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 THERAPY FOR PEDIATRIC CLIENTS WITH MOOD DISORDERS

Assessing Mood Disorders: An African American Child Suffering from Depression

Introduction

Depressive symptoms and other mood disorders cause significant impairment to children because they affect communication and other important functions. Moreover, these conditions are prone to comorbidity and may be difficult to diagnose especially in young children. Proper assessment and accurate diagnose, followed by an effective treatment are necessary when working with children with mood disorders. Moreover, working with children requires an understanding of various ethical issues involved such as parental consent and appropriateness of pharmacological choice for use with the pediatric population (Zhou et al, 2020). A range of antidepressants is used for the treatment of mood disorders in children and adolescents both off-label and FDA-approved. As such, it is important to evaluate patient factors, as well as the risk and benefits of the recommended treatment plan for the choice of medication.

Background

The case is of an 8-year-old African American boy who is described as feeling “sad”. Additionally, the boy has withdrawn from peers, and the mother reports loss of appetite and occasions of irritation. These symptoms are consistent with the DSM-5 criteria for depression in children, include depressed mood, loss/gain of weight, diminished interest in doing things, and irritability. Physical examination of the patient gives an unsatisfactory outcome. Similarly, mental examination reveals that the patient’s mood is sad with blunted affect. The patient, however, does not experience hallucinations or suicidal ideation but indicates sometimes imagining himself dead. These manifestations coupled with the outcome of the Child Depression Rating Scale, which gives a value of 30 proves that the patient is suffering from severe depression. The following is a treatment plan for the patient detailing the pharmacological decisions made with evidence to support the choices.

Decision Point One

Begin Zoloft 25 mg orally daily

I chose to start the patient on Zoloft 25 mg daily as it is advisable to start with small doses and adjust while monitoring the patient’s response and effectiveness of the medication. The rationale for choosing Zoloft is based on its proven efficacy and safety for use with the pediatric population. Zoloft is one of the FDA-approved medications for use in children and adolescents for the treatment of a major depressive disorder. Zoloft is approved for children from 6 years and above. A study by Garland et al. (2016) shows that Zoloft is not only effective for the treatment of depression in children but also well-tolerated for extended periods.

Paxil is the second option but is not a favorable choice for two reasons. First, Paxil is not FDA approved for use with children and adolescents. Secondly, Paxil has the risk of causing suicidal thoughts in children and adolescents, which makes it less safe for this population. A thorough review by Noury (2015) of 359 studies on the efficacy and safety of Paxil for use in the pediatric population concluded that it is neither safe nor effective. Likewise, Wellbutrin is also not indicated by the FDA for use in the pediatric population making it an unfavorable choice in this case (Walkup, 2017). Though it can b used as an off-label medication, it still presents with side effects including seizure and anorexia making it less safe as compared to Zoloft.

My expectation in this decision was to see an improvement in the patient. I expected that the client’s mood would be better and develop an interest in schoolwork. I also expected the patient to report an improvement in appetite and sleep. Contrary to my expectations, the patient reported back in two weeks with no change in symptoms. However, the good news is that they did not experience any side effects with Zoloft.

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Decision Point Two

Increase the dose to 50 mg orally daily  

My reason for choosing to increase the dose is because the patient has shown a good response with Zoloft and registered no side effects. The only problem that the dose initially provided was too low for therapeutic effectiveness. Guidelines on the use of antidepressants recommend that practitioners choose to increase the dose of a well-tolerated drug rather than change to another antidepressant (Kato et al., 2018). On the other hand, given that the first dose did not have any effect on the patient, a dose of 37.5 may not give the desired effect of 50% improvement. The maximum allowed dosage for Zoloft a day is 200 mg, which means 50 mg daily is still on the lower side.

I did not choose Prozac, which was another available option at this point because a change to another drug is not necessary. A change would be considered if Zoloft was having adverse effects on the patient, but in this case, the patient has not experienced any side effects meaning Zoloft is well-tolerated. Moreover, Prozac is not as effective as Zoloft. According to Sahl (2014), Prozac can augment feelings of self-harm in children and adolescents, as well as cause serotonin syndrome due to accumulation of excess serotonin.

For this decision, I expected a substantial improvement in symptoms. I expected that in the next appointment with the client they will note relief from symptoms leading to improvement in sleeping, better appetite, and improved mood. The client returned to the clinic 4 weeks later noting great improvements and relief from the effects of depression. The outcome was as expected because the client noted a 50% percent improvement, which is sufficient in this case. The goal of an effective treatment plan according to Vitiello (2012) is to restore normal function or reduce symptoms, which is what was achieved in this case.  

Decision Point Three

Maintain the current dose

50% symptom improvement is not an optimal therapeutic achievement; however, it is sufficient to restore normal functioning in the patient (Zhou et al, 2020). Thus, it is reasonable to maintain the current dose. Moreover, the medication is well-tolerated at this dose, hence, no need to change. The dosage can be reviewed in the next visit and if necessary, increase the amount. Nevertheless, the patient will be closely monitored to identify any changes or side effects.

8 weeks is a sufficient period for a trial of an antidepressant. Zoloft has proven to be an effective and safe treatment for severe depression in the patient within 8 weeks. Therefore, maintaining the medication is a favorable option over changing to another drug. Making changes to another drug should be a consideration if the current medication fails to give the expected therapeutic effects or has side effects.

Ethical Considerations

Working with adolescents and children requires several ethical considerations particularly when prescribing medication. First, parental consent must be sought when working with the pediatric population. Parents are responsible for making treatment decisions on the behalf of their children. Thus, when creating a treatment plan for the patient, the practitioner should explain to the parents the risks and benefits of the chosen medication. Similarly, the practitioner will educate the parents on the potential side effects of the drug so that they know the effects to watch out for in the patient (Zhou et al, 2020). The parents should also be engaged in the discussion when increasing the dosage for the patient or possible change of medication.

Similarly, the use of off-label drugs is another ethical issue that arises when working with pediatric patients. In most cases, drugs used with the pediatric population are not FDA approved because of the complications in trials and research with children. Thus, psychiatric nurse practitioners rely on evidence from research, experience, and evaluation of risks and benefits of the medication before deciding to use it with a pediatric patient. Similarly, most antidepressants tend to cause suicidal thoughts in children and adolescents (Gordon & Melvin, 2014). Practitioners must therefore carefully select medications after evaluating patient factors to ensure that a person with suicidal ideation is not prescribed medication that can cause an adverse event by increasing suicidal thoughts.

Summary

The patient presents with severe depression, which is one of the mood disorders common in the pediatric population. The first decision was to select supported by the rationale that it is effective, safe, and FDA approved for use in the pediatric population. On the other Paxil and Wellbutrin are not approved by FDA for use with children and adolescents, which makes an unlikely choice for treatment in this case. In addition, dose increment is preferable to change to another antidepressant. since Zoloft showed the effectiveness and good response without side effects, choosing to increase dosage rather than introduce another antidepressant was the best option. Once medication shows the effectiveness of 50% or over, the dosage can be maintained since the aim of the treatment is to restore function through the reduction in symptoms. However, consideration can be made to increase the dose if the symptoms reoccur. Ethical considerations that impact the treatment of pediatric patients include off-label medications, parental consent, and the safety of antidepressant medications in relation to patient factors.

 

References

Garland, E. J., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. J Can Acad Child Adolesc Psychiatry, 25(1), 4–10.

Gordon, M. S. and Melvin, G. A. (2014), Do antidepressants make children and adolescents suicidal? J Paediatr Child Health, 50: 847–854. doi:10.1111/jpc.12655

Kato, T., Furukawa, T., & Mantani, A. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder — the SUN☺D study: a pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC Med, 16(103). https://doi.org/10.1186/s12916-018-1096-5.

Noury, J. L., Nardo, J., Healy, D., Jureidini, J., Raven, M., & Tufanaru, C. (2015). Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ, 351. doi: https://doi.org/10.1136/bmj.h4320.

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

 

Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012

Walkup, J. T. (2017). Antidepressant Efficacy for Depression in Children and Adolescents: Industry- and NIMH-Funded Studies. American Journal of Psychiatry, https://doi.org/10.1176/appi.ajp.2017.16091059.

Zhou, X., Teng, T., & Zhang, Y. (2020). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. The Lancet, 7(7), P581-601. DOI:https://doi.org/10.1016/S2215-0366(20)30137-1.

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