Mood Disorders in Adults – Assignment 1 : Assessing, Diagnosing, and Treating Adults With Mood Disorders — Jessica, age 22 – Solution

Mood Disorders in Adults

I am finally doing everything right. I stayed up all night studying for my final exams and even managed to clean out my closet and order a whole new bedroom from the internet. I know I will ace all my exams. Nothing can go wrong like they did a few months ago. I was so low and was sleeping all the time. I did not think I would ever be happy again, but now I know I can do anything.

—Jessica, age 22

Patients presenting with mood disorders may find that their moods impact their ability to function or that their moods are not consistent with their circumstances. Bipolar and related disorders are one category of mood disorders. They affect nearly 3% of the U.S. population each year (Depression and Bipolar Support Alliance, n.d.). Although being relatively rare in terms of lifetime prevalence, bipolar disorder is burdensome to the individual and health care system because of its early onset, severity, and chronic nature. The average age of onset is around 25 and it affects men and women equally.

The importance of evidence-based intervention for treatment in persons with mood disorders cannot be underestimated. Unstable moods can result in repeat chronic hospitalizations and profound life disruption. Mood disorders are a leading cause of disability worldwide and can contribute to suicide (World Health Organization, 2020). Practitioners should understand that developing a good rapport and relationship with the patient can make a significant difference in the course, symptom management, and stability of the patient.

Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders

It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

To Prepare

· Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.

· Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.

· Review the video,  Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.

· Consider what history would be necessary to collect from this patient.

· Consider what interview questions you would need to ask this patient.

Solution

Introduction to the case (1 page)

The case for this assignment is an 8-year-old African American male who is accompanied by the mother to a hospital’s ER. The boy is exhibiting signs of depression, including sadness, withdrawal, decreased appetite, and occasional irritation (Mullen, 2018). In contrast, the boy had achieved developmental landmarks, while physical and laboratory examinations are unremarkable and within normal limits, respectively. Psychiatric assessment using the Children’s Depression Rating Scale obtained a score of 30, which is a significant indication of depression. According to Posznaski & Mokros (1996), a CDRS-R score of 30 and above indicates depression.

In children and adolescents, depression is a leading cause of morbidity and mortality (Rao, 2013). Major depressive disorder (MDD) is the most prevalent depressive disorder in children, but it frequently goes undiagnosed and untreated due to symptom differences from those seen in adults (Mullen, 2018). Depression is said to be caused by diverse relationships with several genetic and environmental causes. However, there are instances when similar psychopharmacologic treatments are used for both adults and children. As such, caution must be taken when prescribing psychotropic medications. Equally, the question of how to assess and treat pediatric patients with mood disorders is significantly relevant.

CDRS-R is a reliable and valid measure for depression in a pediatric population (Poznanski & Mokros, 1996). Similarly, Rao (2013) argues that biomarkers are critical in determining underlying mechanisms that predispose a child to depressive disorders. The biomarkers may also improve clinical phenotype classifications or distinguish between biological components with varied clinical/treatment representation (Rao, 2013). Since drug metabolism’s genetic heterogeneity regulates variations in drug clearance, half-life, and highest blood concentrations, these tests help the practitioner select a suitable antidepressant drug for a specific condition. They’re handy for detecting potential side effects and determining the best dosage (Rao, 2013).

Decision #1 (1 page)

I selected Zoloft 25 mg orally daily. Sertraline has been found in studies to be effective in treating depression in young children. (Stahl, 2020). According to Magellan Health Services (2013), Zoloft is an SSRI (selective serotonin reuptake inhibitor) that works to increase mood by maintaining serotonin balance in the brain. Additionally, Zoloft 25 mg is a lower dosage critical for the commencement of treatment since antidepressants are known to increase anxiety when first used (Stahl, 2020). Thus, a higher dosage would not be ideal for the client.

Paxil was not chosen because it is classified as a class D antidepressant, thus, have a positive teratogenic effect. It is also contraindicated for children less than 18 years (Magellan Health Services, 2013). In contrast, Wellbutrin was not chosen because it is not typically recommended for children since its efficacy and effectiveness has not been established, has other risks of anorexia and seizures (Magellan Health Services, 2013).

The primary goal for this medication and dosage choice was to decrease the symptoms of depression and improve the patient’s mood. Zoloft has been shown to restore the brain’s serotine balance, leading to improved mood and minimal depressive symptoms (Stahl, 2020).  On the contrary, there was no change after four weeks. The probable cause could have been the initial effects of antidepressants increasing rather than reducing anxiety (Stahl, 2020). Equally, the lack of improvement could be because of the low dosage necessary to achieve immediate impact (Stahl, 2013).

Sertraline is a generic drug and is primarily used as an off-label. It is, therefore, significant to communicate with the client/representative on the lack of Food and Drug approval of the drug despite its efficacy in controlling depression through empirical evidence (Lorberg et al., 2019). As a psychiatric practitioner, it is crucial to remain truthful to the client on the overall efficacy and safety of medications. Equally, it is significant to advise the client of the mean half-life of the dosage and the significance of taking medication as prescribed to ensure consistent treatment and prevent withdrawal (Lorberg et al., 2019).

Decision Point Two #1 (1 page)

I chose to titrate the oral Sertraline to 50 mg per day. According to Magellan Health Services (2013), Sertraline is suitable for treating children, and the prescription quantity can be gradually up to 200mg depending on the client’s response. The initial therapeutic dosage of 25mg might not be adequate for effective treatment and could not realize the anticipated result of decreasing the client’s depression symptoms. According to Howland (2008), a subsequent treatment strategy may be sufficient for patients who do not respond well with initial treatment.

I did not choose Zoloft 37.5mg since it was relatively below the suggested therapeutic dosage. I did not select Prozac 10mg to be consistent with the current medication since there was no significant reason to change medicine. I also intended to continue the same medicines and increase their dosage until the client exhibits no signs of depression. Moreover, Prozac 10mg dosage is primarily recommended for preschoolers by the pharmaceutical products working group (PPWG) (Gleason et al., 2007).

The primary goal for increasing Zoloft dosage to 50mg per day was intended to improve the patient’s brain serotonin balance (Stahl, 2020). Consequently, the expectation was that the desired outcome, i.e., reducing the client’s depression symptoms, was to be achieved since the initial dosage was insufficient. The result was expected as the client reported a 50% reduction of his depressive symptoms after four weeks under the adjusted medication.  The patient also reported effective toleration of the medicines since there was no reported symptom of drugs.  

As a psychiatric practitioner, more awareness of a patient’s cultural attitude to treatment and the variation between the expected and actual outcome of a given dosage is vital in ensuring the patient compliant with the treatment plan (Yasuda et al., 2008). Therefore, it was significant to discuss with the client’s parent concerning the causes of depression to avoid recurrence. It is crucial to communicate to the client/representative concerning the symptoms of depression and the cause.  Patient education is associated with better compliance, improvements, and social functioning among psychiatric patients.

Decision Point Three #1

I chose to maintain the current dose, 50mg of oral Zoloft daily. I decided because the patient was reacting well to medication with a significant reduction of the depressive symptoms. Equally, the client’s adjustment to the current dosage implied optimal treatment and subsequent decrease of depressive symptoms without any adverse side effects (Stahl, 2020). According to Stahl (2013), a pharmacodynamics response to a prescription is the impact a drug has on particular physiologic and pathological mechanisms concerning efficacy and adverse reactions during treatment with an antidepressant.

It’s best to stick with a prescription if the patient has had a good reaction to it. As a result, I passed on the other treatments because the person was reacting well to treatment and had already seen a 50% improvement in symptoms. The primary goal for my choice was to allow the patient to continue responding to medication until full recovery. As expected, the outcome increased the dosage to an optimum level with positive results on the client’s status (Stahl, 2020). After another four weeks, I anticipated a further decrease in symptoms, eventually leading to symptom remission. Therefore, there was no need to change medication.

The decision was medically justified as the patient was already responding well to medication. Equally, there is no evidence further increase will result in additional advantages (Stahl, 2013; Stahl, 2020). Further, the standard safe dosage of Zoloft for depression in children is 50mg. Thus up-titrating the dosage would increase intolerance and side effects of the medication (Gordon & Melvin, 2014; Vitiello, 2012).

Conclusion

Children can display off behavior as a regular part of development. However, it is crucial to watch for significant signs such as withdrawal and irritability. Depress children are often irritable and do not get along with their peers, and feel rejected. These are bridge symptoms serving as risk factors for depressive disorders (Mullen, 2018).  For instance, in this case, the child exhibited signs of depression, including sadness, withdrawal, decreased appetite, and occasional irritation despite achieving typical development landmarks.

In this case, the Children’s Depression Rating Scale was used to prove valid and reliable. The resulting score of 30 gave a clear indication that the child had depression and thus needed medication to lower the symptoms (Posznaski & Mokros, 1996). Consequently, a dosage of Zoloft 25mg oral was initially prescribed and later increased to 50mg leading to a significant reduction in depressive symptoms. The decision to increase the dosage was recommended because when a patient does not respond to an initial dosage, an increase in the dosage is necessary (Howland, 2008). Further, I decided to maintain the dosage since the child had positive toleration and a significant reduction of symptoms exemplified with zero side effects.

Moreover, I was responsible for upholding clinical ethics and responsibility, educating the parent on the chosen medication, expected outcomes, and possible side effects. This was crucial in creating rapport and earning the trust of the clients. Equally, a positive connection ensured that the child’s mother complied with the medication, further improving the child’s condition (Lorberg et al., 2019). The monthly monitoring allowed me to determine the subsequent course of action in terms of the most effective dosage/medication for the child’s condition. As a result, the chosen medication, ethical consideration, and monthly monitoring proved significant in the medical plant’s effectiveness.  

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Gleason, M. M., Egger, H. L., Emslie, G. J., Greenhill, L. L., Kowatch, R. A., Lieberman, A. F., … & Zeanah, C. H. (2007). Psychopharmacological treatment for very young children: contexts and guidelines. Journal of the American Academy of Child & Adolescent Psychiatry, 46(12), 1532-1572.

Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal?. Journal of pediatrics and child health, 50(11), 847-854. https://doi.org/10.1111/jpc.12655

Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf

Magellan Health. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf 

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283. https://doi.org/10.9740/mhc.2018.11.275

Poznanski, E. O., & Mokros, H. B. (1996). Child depression rating scale—Revised. Western Psychological Services.

Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. https://doi.org/10.1002/da.22171

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

Stahl, S. M., & Stahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.

Stallwood, E., Monsour, A., Rodrigues, C., Monga, S., Terwee, C., Offringa, M., & Butcher, N. J. (2020). Systematic Review: The Measurement Properties of the Children’s Depression Rating Scale-Revised in Adolescents With Major Depressive Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2020.10.009

Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. IACAPAP e-textbook of child and adolescent mental health. Geneva, Switzerland: International Association for Child and Adolescent Psychiatry and Allied Professions.

Yasuda, S. U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf

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· Consider patient diagnostics missing from the video: 

Provider Review outside of interview:

Temp 98.2   Pulse  90  Respiration 18   B/P  138/88

Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

The Assignment

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

· Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 

· Objective: What observations did you make during the psychiatric assessment?  

· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the  DSM-5-TR diagnostic criteria for each differential diagnosis and explain what  DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

· Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.

·://nursingstudy.org/nursing-and-healthcare-policy-discussion/”>Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

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