            Experimental studies on the effectiveness of Zoloft in depression reveal that the pharmacological effect of the drug should be felt within the first two weeks (Cheung, Kozloff, & Sacks, 2013). Thus, by the fourth week when the patient visits the clinic for evaluation, he should demonstrate improved mood. Further, the nurse would expect the patient to show improved interest in activities and also interact well with his classmates. Lastly, the patient should also register some improvement in his appetite as well as become less irritated. Week 2: Therapy for Pediatric Clients With Mood Disorders

Differences between Expected Results and Actual Results

            However, upon coming to the clinic for review, the patient did not show any signs of improvement in the symptoms of depression. Hence, the expectations of the nurse during the formulation of the therapy were not met as a consequence. The absence of resolution or improvement of the symptoms could be attributed to either underdosage or lack of response from the patient. Also, the patient did not show any adverse effects towards the drug, which was expected given the dosage that was used. Week 2: Therapy for Pediatric Clients With Mood Disorders

Decision Point Two

Selected Decision

Increase dosage to 50 mg orally

Reasons for the Selection

The 25 mg that was given at the commencement of the pharmacotherapy is the starting dose of Sertraline therapy. Guidelines and EBP-based recommendations have identified 50 mg as the effective dose of Zoloft wherein the therapeutic effect of the drug begins to occur (Cipriani et al., 2016). The option to increase the dosage to 37.5 mg is a non-starter as that is not the effective dose, thus applying it could still fail to improve the symptoms. Also, changing to Prozac 10 mg orally daily could expose the patient to withdrawal symptoms as children have a higher rate of drug metabolism compared to adults thus making them susceptible to this phenomenon as postulated by Cipriani et al. (2016). For these reasons, increasing the dosage to 50 mg is the best decision and is consistent with treatment guidelines.

The Expected Results

            With the increase of Zoloft dosing to 50 mg, which is its effective dosage according to studies, the symptoms of depression in the child should decrease significantly. The 8-year-old African American clients should thus show improvements in mood, reduction in irritation, interest in activities and improved interactions with his peers at school, as well as improved appetite (Sanchez, Reines, & Montgomery, 2014). At 50 mg, Zoloft is anticipated to positively modulate the levels of neurotransmitters in the brain hence these results.

Differences between Expected Results and Actual Results

            The pediatric client visited after four weeks and revealed that the symptoms had improved. The Children’s Depression Rating Scale buttressed these claims by revealing that indeed the symptoms had reduced by 50%. This was consistent with the anticipated results by the nurse at the point of reviewing the initial intervention. Further, the nurse expected certain side effects associated with Zoloft such as headaches, insomnia/sedation, and gastrointestinal upsets. Nevertheless, none of them appeared pointing to excellent tolerance by the client. Even then, the most important expectation, the improvement of depression symptoms, was achieved by this decision. Week 2: Therapy for Pediatric Clients With Mood Disorders

Decision Point Three

Selected Decision

Increase the dose to 75 mg orally daily.

Reasons for the Selection

            The patient registered a 50% in the reduction of symptoms at 50 mg of the Zoloft dosage. Whereas this is a sufficient symptom reduction and response to therapy was demonstrated, a full remission has not been achieved. Given that the client has tolerated the drug well even at 50 mg, the nurse should consider increasing the dosage to 75 mg while instructing the client’s support system to monitor for adverse events (Kunitosha et al., 2018). Further, given that response to Zoloft has already been realized, the option to change the drug to SNRI cannot be adopted as this will raise complications including suicidal ideations by the client.

Expected Results

            The administration of Zoloft at 75 mg orally daily is expected to lead to a full remission of the depression symptoms in the pediatric client. According to literature, the maximum dosage of Zoloft is 200 mg whole effective dosage is at 50 mg (Stahl, 2014b). Given that the client had already responded to the 50 mg dosage while registering a 50% improvement in symptoms, the nurse is expected to pursue full remission in consultation with the client and his parent (Zuckerbrot et al., 2018). Thus, four weeks after the introduction of the 75 mg dose, the client is expected to have a full resolution of sadness, fully interact with classmates and peers, demonstrate proper appetite and zero instances of irritation.

Differences between Expected Results and Actual Results

The decision to increase the dosage to 75 mg appears to be in line with the standard guideline for addressing depression symptoms in pediatric clients. It is advised that in the presence of excellent tolerance, the dosage can be increased in order to achieve full remission of symptoms instead of maintaining it at the effective dose. Whereas this increase may introduce some side effects, the psychiatric nurse practitioner is justified to pursue full remission as these adverse effects have not emerged yet.

Impact of Ethical Considerations on the Treatment Plan

            The usage of antipsychotics in depression care plan exposes a client to many side effects irrespective of the chosen drug. These risks include the causation of suicidal tendencies in pediatric clients, especially when they do not interact with their peers or classmates. Thus, during the formulation of the therapy, the psychiatric nurse practitioner should inform the client and his family of the possible side effect associated with each drug option (Weihs et al., 2018). In the present scenario, the PMNHP should discuss the advantages and disadvantages of increasing the Zoloft dosage from the effective dose of 50 mg to 75 mg in order to achieve full resolution of the symptoms. By doing this, the clients would be empowered to make their decision regarding the direction of the therapy.

Conclusion

Depression in children and adolescents leaves significant and often debilitating imprints on multifarious functioning of their lives. However, with accurate diagnosis and appropriate pharmacological interventions, the symptomatology of the disease can undergo full resolution. During the administeration of a pharmacotherapy, a psychiatric nurse practitioner needs to consider few variables such as safety, tolerability and in some cases metabolism of a pharmacological agent. Further, during the formulation of such interventions, a nurse needs to be cognizant of their ethical responsibility towards a patient in order to increase compliance.

References: Week 2: Therapy for Pediatric Clients With Mood Disordes

Cheung, A. H., Kozloff, N., & Sacks, D. (2013). Pediatric depression: an evidence-based update on treatment interventions. Current psychiatry reports, 15(8), 381.

Cipriani, A., Xinyu Zhou, Del Giovane, C., Hetrick, S. E., Bin Qin, Whittington, C., … Zhou, X. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet, 388(10047), 881–890. https://doi.org/10.1016/S0140-6736(16)30385-3

Isa, A., Bernstein, I., Trivedi, M., Mayes, T., Kennard, B., & Emslie, G. (2014). Childhood Depression Subscales Using Repeated Sessions on Children’s Depression Rating Scale – Revised (CDRS-R) Scores. Journal of Child & Adolescent Psychopharmacology, 24(6), 318–324. https://doi.org/10.1089/cap.2013.0127

Kunitoshi Kamijima, Mahito Kimura, Kazuo Kuwahara, Yuri Kitayama, & Yoshihiro Tadori. (2018). Randomized, double-blind comparison of aripiprazole/ sertraline combination and placebo/sertraline combination in patients with major depressive disorder. Psychiatry & Clinical Neurosciences, 72(8), 591–601. https://doi.org/10.1111/pcn.12663

Sanchez, C., Reines, E., & Montgomery, S. (2014). A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int. Clin Psychopharmacology, 29(4), 185-96.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Weihs, K. L., Murphy, W., Abbas, R., Chiles, D., England, R. D., Ramaker, S., & Wajsbrot, D. B. (2018). Desvenlafaxine Versus Placebo in a Fluoxetine-Referenced Study of Children and Adolescents with Major Depressive Disorder. Journal of Child & Adolescent Psychopharmacology, 28(1), 36–46. https://doi.org/10.1089/cap.2017.0100

Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., & Laraque, D. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part i. Practice preparation, identification, assessment, and initial management. American Academy of Pediatrics, 144(3), e1299.

Monden R., Roest, A.M., van Ravenzwaaij D., Wagenmakers E.J., Morey R., Wardenaar K.J., de Jonge, P. (2018). The comparative evidence basis for the efficacy of second-generation antidepressants in the treatment of depression in the US: A Bayesian meta-analysis of Food and Drug Administration reviews. Journal of Affective Disorders. 235: 393–398.

Nevels, R. M., Gontkovsky, S. T., & Williams, B. E. (2016). Paroxetine-The Antidepressant from Hell? Probably Not, But Caution Required. Psychopharmacology bulletin, 46(1), 77-104.

Module 2: Disorders With Affective Components

As a psychiatric nurse practitioner (PNP), does that research finding surprise you? How do PNPs ensure that effective psychopharmacologic treatments are prescribed to address the prevalence of affective disorders?

Consider for example that current treatments are sub-optimal, resulting in poor patient responses and uncertain modes-of-action (Plant, 2017). While it is no surprise that mental health medicine and clinical approaches are constantly evolving, novel insights into the underlying mechanisms of how affective disorders arise, remain. Additionally, the use of psychopharmacologic treatments may not always be consistent with a patient’s preferred treatment plan. Thus, your skills and understanding of how to assess and treat patients with affective disorders are important in ensuring positive patient outcomes and may also contribute to the research needed to connect clinical observations to the neuroscience, physiology, and pharmacologic processes needed to treat these disorders.

Reference:
Plant, N. (2017). Can a systems approach produce a better understanding of mood disorders? Biochimica et Biophysica Acta, 1861(1), 3335-3344. https://doi.org/10.1016/J.BBAGEN.2016.08.016

What’s Happening This Module?

Module 2, Disorders With Affective Components, is a 6-week module. During Week 4, you will begin applying your assessment and therapy skills as you engage in your first Assignment assessing and treating pediatric patients with mood disorders. In Week 5, you will continue to apply your assessment and therapy skills as you assess and treat patients presenting with bipolar disorders. As you engage with the decision tree exercises, reflect on the critical decision-making skills that you, as a psychiatric nurse practitioner, are making, as these skills are essential to your current and future practice. In Week 6, you will assess and treat patients presenting with anxiety and posttraumatic stress disorder (PTSD). You will also complete your Midterm Exam. During Week 7, you will assess and treat patients presenting with schizophrenia. In Week 8, you will complete a Short Answer Assessment in which you will synthesize your understanding of sleep/wake disorders. You will also continue to apply your assessment and therapy skills as you assess and treat patients presenting with sleep/wake disorders. During Week 9, you will examine psychopharmacologic therapies for patients with ADHD/ODD and you will complete a Quiz to test your understanding of the content explored in this module

 

What do I have to do? When do I have to do it?
Review your Learning Resources. Days 1–7, Weeks 4–9
Assignment: Assessing and Treating Pediatric Patients With Mood Disorders Submit your Assignment by Day 7 of Week 4.
Assignment: Assessing and Treating Patients With Bipolar Disorder Submit your Assignment by Day 7 of Week 5.
Assignment: Assessing and Treating Patients With Anxiety Disorders Submit your Assignment by Day 7 of Week 6.
Midterm Exam Complete Midterm Exam by Day 7 of Week 6.
Discussion: Treatment for a Patient With Insomnia Post by Day 3 of Week 7 and respond to your colleagues by Day 6 of Week 7.
Assignment: Assessing and Treating Patients With Psychosis and Schizophrenia Submit your Assignment by Day 7 of Week 7.
Assignment 1: Short Answer Assessment Submit your Assignment by Day 7 of Week 8.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders Submit your Assignment by Day 7 of Week 8.
Assignment: Assessing and Treating Patients With ADHD/ODD Submit your Assignment by Day 7 of Week 9.
Quiz: Assessing and Treating Patients With Psychopharmacology Complete Quiz by Day 7 of Week 9.

 

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