Assessing and Treating Pediatric Clients With Mood Disorders

Mood disorders are described and categorized by noted disturbances and fluctuations in patient mood. These alterations often lead to severe disruption of daily activates and negatively impact patient interactions. The diagnosis of a mood disorder involves the presence or absence of at least one noted major depressive, manic, or hypomanic episode. For the clinical diagnosis of a depressive episode, patients must experience at least four of the following symptoms for at least two weeks: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty concentrating; or recurrent thoughts of death or suicide (Nelson, 2019). Depression can occur in patients of all ages, but their clinical presentations, level of disorder development, treatment options, and outcomes often vary.

While many adults often request medical treatment for experienced depressive symptoms, children may not be able to express feeling sad or depressed. Approximately 1.9 million children aged 3-17 years have diagnosed depression, and nearly 8 in 10 children with diagnosed depression have received treatment (Centers for Disease Control and Prevention, 2020).The diagnostic criteria for depression is the same for children and adolescents, but deviations often exist because of varying cognitive, emotional, and social development (Patra, 2019). Some behaviors seen in children with depression include feeling sad, hopeless, or irritable, changes in eating and sleeping patterns, irregular temper tantrums, and not wanting to do fun things (Centers for Disease Control and Prevention, 2020). Identifying and reporting these noted behaviors can lead to the diagnosis and treatment of childhood depression.  

Purpose of the Assignment

The purpose of this assignment is to review an interactive case study involving the care of a pediatric patient presenting with mood disorder symptoms. There will be a review of the patient presentation and the development of an individualized care plan for patient treatment. Three patient care decision points and their respective outcomes will be discussed to evaluate their impact. Lastly, ethical and legal implications will be considered in regard to the risks and benefits involved in the specialized care of pediatric patients.

Case Study Summary

The presenting patient is an 8-year-old African American male who is brought to the emergency room by his mother with displayed signs of depression. His mother reports that her son has been noticeably withdrawn, isolative, and occasionally irritable during interactions in the home and school setting. She reports a noted decrease in his appetite but shares that he has reached all developmental landmarks at the appropriate ages. His physical examination is unremarkable, and his recent laboratory studies are within normal limits.

On assessment, the patient is alert, oriented, and utilizes clear and coherent speech. He presents with a fairly blunted affect but smiles appropriately during the interview. He does not endorse current active suicidal ideation, but self-reports feeling “sad” and admits to often thinking about himself being dead and what that would be like. He denies and does not display signs of visual or auditory hallucinations, delusions, or paranoid thought processes. The administered Children’s Depression Rating Scale indicates significant depression with an obtained score of 30.

                                                                Decision Point 1

During the first decision point, the Psychiatric Mental Health Nurse Practitioner (PMHNP) is provided three antidepressant medication regimens to select from for this presenting patient. The offered treatment options include the initiation of Sertraline (Zoloft) 25 mg orally once daily, Paroxetine (Paxil) 10 mg orally once daily, or bupropion (Wellbutrin) 75 mg orally twice daily. As the PMHNP initiating care for this patient, the start of Zoloft 25 mg orally once daily would be the first decision made for initiating pharmacological treatment for this patient.

Decision Rationale

The PHMNP must select an appropriate antidepressant medication to help decrease depression symptoms for this pediatric patient. SSRIs have a relatively safe adverse effect profile, very low lethality after overdose, and only once-daily administration, making SSRIs the most commonly used medications for depression (Giardino, 2017). In the United States, the Food and Drug Administration (FDA) has approved the use of Escitalopram (Lexapro) for children twelve and older and Fluoxetine (Prozac) for children eight and older with major depressive disorder symptoms, while other antidepressants are frequently used off-label (Maruf, Greenslade, Arnold, & Bousman, 2019). None of the available options are FDA-approved for use with our eight-year-old patient. The PMHNP should use currently available evidence to help guide this clinical decision.

The appropriate selection of antidepressant medication should be based on previously conducted testing and recommended therapies for patients with similar presenting characteristics. Evidence from randomized, clinical trials suggests efficacy in the treatment of moderate to severe MDD using 3 selective serotonin reuptake inhibitors (SSRIs): fluoxetine, sertraline, and citalopram (Giardino, 2017). Randomized trials have shown efficacy of sertraline use for depression in adolescents, but they have not yet received FDA approval for use in children and adolescents with depression (Patra, 2019). While only a few SSRIs are FDA-approved for pediatric indications, the lack of FDA approval is typically related to a lack of sufficient testing in randomized controlled trials (RCTs) for specific pediatric indications, rather than to demonstrable differences in efficacy between antidepressant agents (Dwyer & Bloch, 2019). The FDA has approved one antidepressant for a pediatric use but testing and review of evidence is still being conducted to determine best practice measures.

In contrast to the efficacy shown in sertraline use for pediatric depression, other studies have exhibited some negative outcomes for alternate antidepressant use. Clinical studies involving the use of Paroxetine have shown a higher profile of side effects when used to treat childhood depression (Bhatia, 2018). Paroxetine has not shown any benefit in RCTs involving pediatric depression; but there are safety concerns and occurrence of severe discontinuation and withdrawal symptoms owed to its short half-life (Patra, 2019). Because Paroxetine has a high-risk of adverse side effects in pediatric use, this medication should not be the chosen antidepressant initiated for an eight-year-old patient with depression.

Bupropion (Wellbutrin) is a norepinephrine dopamine reuptake inhibitor (NDRI) that is FDA-approved for major depressive disorder in adults, but it is not approved for use in the pediatric population. Stahl (2017) shared that Bupropion has proven to be a useful antidepressant for patients who cannot tolerate the serotonergic side effects of SSRIs, and for patients whose depression does not respond to serotonergic boosting SSRIs. Our patient has not yet utilized an SSRI medication, so there are no current side effects or lack of medication response in place. SSRI use should be implemented prior to the start of an alternate antidepressant drug class. 

Desired Treatment Goals

During the initiation of antidepressant medication use for this patient, the first treatment goals would be a noted decrease in reported depressive symptoms and an improvement in presentation and mood. The goals of treatment should be to achieve remission, reduce relapse and recurrence, and a return to their previous level of occupational and psychosocial function (MN Community Measurement, 2020). The decision to initiate pharmaceutical treatment for this patient would involve a detailed review of treatment expectations with the patient and their parent or caretaker. Acute phase treatment aims at achieving response, which is defined as at least 50% reduction in symptoms (Patra, 2019). The goal for depression care is to achieve remission of all symptoms, so the first goal for our patient would be to achieve a 50 % decrease in reported depressive symptoms by the time of his next appointment.

Patient Outcome

After the Zoloft 25 mg daily treatment was initiated, the patient returns to the clinic in four weeks with no change in reported depressive symptoms. This patient response does vary from what was anticipated, because the patient did not experience a noted response with utilized medication. It is important to note that the patient did not present with any alarming side effect or adverse reactions, and he also does not present with worsening depression or increased intensity in his symptoms. Off-label medications are generally effective and well-tolerated, but 25% – 48% of children will not respond to treatment or will experience physical, emotional, or behavioral adverse drug reactions (Maruf, Greenslade, Arnold, & Bousman, 2019). The goal of treatment is to achieve a patient response with medication use and to return to his prior level of functioning. The PMHNP should be monitoring for adverse side effects during all phases of treatment and patient care while reviewing the status of noted patient symptoms.

Decision Point 2

Decision point two included three available medication regimen adjustments. The PMHNP can chose to increase the Zoloft dose to 37.5 mg orally daily, increase the Zoloft dose to 50 mg orally daily, or change the medication entirely from Zoloft to Prozac 10 mg orally daily. When the initial dose of medication is not effective at reaching the desires patient outcome, adjustments are required for future analysis. The PMHNP should increase the dose of Zoloft to 50 mg orally once daily to determine if this chosen medication can effectively decrease depressive symptoms for the presenting patient at double the current dose. 

Decision Rationale

The patient did not present with a decrease in depressive symptoms after the first four weeks of medication use as anticipated. The patient did not present with any alarming side effect or adverse reactions, so the PHMNP should not switch to a new medication until an adequate trial of Zoloft has been conducted. An adequate trial of a selective serotonin reuptake inhibitor (SSRI) involves 4 to 6 weeks at a therapeutic dose (Giles & Martini, 2016). Although the patient has been utilizing the initial therapy for four weeks, the PMHNP has not concluded that this would be the appropriate therapeutic dose for this patient. The full benefit of SSRI use for depression may take as long as 8 weeks. A meta-analysis of depression studies in pediatric care suggests that significant benefits from placebo are observed as early as 2 weeks, and that further treatment advances are minimal after 4 weeks. A minimum 4- to 6-week trial at therapeutic dosing is recommended before deeming a specified medication a treatment failure (Dwyer & Bloch, 2019). Because this patient did not show any change in symptoms, the decision was made to double the dosing instead as opposed to using a smaller increase in dosing.

Desired Treatment Goals

The goal of this selected decision was to determine if an increased dose of Zoloft could help decrease noted depression symptoms at an increased dose. The goal would again be to achieve symptoms remission and return to patient baseline functioning. Equal importance should be placed on the achievement of decreased depression and also the avoidance of adverse side effects. It is important to determine if medications are effective in a timely manner while also avoiding patient harm with use. With this dose increase, we would be provided a view of medication potential for response initiation. If the patient did not respond with double the dose of Zoloft treatment, we would be able to determine that this medication is failing for use with our presenting patient.  

Patient Outcome

In response to increasing the Zoloft dose to 50 mg orally daily, the patient returns to the clinic in four weeks and reports that he is tolerating the medication well and has achieved a 50% decrease in depressive symptoms. This outcome does match the desires goal that was placed for patient response to treatment and avoidance of adverse side effects. Although the initial dose was not able to provide the patient with a decrease in experienced depressive symptoms, the increased dose could have easily been as unsuccessful as the initial treatment. The doubled dose of Zoloft was able to produce a patient response, so we are provided a positive step forward as we aim for symptom remission.

Decision Point 3

Decision point three included three available medication regimen choices. The PMHNP can either maintain the current Zoloft dose of 50 mg orally daily, increase the Zoloft dose to 75 mg orally daily, or change the provided medication to an SSRI. The patient has currently reached a decrease in reported depressive symptoms by 50%. The PMHNP should maintain the current dose of Zoloft at 50 mg orally daily and schedule a follow-up appointment in four more weeks to review patient response to treatment.

Decision Rationale

Because this patient is currently responding to the provided therapy, the PMHNP should continue to monitor if depressive symptoms continue to decrease at the currently provided Zoloft 50 mg daily dose. The PMHNP should not switch the medication class until this SSRI class is proven to be a failure for this patient. After 2 failed SSRI trials, consideration should be given to a non-SSRI medication, usually a SNRI, along with continued utilization of therapy interventions. (Giles & Martini, 2016). This was the first SSRI medication trial for this patient, and it was not proven to be failure. The PMHNP should not switch to a different medication or medication class due to the noted 50% decrease in depression symptoms while also being able to tolerate the medication. The PHMNP should not increase the medication dose too soon because we should monitor for true symptom response to each therapeutic dose provided.

Desired Treatment Goals

The patient goal continues to be a noted decrease in depressive symptoms, avoidance of adverse side effects, and avoidance of return to the disease state. Stahl (2017) shared that the goal of treatment of depression is complete remission of current symptoms as well as prevention of future relapses. Our goal for the presenting patient should be a continued decrease in depressive symptoms that brings the patient to a full remission state. We want our patient to report full symptoms ] reduction and t mood improvement at the next follow-up appointment.

Patient Outcome

The patient returns to the clinic in four weeks and has achieved a sufficient reduction in his depressive symptoms with currently prescribed Zoloft 50 mg daily use. The patient should follow-up with the PHMNP in an additional four weeks to determine if symptoms have decrease fully to remission. This outcome does vary from the developed goal because we would like this patient to have reached remission by this point in treatment. This medication dose could be maintained or increase to the 75 mg daily dose depending on symptom reporting at the next scheduled follow-up. If symptoms reduction has halted by the next appointment, the PHMNP can then recommend increasing the dose to 75 mg daily to potentially reach full symptom relief.

Conclusion

Providers must always balance the risks and benefits of prescribing specified medications for their patients. The provided Zoloft medication for our eight-year-old patient would be considered an off-label use of this medication. This comes with several challenges, clinical judgement skill use, and close patient monitoring. Stahl (2017) shared that parents should be informed if a medication is specifically approved for the disorder being treated, or if it is “off-label” but nevertheless good clinical practice and based upon prudent extrapolation of controlled data from adults and experience in children and adolescents versus formal FDA approval. Providers are often forced to prescribe medications off-label as we await the conduction of further research. The American Academy of Pediatrics adopted a policy statement and defined off-label medication use in children as “a drug that is not included in the FDA package insert [and] does not imply improper, illegal contraindicated or investigational use” (Allen, Garbe, Lees, Aziz, Chaaban, Miller, Johnson, & DeLeon, 2018). There is a great deal of concern from surrounding the off-label use and also a potential increased risk of suicide in children prescribed antidepressant medications.

One of the greatest challenges to consider when treating patients with depression is the potential risk for increased suicidality. Epidemiological studies have established that suicide risk has actually decreased with increased antidepressant use, but the initial improvement in patient energy levels may have the potential to increase suicidality (Patra, 2019). All patients should be closely monitored and re-assessed for symptom and mood improvement while using antidepressants. Thorough medication education is important to ensure that all benefits and possible risks are reviewed and understood by the patient and their family or caregivers.

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://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677268/

Bhatia, Richa. (2018). Childhood Depression. Anxiety and Depression Association of America. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/childhood-depression

Centers for Disease Control and Prevention. (2020, March). Anxiety and Depression.

https://www.cdc.gov/childrensmentalhealth/depression.html

Centers for Disease Control and Prevention. (2020, March). Data and Statistics on Children’s

            Mental Health. https://www.cdc.gov/childrensmentalhealth/data.html

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current

psychiatry, 18(9), 26–42F. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738970/

Food and Drug Administration. (2018, February). Suicidality in Children and Adolescents Being Treated With Antidepressant Medications. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications

Giles, L. L., & Martini, D. R. (2016). Challenges and Promises of Pediatric Psychopharmacology. Academic Pediatrics, 16(6), 508–518. https://doi.org/10.1016/j.acap.2016.03.011

Maruf, A. A., Greenslade, A., Arnold, P. D., & Bousman, C. (2019). Antidepressant pharmacogenetics in children and young adults: A systematic review. Journal of Affective Disorders, 254, 98–108. https://doi.org/10.1016/j.jad.2019.05.025

MN Community Measurement. (2020, May). Depression Remission at Twelve Months. https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS159v7.html

Nelson, E. M. M. (2019). Mood disorders. Salem Press Encyclopedia of Health.

Patra S. (2019). Assessment and management of pediatric depression. Indian journal of psychiatry, 61(3), 300–306. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_446_18

Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press.

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