Therapy for Pediatric Clients with Mood Disorders
Therapy for Pediatric Clients with Mood Disorders
Therapy for Pediatric Clients with Mood Disorders 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· Mother reports that teacher said child is withdrawn from peers in class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
· 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)
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
Decision Point One
Begin Zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Slight increase in mood
· No HAM-D results
· No adverse events reported
Decision Point Two
Select what the PMHNP should do next:
Increase dose to 37.5 mg orally daily
Increase dose to 50 mg orally daily
Change to Prozac 10 mg orally daily
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%. Client tolerating well
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose
Increase to 75 mg orally daily
Change to a SNRI
Decision Point Three
Maintain current dose
RESULTS OF DECISION POINT THREE
Guidance to Student At this point, sufficient symptom reduction has been achieved. It is considered a full response to therapy when symptoms are reduced by 50% or more on the HAM-D. Do not confuse this with full symptom resolution which would be a 100% reduction in symptoms as measured on the HAM-D. It would be in the best interest of the patient to continue with the current dose of medication and re-assess in 4 weeks. Remember, any change in dose resets the “clock” for a full assessment of therapy efficacy. Waiting an additional 4 weeks (8 weeks total from dose change) would allow additional benefit to be recognized. An increase in dose would not be warranted at this point in time as it would lead to an increased potential for adverse events. This could fracture the therapeutic alliance created with your patient and lead to loss to follow-up, loss of symptom control, and other negative consequences to the patient. 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.
