Assessing and Treating Pediatric Clients with Mood Disorders

Background
The client in the present scenario is an 8-year-old African American male who presents with signs of depression. Some of the reported symptoms include; feeling of sadness, occasional irritation, and decreased appetite. The score obtained upon the administration of the Children’s Depression Rating Scale indicates significant depression. This text concerns itself with three decisions relating to the medications prescribed for the 8-year-old.
Discussion
I. Zoloft
Decision Point 1: Begin Zoloft 25 mg orally daily
Studies conducted in the past have indicated that for children and adolescents suffering from depression, Zoloft (Sertraline) happens to be largely effective. According to Hritzak and Culhane (2004), “Sertraline (Zoloft) is effective and generally well tolerated for the short-term treatment of major depressive disorder in both children and adolescents” (17). In essence, Sertraline, which is essentially an SSRI, impacts unbalanced brain chemicals in persons suffering from anxiety disorders, panic disorders, as well as depression. Low serotonin levels are often responsible for depression. Thus, Zoloft comes in handy in the restoration of serotonin levels in the brain.
In the present scenario, I selected a dose of 25 mg daily because the client in this case is an 8-year-old. 50 mg daily happens to be the standard dose for adults. The dose selected in this case would also permit me to raise the dose in the course of time as needed. I would in this case expect a favorable change in depressive symptoms during the next appointment.
The results of decision point one indicate that the client returned to the clinic in 4 weeks and there was no change in the symptoms of depression. In this case, it appears that the 25 mg daily dose was low.
Decision Point 2: Increase dose to 37.5 mg orally daily
The decision to increase the dosage in this case is based on the client’s progress thus far. Depressive symptoms have not changed at all. The age of the client was still taken into consideration in the decision to increase the dosage to 37.5 mg orally/day instead of 50 mg orally once/day. It is expected that the client will be exhibiting favorable change (20%-25%) in depressive symptoms during the next visit.
The results of decision point 2 indicate that there was a 20% decrease in depressive symptoms. Further, the 8-year-old also points out that they feel somewhat better. The present change could be attributed to the increase in dosage of 25 mg orally/day to 37.5 mg orally/day. As it has been pointed out elsewhere in this text, the initial dose selected gave room for an upward variation of dosage in the course of time as necessary – titrating over a period of time to the max dose depending on the outcomes.
Decision Point 3: Increase to 50 mg orally daily
The decision to increase dosage in this case is based on the results of decision point 2 where an increase in dosage from 25 mg orally daily to 37.5 mg orally daily resulted in a 20% decrease in depressive symptoms. It is expected that during the next visit, the client will exhibit a 40%-50% decrease in depressive symptoms.
The results of decision point 3 indicate that there has not been sufficient reduction in depressive symptoms. At this point, I would consider introducing another SSRI because it is clear that the utilization of the present SSRI has not resulted in significant symptom reduction. In so doing, I would be guided by the assertion that “switching from one SSRI to another can be staggered and overlapping, as long as the combined total daily dose remains equivalent and comparable… a staggered switch can usually be completed over a few weeks” (American Academy of Pediatrics, 2020).
II. Praxil
Decision Point 1: Begin Paxil 10 mg orally daily
An SSRI, Paxil (paroxetine) comes in handy in the treatment of depression due to its action of increasing brain serotonin levels. It was for this reason that the drug was selected. From the onset, it should however be noted that there are a few concerns that have been raised about this particular drug in the past. Indeed, in the words of Mullen (2018), “paroxetine is useful for severe anxiety but carries the risk of increased suicidality compared with other SSRIs and increased sedation in the pediatric and young adult population” (278). For this reason, I would be on the lookout for changes in the 8-year-old’s symptoms or mood changes. In this case, a low starting dose was selected.
The results of the decision point one indicates that there was “a reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea” upon return to the clinic after 4 weeks. I had expected a significant reduction in the severity of depression. The side effects exhibited in this case are, however, a concern. Navels, Gentkovsky, and Williams (2016) point out that “common side effects associated with paroxetine are sleepiness, yawning, dry mouth, headache, upset stomach/nausea, mild mental fogginess, dizziness, appetite loss, weight gain, nervousness and occasional jitters, delayed ejaculation, and anorgasmia” (83). For this reason, it would be prudent to decrease the drug dose for a short period of time before readjusting the dose upwards in an attempt to eliminate or reign in the exhibited side effects.
Decision Point 2: Decrease dose for 7 days then return to previous 10 mg day dose
In this case, I would be interested in eliminating or decreasing the severity of the side effects without necessarily compromising the therapeutic gains made so far.
The results of the decision point 2 indicate that upon dose reduction, the side effects mentioned subsided. However, once the original dosage was reinitiated, the side effects returned. It is clear at this point that the intended outcomes may not be achieved due to the unfavorable side effects.
Decision Point 3: Change to a different SSRI
It is important to note that in some scenarios, adverse side effects have been known to affect or limit patient adherence to a treatment regimen or plan (Fainzang, 2011). In this case, therefore, it would be advisable to consider another SSRI.
III. Wellbutrin
Decision Point 1: Begin Wellbutrin 75 mg orally BID
Wellbutrin (Bupropion) could be described as a norepinephrine-dopamine reuptake inhibitor (NDRI). In basic terms, it could be perceived as an antidepressant that comes in handy in the management of depression. Unlike various SSRIs, the main effect of this medication happens to be on dopamine. The impact of dopamine as a ‘feel-good neurotransmitter’ has been well-documented. By increasing dopamine levels in the brain, Wellbutrin plays a significant role in the favorable alteration of mood. It should also be noted that as Patel, Allen, Haque, Angelescu, Baumeister, and Tracy (2016) point out, the pharmacology of Bupropion happens to be unique. In the words of the authors, it inhibits “the reuptake of noradrenaline and dopamine, potentially providing pharmacological augmentation to more common antidepressants such as selective serotonergic reuptake inhibitors (SSRIs)” (Patel, Allen, Haque, Angelescu, Baumeister, and Tracy, 2016, p. 122). I would expect to see a significant relief in the depressive symptoms when the client returns to the clinic.
The results of the decision part 1 indicate that upon his return to the clinic, it was reported that the 8-year-old experienced difficulty sleeping at night. This outcome, as Milev (2015) points out, could be attributed to the drug’s twice a day dosing. As the author points out, “the twice a day dosing may result in complaints of insomnia and may necessitate discontinuing the medication or adding a sleep promoting agent” (Milev, 2015). In the present case, I will thus consider the extended release 150 mg orally/day (morning).
Decision Point 2: Change from immediate release to extended release 150 mg orally daily in the morning
As it has been pointed out above, the twice (two timed) a day dosing has been associated with insomnia complaints. The decision made in this case is therefore an attempt to normalize sleeping patterns without necessarily interfering with therapeutic gains.
The results of decision 2 indicate that following his return to the clinic, the sleep patterns of the client had returned to baseline. It should however be noted that in as far as depressive symptoms were concerned, there was no change exhibited. Towards this end, I would consider increasing the dosage.
Decision Point 3: Increase dose to 300 mg orally daily
This decision was made as the previous dosage did not result in meaningful decrease in depressive symptoms. Thus, in this case, an increase in dosage (and further monitoring) would be more appropriate than switching to an SSRI.
References
American Academy of Pediatrics (2020). Sertraline - Zoloft (Oral Solution). Retrieved from https://www.aap.org/en-us/professional-resources/Psychopharmacology/Pages/Sertraline-Zoloft-Oral-Solution.aspx
Fainzang, S. (2011). Discourse on safe drug use: symbolic logics and ethical aspects. Drug Saf., 33(8), 623-629.
Hritzak, K. & Culhane, N.S. (2004). Sertraline effective for children and adolescents with major depression. J Fam Pract., 53(1), 8-14.
Milev, D.R. (2015). Does Sleep Quality Change after Switch from Wellbutrin SR to Wellbutrin XL in Patients with Major Depressive Disorder? Retrieved from https://clinicaltrials.gov/ct2/show/NCT00616915
Mullen, S. (2018). Major depressive disorder in children and adolescents. Ment Health Clin., 8(6), 275-283.
Navels, R.M., Gentkovsky, S.T. & Williams, B.E. (2016). Paroxetine—The Antidepressant from Hell? Probably Not, But Caution Required. Psychopharmacol Bull., 46(1), 77-104.
Patel, K., Allen, S., Haque, M.N., Angelescu, L., Baumeister, D. & Tracy, D.K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. The Adv Psychopharmacol., 6(2), 99-144.