Erica Daniels-Dottir is a 13-year-old Caucasian teenager who was admitted today to an inpatient adolescent psychiatric unit for suicidal ideation and reports of severe depression. She has no other significant medical problems. You are at a meeting with Erica and her mothers, Sally Daniels and Thea Sindridottir. Erica has had severe mood swings, irritability, and dangerous and impulsive behavior. This is her third suicide attempt in the past two months.
From your perspective as Erica’s psychiatric nurse practitioner, answer the following questions FOUR-page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.
1. You are assigned to complete a psychiatric evaluation on Erica. Identify the clinical presentation and symptoms you would expect to see if you were to make a diagnosis of Major Depression.
2. What lab tests would you order? Discuss the rationale for each test.
3. Erica’s mothers want to know how their daughter could be depressed enough to require psychiatric hospitalization. What information would you need from Erica’s mothers relative to family, Erica’s current and past functioning, and the rationale for needing inpatient psychiatric treatment rather than outpatient treatment at this time?
4. Erica’s mothers tell you they do not want to medicate her. How do you discuss medication treatment with parents of teenagers and of younger patients? How young is too young? At what age do you consider the child’s opinion? (Optional: Imagine that Sally and Thea are divorced, and that one of them wants medications and the other does not. How do you mediate that conversation?)
5. Identify pharmacological and non-pharmacological interventions you might recommend. Include a specific recommendation of a psychotropic medication (include starting dose and side effects to monitor). Provide the rationale for these recommendations. Identify how the drug you select is metabolized and its mechanism of action.
6. How would you know when Erica would be ready for a safe discharge relative to symptom presentation and functioning? What are the potential complications if these symptoms are not well managed?
SOLUTION TO THE CASE STUDY
Clinical Presentation and symptoms
Major depression is one of the most common psychiatric conditions that affect children and adolescents. Because of its symptom variation from adult criteria, major depressive disorder (MDD) in this age bracket is often unrecognized and untreated (Mullen, 2018). To establish the diagnosis of MDD in Erica, I will consider the DSM-5 criteria alongside other common symptoms in children and adolescents according to evidence-based practice guidelines.
An individual with MDD will present with a depressed mood and for children and adolescents, it can present as an irritable mood. Diminished interest in almost all activities, significant weight changes, sleep disturbance, loss of energy, diminished ability to think, and recurrent suicidal ideation are all signs to look for in patients with MDD (Mullen, 2018). I will also look for issues with self-esteem, impulsivity, behavior changes, and poor school performance that are consistent with adolescent depression. The presence of any five of these symptoms for the past two weeks will indicate that Erica has MDD.
Major depression is a clinical diagnosis based on the patient’s history and physical findings. Laboratory investigations are only useful to exclude potential medical illnesses that may present as major depression. The first test I will want to order is a complete blood count (CBC). CBC will be used to assess if the patient has anemia that is among the causes of depression (Zuckerbrot et al., 2018). The test can also be used to evaluate the levels of RBCs and WBCs to guide the choice of medication. Some drugs used to manage MDD like lamotrigine can cause bone marrow suppression which will be fatal in patients with already depressed bone marrow.
Thyroid-stimulating hormone (TSH) is another crucial test for patients with MDD. Hypothyroidism happens when the body does not produce enough thyroid hormones and presents with symptoms like depression, fatigue, weight gain, difficulty concentrating, and sluggishness (Zuckerbrot et al., 2018). Determining the levels of TSH can help in regulating the dosage of antidepressants while addressing the underlying cause. I will also want to order a comprehensive metabolic panel (CMP) to assess BUN and creatinine levels that could indicate kidney disease alongside kidney functioning before the prescription of antidepressants.
Acute psychiatric hospitalization is a structured level of care designed to meet the needs of patients whose manifestation puts them at risk of self-harm, or harm to others. Erica is a patient presenting with signs of MDD and she may require inpatient hospitalization for effective monitoring and treatment. Before making this decision, I would like to understand the patient’s history, especially the family history of psychiatric illnesses. Understanding the history of illnesses like depression, bipolar disorder, and suicide can help in selecting treatment modalities for Erica. Secondly, I will want to understand her current medical history including known illnesses and their treatment. I would also like to know any history of substance abuse, past relationships between the patient and the family members, and any significant life changes like the loss of a loved one that could be the trigger to Erica’s depression.
Comprehensive psychiatric history taking and assessment of the patient are required before inpatient hospitalization. The person must have a psychiatric diagnosis excluding conditions like mental retardation, substance abuse, or senility unless these conditions coexist with the patient’s diagnosis. Secondly, the provider must determine that the patient cannot be appropriately treated as an outpatient because of the need for 24-hour monitoring and management or supervision. The patient will also require inpatient hospitalization if they pose significant harm to self or others, or the destruction of property. Erica meets this criterion and will require inpatient hospitalization for treatment and monitoring.
Psychiatric medications can be an effective part of treatment for children and adolescents with MDD. Erica’s mothers are right to be concerned about the use of medication to manage Erica’s depression because not all medications are safe. To ensure the parents agree to the treatment, I will begin by discussing the results of the assessment and the risks of leaving Erica without treatment. I will explain how the use of medications will help achieve the balance of neurotransmitters in the brain that could potentially relieve Erica’s symptoms (Saya et al., 2019). I will professionally present evidence from research and clinical practice guidelines for the management of MDD in adolescents and children. I will explain the FDA-approved drugs for MDD in children and adolescents alongside the potential benefits of medication.
Pharmacotherapy options are limited to children and adolescents because of potential side effects. I will explain the FDA-approved antidepressants that can be prescribed for Erica. For example, some medications like sertraline are recommended for children 6 years or older and most antidepressants like fluoxetine can be used for children 8 years and older (Zuckerbrot et al., 2018). Regarding the age for considering the child’s opinion, I would like to think that a 15-year-old is mature enough to contribute. Legally, most states require the child to be 18 years and over to make medical decisions. If Erica’s parents are divorced and disagree with Erica’s treatment approach, I will opt for the option of mediation. I will present facts about Erica’s condition, the consequences of both treatment approaches, and guide the parents in choosing the right decision. I will opt for a written settlement agreement to avoid setbacks and legal issues that may result.
Pharmacological and Non-Pharmacological Interventions
Antidepressants are the recommended pharmacological therapies for MDD. In Erica’s case, I will consider starting her on Fluoxetine 10 mg PO once daily and then increase the dosage to 20mg after two weeks (Stahl, 2017). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that exerts its effect by blocking the reuptake of serotonin into presynaptic serotonin neurons. The drug is metabolized in the liver to norfluoxetine by several enzymes including CYP1A2 and CYP34A. Common side effects of the drug include nausea, headache, and trouble sleeping. Fluoxetine has a black box warning for increased suicidality making it crucial for monitoring patients closely (Stahl, 2017). The non-pharmacological intervention I will recommend for Erica is cognitive-behavioral therapy (CBT). This therapy modifies thought patterns to change moods and behaviors in affected individuals. CBT will help Erica learn to developed more balanced and constructive ways to respond to stressors.
Discharge planning is an important part of Erica’s treatment that will help to ascertain recovery before going home. The first part I will consider is the administration of the PH-9 questionnaire to ascertain if Erica’s depression scale has reduced to lower levels. Potential complications if MDD is not well-managed may include weight gain, the development of chronic conditions like diabetes and cancer, and self-harm (Mullen, 2018). Self-harm may extend to suicide if the patient is not well monitored while other effects like drug use may develop, especially in adolescents.
Mullen S. (2018). Major depressive disorder in children and adolescents. The Mental Health Clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275
Saya, A., Brugnoli, C., Piazzi, G., Liberato, D., Di Ciaccia, G., Niolu, C., & Siracusano, A. (2019). Criteria, procedures, and future prospects of involuntary treatment in psychiatry around the world: A narrative review. Frontiers in Psychiatry, 10, 271. https://doi.org/10.3389/fpsyt.2019.00271
Stahl, S. (2017). Prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). Cambridge University Press.
Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R., Laraque, D., & GLAD-PC STEERING GROUP (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3), e20174081. https://doi.org/10.1542/peds.2017-4081
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