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

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• Mother reports that teacher said child is withdrawn from peers in class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
• Client seen by Psychiatric Nurse Practitioner

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.

The PMHNP administers the Children\\\’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression) The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

RESOURCES

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

Decision Point One

Select what the PMHNP should do:

Begin Zoloft 25 mg orally daily

Begin Paxil 10 mg orally daily

Begin Wellbutrin 75 mg orally BID

Assessment and Treatment of a Pediatric Patient MDD – The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

Introduction – Assessment and Treatment of a Pediatric Patient MDD

Major Depressive Disorder (MDD) is known to significantly impact the individual, particularly when its onset happens in the patient’s early years. Mental health care experts acknowledge that the incidence of depression increases across the lifespan from childhood, through adolescence, and into adulthood (Mullen, 2018). Suffice it to say that early therapeutic intervention through therapy or pharmacotherapy holds the key to effective treatment and management of MDD. Successful interventions improve patient outcomes and significantly lower the risk of suicide, SUDs, and chronic psychosocial impairment in adulthood, amongst other factors. To illustrate this overarching goal, this paper presents a three-point decision tree of an 8-year-old African American boy who presents to the ER accompanied by his mother with clinical manifestations indicative of depression. 

It is important to note that pediatric depression is usually undiagnosed or misdiagnosed and therefore receives no treatment or gets ineffective treatment as some of the symptoms seen in adults are not present in children. Upon psychiatric evaluation using the Children’s Depression Rating Scale, a score of 30 was suggestive of depression. The CDRS-R is reliable, and a valid measure of pediatric depression as a biomarker is pivotal in establishing the underlying mechanism predisposing a child to mood disorders like MDD (Elsiņa & Martinsone, 2019). Subsequently, the mental healthcare provider must exercise caution when prescribing psychotropic drugs if successful assessment, treatment, and management of child patients suspected or diagnosed with mood disorders. This rationale stems from the fact that a medication’s metabolism and genetic heterogeneity control the distinctions in the drug’s clearance, its half-life, and optimal blood concentrations. In this pediatric patient case scenario, I encountered the following decision points.

Decision Point 1 Medication Selected Zoloft

It is important to acknowledge that a provider has a wide range of treatment options to sleet from once a diagnosis of MDD is determined. For example, Neavine et al. (2018) note that pediatric MDD treatment currently involves psychotherapy and prescribing selective serotonin reuptake inhibitors( SSRIs) like fluoxetine and Escitalopram. However, the listed medications are Zoloft 25 mg, Paxil 10mg, and Wellbutrin 75 mg, all to be taken orally daily. 

At the first decision point (DP#1), I opted to prescribe Zoloft 25mg PO daily. This choice was informed by the fact that comparative studies have established that Zoloft (Sertraline) effectively treats pediatrics diagnosed with MDD (Zhou et al., 2020). However, these researchers point out that in terms of acceptability, sertraline had more dropouts than nefazodone and fluoxetine. In a study conducted by Dwyer & Bloch (2019), the researcher found that SSRIs, of which Zoloft is one, effectively manage pediatric MDD amongst other psychiatric conditions. Another reason why I selected Zoloft 25 mg is that as a mental health provider, I must also take into consideration the fact that the FDA has approved only a few SSRIs for pediatric indications because of lack of sufficient testing in randomized controlled trials for specific childhood indications with demonstrable distinctions in efficacy between various antidepressant agents. There is also no current data suggesting the inferiority of one agent compared to another in children or grown-ups. Lastly, Zoloft 25mg is a lower dosage needed to initiate treatment as all antidepressants are known to increase anxiety when initially prescribed. A dose above 25mg would not be ideal for this pediatric patient (Stahl, 2020).

Although Paxil, whose generic name is Paroxetine, is an SSRI, I did not select it because it is categorized as a class D antidepressant, meaning it has a positive teratogenic impact. For patients less than 18 years, Paroxetine is also contraindicated (Nevels et al., 2016). The researchers also noted that Paroxetine is associated with more weight gain than sertraline. The respective weight gain experienced by patients taking Paroxetine was 3.6% greater than those of sertraline at 1.0%. Similarly, Wellbutrin (bupropion) was not selected as a first-line medication in this patient because it is not conventionally prescribed in pediatrics due to lack of its effectiveness despite its risks of anorexia and neurologic symptoms like seizures (Dwyer & Bloch, 2019).

           The treatment goal for Zoloft 25mg medication and dosage was to alleviate the pediatric patient’s depressive symptoms and significantly improve the patient’s moods. Studies abound whose findings demonstrate its ability to restore serotonin balance in the brain, enhance mood, and minimize depressive symptoms. A case in point is a study that determined that when combined with sertraline, physical exercise decreased affective symptoms and psychomotor retardation in MDD patients (Guerrera et al., 2020). 

Despite this goal, the actual outcome was contrary to the expected outcome as the patient’s symptoms had not improved when he returned to the clinic for a follow-up visit four weeks later. This was probably because Zoloft does not decrease depressive symptoms until after six weeks of administration, although it improves mental- health-related quality of life (Lewis et al., 2018). As the provider, I communicated with the client’s representative (mother) on the absence of an FDA approval for Zoloft despite its clinical efficacy to control depression in empirical studies.

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Decision Point # 2- Changing to Prozac 10mg PO Daily Next Treatment Option

The results of DP#`1 were that the client returned to the clinic after four weeks with no improvement in the depressive symptoms, while the listed treatment options at DP#2 were to increase the dosage by 12.5 mg so that the daily dose would be 37.5mg PO daily. The second option was to double the initial dose of 25mg and have the patient take 50mg daily or change to Prozac 10mg PO daily.

I opted to switch to Prozac 10mg PO daily. Contemporary mental health care providers recommend that Prozac be the drug of choice in pediatric and adolescent depression treatment because it has the best evidence base currently available and licensed for patients aged eight years or more. Yan et al. (2019), when conducting a multicenter network meta-analysis with over 5,000 subjects aged between 6 and 20 years, determined that Prozac was the most officious and well-tolerated. This meta-analysis compared fluoxetine with several other medications, and using the available evidence, fluoxetine emerged as the most reliable evidence supporting its treatment in the treatment of MDD through pharmacotherapy. 

According to Anvvari et al. (2020), either Prozac or Lexapro should be first-line antidepressants for minors with reinforcement of cognitive-behavioral therapy. These scholars recommend using Zoloft on co-occurring psychiatric conditions like obsessive-compulsive disorder. As a result, titrating Zoloft to 37.5 mg or 50 mg was ruled out. Del Casale et al. (2019) report that doses of 20-60 mg daily are correlated with significant symptom improvement in OCD. However, in this patient’s case, an initial dose of Paroxetine 25 mg had no symptom alleviation. Additionally, current evidence on sertraline prescribing in MDD should not be recommended even for off-label children between the ages of 6 and 11 years (Elsevier, 2020).

The primary goal of changing from Zoloft 25mg to Prozac 10 mg PO daily was to improve the patient’s serotonin balance within the brain. As a result, the actual outcomes mirrored the expected outcome since when the patient returned to the clinic after one month, both patient and mother reported reduced depressive symptoms. The specific target was to reduce the depressive symptoms by half. Administering the CDRS-R scale would have an aggregate score of 15 or less, indicating moderate to mild depression. A maintenance dose is 20 mg in the morning every day (Dwyer & Bloch 2019). A pediatric patient should not have higher doses, and the initial dose of 10 mg should be titrated to a maximum of 20 mg

Decision Point # 3(DP#3) – Increasing the Current Dose of Prozac 10mg to 20 mg PO daily

The results of DP#2 were that the patient returned to the clinic with significant improvement in the depressive symptoms but below the expected alleviation by 50%. At the same time, the listed treatment options were to maintain the current dose of 10 mg, increase to 20 mg daily, or introduce another antidepressant-like Lexapro 10mg.

I opted to increase the current Prozac 10mg to 20mg PO daily dose because the patient’s response was as desired. The depressive symptoms were significantly reduced. Hernández-Otero et al. (2017) observe that while teens receive the same dose as adults, children need to get a slightly lower dose through a single dose in the morning. This helps in liquid management in children. It is also good to stick with a prescribed medication in the medical field if the patient registered positive outcomes. Hinging on this medical principle, I ignored option one of sticking to the current because while the patient had shown some improvement, it was not as per the target of 50%, hence the decision to increase the dosage to 20mg daily, which happens to be the therapeutic range in MDD. Additionally, the phase maintenance dose is expected to be carefully adjusted once clinical improvement is realized over the next six months. Option three of introducing Lexapro 10mg was also ignored because it has been less effective in managing MDD. Moreover, the patient did not have side effects that would necessitate a switchover to Lexapro.

The primary goal for increasing the current dose to a therapeutic range of 20 mg was to let the client continue responding to the medication until full recovery is achieved. I anticipate that increasing the current dosage to the optimum will yield positive outcomes. A follow-up visit four weeks later would see elevated symptom alleviations finally ending in total symptoms remission. Subsequently, there was a need to increase the current dosage. Dwyer & Block (2017) recommend a break in the treatment course if remission is achieved and maintained for 6-8 weeks. These should be followed by a continuation phase of between 16 and 20 weeks to prevent a relapse. A point to consider is that the length of the last phase (the maintenance phase) will depend on the child’s history the underlying therapeutic indication, amongst other factors. I anticipate the child to have total remission. Anvari et al. (2020) report that in a double-blinded RCT with 219 children subjects aged between 8 and 18 participating, the patients had better remission of MDD symptoms within nine weeks of taking fluoxetine 20mg daily. 

Conclusion and Ethical Considerations

This three-point decision-making tree for an 8-year child diagnosed with MDD has established that if psychotherapy proves ineffective, pharmacotherapy interventions like off-label use of Zoloft or the FDA-approved use of Prozac 10mg is an appropriate alternative or adjunctive intervention. Current guidelines recommend treatment modification if no response is noted within four weeks. Lastly, excellence in the sub-sector of psycho-pharmacotherapy requires that the mental health care provider be sensitive to ethical considerations, particularly when dealing with child patients. The guiding premise should be to heal, relieve the patient’s suffering, and expedite the remission of symptoms.

References

Anvari, A. A., Carroll, M. P., & Klein, D. A. (2020). Primary Care Clinicians Can Effectively Treat Depression in Children and Adolescents. American Family Physician, 102(4), 198-199.

Del Casale, A., Sorice, S., Padovano, A., Simmaco, M., Ferracuti, S., Lamis, D. A., … & Pompili, M. (2019). Psychopharmacological treatment of obsessive-compulsive disorder (OCD). Current Neuropharmacology, 17(8), 710-736.

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for pediatric patients. Current Psychiatry, 18(9), 26.

Elsevier (2020) Major Depressive Disorder URL: https://www.elsevier.com/__data/assets/pdf_file/0018/1010277/Major-depressive-disorder_CO_300419.pdf

Elsiņa, I., & Martinsone, B. (2019, May). Children’s Depression Rating Scale-Revised (CDRS-R)–Development of the Latvian version and psychometric properties in adolescents’ clinical and non-clinical sample. In SOCIETY. INTEGRATION. EDUCATION. Proceedings of the International Scientific Conference (Vol. 7, pp. 65-74).

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. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4.

Guerrera, C. S., Furneri, G., Grasso, M., Caruso, G., Castellano, S., Drago, F., … & Caraci, F. (2020). Antidepressant drugs and physical activity: a possible synergism in treating major depression?. Frontiers in psychology, 11, 857.

Hernández-Otero, I., Sánchez-Lafuente, C. G., & González, C. H. (2017). Use of Antidepressants in Children and Adolescents. In Child and Adolescent Mental Health. IntechOpen.

Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., … & Gluud, C. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC psychiatry, 17(1), 1-28.

Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomized trial. The Lancet Psychiatry, 6(11), 903-914.

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283.

Neavin, D. R., Joyce, J., & Swintak, C. (2018). Treatment of major depressive disorder in pediatric populations. Diseases, 6(2), 48.

Nevels, R. M., Gontkovsky, S. T., & Williams, B. E. (2016). Paroxetine—the antidepressant from hell? Probably not, but caution is required. Psychopharmacology Bulletin, 46(1), 77.

Stahl, S. M. (2020). Prescriber’s Guide: Stahl’s Essential psychopharmacology. Cambridge University Press.