Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page) Case Study on Decision Points An African American Child Suffering from Depression Essay Paper

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

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Case Study on Decision Points: An African American Child Suffering from Depression

Mood disorders such as the depressive disorders in the DSM-5 have quite some distinct characteristics that are for instance shared by major depression and persistent depressive disorder or cyclothymia (APA, 2013). These two are prominent depressive disorders in the DSM-5. These characteristics include but are not limited to irritability, a sense of loneliness, and unexplained sadness. Based on the subjective and objective information obtained about the boy in this case study, they meet the DSM-5 diagnostic criteria for major depressive disorder or MDD. He had been put through the psychometric evaluation tool that is the Children’s Depression Rating Scale or CDRS. This indeed showed that he was having depression. The purpose of the paper is to show how three decisions on the drug treatment of this minor are made to effectively manage his depression using medications.

Decision Point Number One

Of the three first line-up of psychoactive medications presented at this decision point, the decision is made to go with a selective serotonin reuptake inhibitor antidepressant referred to as sertraline or Zoloft. This is a medication approved by the US Food and Drug Administration or FDA for the treatment of depression in adults only. However, evidence-based practice shows that it has been used as an off-label choice in previous attempts at managing juvenile depression with a lot of success. Thus despite risk data and safety profile in children, sertraline is commenced at this point at a starting dose 25 mg orally each day (Rosenthal & Burchum, 2018; Stahl, 2017). According to Allen et al. (2018), Mir and Geer (2017), and Vijay et al. (2018); off-label prescription of medications is a practice that is not so uncommon in the face of lack of pharmacotherapy options in managing depression in children.

Enough scholarly evidence exists to back up the claim that off-label sertraline in depression management in children is actually evidence-based practice. One of the sources that provide this evidence is Chon et al. (2017). It is because of this strong efficacy evidence that the other two alternatives presented at this first decision point were not considered. The evidence also shows that the sertraline is effective but does not begin to show its therapeutic effect fast. Also, the therapeutic effect is dose-dependent going by the evidence. As a matter of fact, it may take between four and six weeks for the effect to be apparent (Stahl, 2017). The hope in prescribing sertraline was that the child would start being free of depression symptoms after at least the first four weeks. This progress would be monitored by doing a CDRS test every time they are brought back for follow up (Shanahan et al., 1987). A good outcome would be a dropping score that is somewhere below thirty points.

Ethical considerations were also taken into account during this first decision point. The very action of considering off-label prescription of sertraline because of its history of efficacy and despite lack of FDA approval was an act in beneficence (Haswell, 2019). The other indication of beneficence was the fact that using sertraline would potentially save the boy’s life since he is suicidal. After starting the sertraline, this boy was put under close surveillance for any possibility of unforeseen side effects give the lack of safety information of sertraline on children. This included educating the parents on what to look out for and to report promptly. This is respect for the ethical principle of nonmaleficence or primum non nocere.  Case Study on Decision Points An African American Child Suffering from Depression Essay Paper

Decision Point Number Two

After four weeks of taking the sertraline the boy is returned by the parents to the facility for review and reassessment. They report that there has been no improvement since they went home with the child on sertraline 25 mg orally daily. This is not surprising given the fact that it has already been indicated that the therapeutic effect of sertraline (that is also dose-dependent) does not set in until after four to six weeks. To increase the chances of a more robust therapeutic effect and quicker remission, the dose of the sertraline is raised to 50 mg orally every day at this second decision point.

This decision like the previous one was also guided by evidence-based practice or EBP (Melnyk & Fineout-Overholt, 2019). Available evidence is that the therapeutic effect would set in after this second visit. Therefore, to potentiate the action and set up the patient for maximum therapeutic benefit, the dose of the sertraline (Zoloft) is doubled. Looking at their profiles and history of efficacy in managing depression in minors, sertraline was seen as the best choice compared to the presented alternatives (Stahl, 2017). What remained now was to wait for the child to be brought back after a further four weeks and test them again using the CDRS to gauge progress.

One of the other alternatives was that the sertraline (Zoloft) dose be increased to 37.5 mg orally every day. Going by the available data on off-label sertraline, increasing the dose by this small margin would in most likelihood not have had the effect desired. The third option was to stop the sertraline and commence the other selective serotonin reuptake inhibitor fluoxetine (Prozac) at a dose of 10 mg orally every day. Looked at critically, this action would have not been well thought out simply because the sertraline will have not yet been given enough time to act. After all, its therapeutic effect is only at its peak after 4-6 weeks as indicated already in the above account.  It would sound paradoxical that this decision is taken at this second decision point since fluoxetine as opposed to sertraline is actually FDA-approved to treat depression even in children. However, in clinical practice that is evidence-based, only the weight of the available evidence guides practice. In this case, the balance tilted in favor of sertraline or Zoloft.

The ethical considerations at this decision point include effecting autonomy by fully allowing the parents to take part in the decision making. This would require convincing them that the sertraline will work despite showing no progress in the first 4 weeks. What I hoped to achieve by increasing the dose of the sertraline to twice its initial size was a reduction in the symptom profile of the boy by half. This I would assess by taking the CDRS scores and comparing with the baseline that was documented. Case Study on Decision Points An African American Child Suffering from Depression Essay Paper

Decision Point Number Three

At this second follow up visit the patient has now been on the sertraline for a total of eight weeks. Unlike the previous follow up visit, this time the parents report that they have seen a change for the better. Their observation is that the child is now getting better on the medication. This proved the evidence right that the therapeutic action of sertraline starts after six to eight weeks. There were no reports of side effects and this also meant that the boy was tolerating the off-label sertraline very well. To confirm the parents’ account of progress, the psychometric CDRS was performed again and it clearly showed that the boy’s symptoms of depression had already reduced by half. Because of this encouraging response, there was clearly no justification for stopping the sertraline now. The decision at this third decision point is then taken to further increase the dose of the sertraline to 75 mg orally every day. This is done to maximize the therapeutic effect of the Zoloft and also to keep the boy in remission in the long term.

According to the anecdotal and scientific evidence available, the dose of 75 mg is not high but still within the therapeutic range of off-label prescription of sertraline (Chon et al., 2017). Since the patient is tolerating the medication well and also responding favorably, an increase in the dose by another 25% sounds like a logical clinical step. The hope in doing this was that at the 12 week mark or the next follow up visit, the symptoms of the boy would have dropped by a further 25% to stand at 75% symptom reduction. Nonmaleficence at this decision point remains the overriding ethical consideration considering the potential risk of side effects.

Conclusion

The case of this boy is informative in that it gives a very important clinical lesson. It is not obvious that only FDA-approved medications will be efficacious in treating mental health conditions. As seen in this case, fluoxetine (Prozac) which is FDA-approved was shunned in preference for off-label sertraline (Zoloft) based purely on clinical data on efficacy observed in previous trials.

References

Allen, H.C., Garbe, M.C., Lees, J., Aziz, N., Chaaban, H., Miller, J.L., Johnson, P., & DeLeon, S. (2018). Off-label medication use in children, more common than we think: A systematic review of the literature. The Journal of the Oklahoma State Medical Association, 111(8), 776–783. https://europepmc.org/article/pmc/pmc6677268

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Chon, M-W., Lee, J., Chung, S., Kim, Y., & Kim, H-W. (2017). Prescription pattern of antidepressants for children and adolescents in Korea based on nationwide data. Journal of Korean Medical Science, 32(10), 1694-1701. https://doi.org/10.3346/jkms.2017.32.10.1694

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Mir, A.N. & Geer, M.I. (2017). Off-label use of medicines in children. International Journal of Pharmaceutical Sciences and Research. https://ijpsr.com/bft-article/off-label-use-of-medicines-in-children/?view=fulltext

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for nurse practitioners and physician assistants. Elsevier.

Shanahan, K.M., Zolkowski-Wynne, J., Coury, D.L., Collins, E.W., & O’Shea, J.S. (1987). The Children’s Depression Rating Scale for normal and depressed outpatients. Clinical Pediatrics, 26(5), 245-247. https://doi.org/10.1177/000992288702600506

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Vijay, A., Becker, J.E., & Ross, J.S. (2018). Patterns and predictors of off-label prescription of psychiatric drugs. PLoS ONE 13(7): e0198363. https://doi.org/10.1371/journal.pone.0198363

Case Study on Decision Points An African American Child Suffering from Depression Essay Paper