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.

 

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6630_Week4_Assignment_Rubric

 

 

Excellent Point range: 90–100

Good Point range: 80–89

Fair Point range: 70–79

Poor Point range: 0–69

 

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.

9 (9%) – 10 (10%)

The response accurately, clearly, and fully summarizes in detail the case for the Assignment. The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

8 (8%) – 8 (8%)

The response accurately summarizes the case for the Assignment. The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.

7 (7%) – 7 (7%)

The response inaccurately or vaguely summarizes the case for the Assignment. The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

0 (0%) – 6 (6%)

The response inaccurately and vaguely summarizes the case for the Assignment, or is missing. The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

 

Decision #1 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

 

Decision #2 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

 

Decision #3 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

 

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.

14 (14%) – 15 (15%)

The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient. The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.

12 (12%) – 13 (13%)

The response accurately summarizes the recommendations on the treatment options selected for this patient. The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided.

11 (11%) – 11 (11%)

The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient. The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided.

0 (0%) – 10 (10%)

The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing. The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.

 

Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

 

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

0 (0%) – 3 (3%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

 

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3 or 4) APA format errors.

0 (0%) – 3 (3%)

Contains many (≥ 5) APA format errors.

 

 

Total Points: 100

Name: NURS_6630_Week4_Assignment_Rubric

 

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.

Therapy for Pediatric Clients with Mood Disorders

An African American Child Suffering From Depression

 

Decision Point One

BACKGROUND INFORMATION

The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

  • Client complained of feeling “sad”
  • Mother reports that teacher said child is withdrawn from peers in class
  • Mother notes decreased appetite and occasional periods of irritation
  • Client reached all developmental landmarks at appropriate ages
  • Physical exam unremarkable
  • Laboratory studies WNL
  • Child referred to psychiatry for evaluation

 

MENTAL STATUS EXAM

Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation, but does admit that he often thinks about himself being dead and what it would be like to be dead.

You administer the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

 

RESOURCES

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

 

Therapy for Pediatric Clients with Mood Disorders

An African American Child Suffering From Depression

 

BACKGROUND INFORMATION

 

The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

Client complained of feeling “sad”

Mother reports that teacher said child is withdrawn from peers in class

Mother notes decreased appetite and occasional periods of irritation

Client reached all developmental landmarks at appropriate ages

Physical exam unremarkable

Laboratory studies WNL

Child referred to psychiatry for evaluation

 

MENTAL STATUS EXAM

 

Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation, but does admit that he often thinks about himself being dead and what it would be like to be dead.

 

You administer the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

 

 

RESOURCES

 

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

 

 

Decision Point One

Select what you should do:

 

Decision Point One

 

 

Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

No change in depressive symptoms at all

 

Decision Point Two

 

 

Increase dose to 37.5 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Depressive symptoms decrease by 20%. Client reports feeling a little bit better

 

Decision Point Three

 

 

Maintain current dose

Guidance to Student

At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.

 

 

Decision Point One

 

 

Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

No change in depressive symptoms at all

 

Decision Point Two

 

Increase dose to 50 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Depressive symptoms decrease by 50%. Cleint tolerating well

 

Decision Point Three

 

Increase to 75 mg orally daily

Guidance to Student

At this point, sufficient symptom reduction has been achieved. This is considered a “response” to therapy. Can continue with current dose for additional 4 week to see if any further reductions in depressive symptoms are noted. An increase in dose may be warranted since this is not “full” remission- Discuss pros/cons of increasing drug dose with client at this time and empower the client to be part of the decision. There is no indication that the drug therapy should be changed to an SNRI at this point as the client is clearly responding to this therapy.

 

 

Decision Point One

Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

No change in depressive symptoms at all

 

Decision Point Two

Increase dose to 50 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Depressive symptoms decrease by 50%. Cleint tolerating well

 

Decision Point Three

 

Maintain current dose

Guidance to Student

At this point, sufficient symptom reduction has been achieved. This is considered a “response” to therapy. Can continue with current dose for additional 4 week to see if any further reductions in depressive symptoms are noted. An increase in dose may be warranted since this is not “full” remission- Discuss pros/cons of increasing drug dose with client at this time and empower the client to be part of the decision. There is no indication that the drug therapy should be changed to an SNRI at this point as the client is clearly responding to this therapy.

 

 

Decision Point One

 

 

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea

Decision Point Two

 

 

Decrease dose for 7 days then return to previous 10 mg day dose

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose

 

Decision Point Three

 

 

Attempt to decrease dose for another 7 days then return to 10 mg dose

Guidance to Student

Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, you will need to select a different agent as these side effects are unfavorable to the client and may result in refusal to take treatment. Also, continuing to drop medication dose to subtherapeutic level will do minimal to treat depressive symptoms. Changing to a different SSRI would be the ideal choice as not all SSRIs have the same side effect profile in all clients. It would not be appropriate to increase the dose at this time as it would most likely result in increased intensity of side effects.

 

 

Decision Point One

 

 

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea

 

Decision Point Two

 

 

Increase dose to 20 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Nausea, vomiting, and diarrhea has increased and client is refusing to take medication

 

Decision Point Three

 

 

Continue same dose and encourage child to take medication

Guidance to Student

Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, you will need to select a different agent as these side effects are unfavorable to the client and may result in continued refusal to take treatment. Changing to a different SSRI may be appropriate if the trial decrease of dose is unsuccessful and if the nausea, vomiting, and diarrhea return with reinitiation of 20 mg orally daily. Changing the medication may be appropriate as not all SSRIs have the same side effect profile in all clients.

 

Decision Point One

 

 

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea

 

Decision Point Two

 

 

Change to Prozac 10 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

There is a 25% reduction in symptoms, client’s side effects of nausea, vomiting, and diarrhea have resolved. Client reports that he is feeling a “little bit better”

 

Decision Point Three

 

 

Continue current dose

Guidance to Student

You have two equally compelling choices at this point. The client has only been taking the current drug at its current dose for 4 weeks. It would be appropriate to continue at current dose. Additionally, you could also increase the dose to 20 mg orally daily. A discussion of risk/benefits should be had with the childs guardian regarding this and collaborative decision making should occur. There is no indication at this point that augmentation agents are required as the child is showing a partial response to therapy.

 

 

Decision Point One

 

 

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea

 

Decision Point Two

 

 

Decrease dose for 7 days then return to previous 10 mg day dose

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose

 

Decision Point Three

 

 

Change to a different SSRI

Guidance to Student

Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, you will need to select a different agent as these side effects are unfavorable to the client and may result in refusal to take treatment. Also, continuing to drop medication dose to subtherapeutic level will do minimal to treat depressive symptoms. Changing to a different SSRI would be the ideal choice as not all SSRIs have the same side effect profile in all clients. It would not be appropriate to increase the dose at this time as it would most likely result in increased intensity of side effects.

 

 

Decision Point One

 

 

Begin Wellbutrin 75 mg orally BID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Child is unable to fall asleep at night

 

Decision Point Two

 

 

Change from immediate release to extended release 150 mg orally daily in the morning

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Child’s sleep patterns return to baseline. No change in depressive symptoms

 

Decision Point Three

 

 

Change to SSRI

Guidance to Student

You can continue drug therapy for another 4 weeks, however, it is discouraging that there have been no changes in depressive symptomatology. Increasing the dose to 300 mg orally daily may be appropriate if the child is tolerating the medication well. Changing to an SSRI may also be appropriate, but it may be more prudent to give the Wellbutrin at an appropriate dose for an adequate duration of therapy before switching therapeutic classes.

 

Decision Point One

 

 

Begin Wellbutrin 75 mg orally BID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Child is unable to fall asleep at night

 

Decision Point Two

 

 

Give second dose of the day at 1:00 pm in the afternoon

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

No change in sleeping patterns, child is getting more difficult to wake for school

 

Decision Point Three

 

 

Change administration to giving both immediate release tablets in the morning

Guidance to Student

It is clear that the side effect after 4 weeks persists, the likelihood of it abating is quite low at this point, indicating that the PMHMP must do something. Administering both tablets of 75 mg in the morning may be an option, but then blood levels are not maintained throughout the day. There is also an increased risk of side effects (including seizure as this drug reduces seizure threshold). The correct answer would be to change the drug to an extended release formulation and administer in the morning.

 

Decision Point One

 

 

Begin Wellbutrin 75 mg orally BID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Child is unable to fall asleep at night

 

Decision Point Two

 

 

Change to Lexapro 10 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms

 

Decision Point Three

 

 

Continue current dose

Guidance to Student

At this point, there is no indicating that you should change back to Wellbutrin as the child is tolerating the current medication without mention of side effects. Also, the child is experiencing a reduction in symptoms. You could also increase the dose to 15 mg orally daily, but the child has only been taking the drug for 4 weeks at this point. It may be more prudent to give the current therapy an additional 4 weeks before making any decisions to change current dose.

 

Decision Point One

 

 

Begin Wellbutrin 75 mg orally BID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Child is unable to fall asleep at night

Decision Point Two

 

 

Change to Lexapro 10 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms

Decision Point Three

 

Increase dose to 15 mg orally daily

Guidance to Student

At this point, there is no indicating that you should change back to Wellbutrin as the child is tolerating the current medication without mention of side effects. Also, the child is experiencing a reduction in symptoms. You could also increase the dose to 15 mg orally daily, but the child has only been taking the drug for 4 weeks at this point. It may be more prudent to give the current therapy an additional 4 weeks before making any decisions to change current dose.

 

 

 

 

 

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