Transcript 18 yo male/CC medication reconciliation following outpatient

Adolescent Depression
Mary Ann Hudson, RN
College of Nursing
The Ohio State University
18 yo male/CC medication reconciliation
following outpatient psychiatric visit
Hx: 12 mo hx of major depressive disorder meeting
more than five of the symptoms for MDD in DSMIV-TR. Acute history of inpatient and outpatient
treatment for MDD following medication failure and
acute hypersomnia. Mat Hx of depression and
anxiety. Pat Hx of depression.
Co-morbidities: ADHD, inattentive type, Dx at 8 yo.
Acute Hx of hypersomnia, Dx following sleep study
series.
Exam: HEENT, wnl; CV/Pulm, wnl; GI/GU, wnl;
MS/Neuro, wnl. Affect: flat. 67”, 146#, 108/60, BMI
23
Current Diagnoses/Differentials
and Plan of Care
Current Diagnoses: Major Depression; ADHD, inattentive
type; hypersomnia.
Note: A recent meta-analysis has found that “18 percent of children diagnosed
early with ADHD suffered from depression as adolescents, about 10 times the rate
among those without ADHD. Children with early ADHD were five times as likely to
have considered suicide at least once, and twice as likely to have made an
attempt.”*
Differentials (Vessey, et. al.): adjustment disorders; anxiety
disorders; ADHD; eating disorders; recurrent injuries (TBI);
somatic complaints; substance abuse.
Plan of Care: Adderall 10mg;Buspar 30mg BID;Lithium
900mg divided 600 a.m./300 p.m.;Prozac 40mg;melatonin
9mg. Weekly CBT and additional weekly group session.
*University of Chicago Medical Center (2010, October 4). Children with ADHD at increased risk for depression
and suicidal thoughts as adolescents. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com
/releases/2010/10/101004162834.htm
Cheung, A.H., Zuckerbrot, R.A., Jensen, P.S. (2007). Expert survey for the
management of adolescent depression in primary care. Pediatrics, 1201,
e101-e107.
Summary: an expert survey of pediatric providers in order
to consolidate typical management of depressed
adolescent clients in primary care and develop the GLADPC guidelines for treatment. Survey was combined with
current research, focus groups, and meta-analysis to
create universal guidelines to manage pediatric
depression clients.
Results: PCP have special accountability for the
management of these clients due to the shortage of
mental health specialists. Guidelines should be applied
and close following of these clients is best practice.
Correll, C.U. (2008). Antipsychotic use in children and adolescents: Minimizing
adverse effects to maximize outcomes. Journal of the American Academy of
Child and Adolescent Psychiatry, 47(1), 9-20.
Summary: Increasingly, adolescent pharmacological
psychiatry resembles adult treatment plans.
Providers still must be aware of the differing
pharmacokinetics and pharmacodynamics of these
medications when applied to adolescent clients.
Weights or even BSA may not be accurate measures
of efficacy due to rapid growth and hormonal
changes that are hallmarks of this period.
Results: Minimizing adverse effects relies on careful
and frequent follow-up, documentation, slow and
low titration, and adjunct management.
Diler, R.S., Daviss, W.B., Lopez, A. (2007). Differentiating major depressive
disorders in youths with attention deficient hyperactivity disorder. Journal of
Affective Disorders, 102, 125-130
Summary: As ADHD clients age and respond to
pharmacological treatments, it may be increasingly
difficult to screen for depressive disorders due to
alterations in psychomotor and sleep behaviors,
especially.
Results: Fewer than 1/3 of adolescents with depressive
disorder are experiencing only depression. Anxiety is the
most frequent co-morbidity, followed by ADHD. In
differentiating ADHD from Depression, 16% of youths
with ADHD ALSO had depression. Mood/anhedonia
symptoms and cognitive symptoms differentiate between
these diagnoses, but they are often co-current.
Trowell, L., Joffe, I., Campbell, J. (2007). Childhood depression: A place for
psychotherapy. An outcome study comparing individual psychodynamic and
family therapy. Journal of Child and Adolescent Psychiatry, 16, 157-167.
Summary: Both psychodynamic (talk) therapy and
cognitive behavior therapy are equally effective in the
treatment of adolescent depression and outcome studies
suggest that therapy should be cocurrent to
pharmacological or alternative management of
adolescent depression.
Results: Psychodynamic, CBT, and family therapy are all
effective in the treatment and prognosis of adolescent
depression and may be a primary treatment and should
always be a cocurrent treatment with organic
management. Therapies and pharmacological
management are synergistic and behaviors learned in
therapy influence functional brain chemistry.
Cheung, A.H., Zuckerbot, R.A., Jensen, P.S. (2007). Guidelines for adolescent
depression in primary care (GLAD-PC: II. Treatment and ongoing
management. Pediatrics, 120, e1313-1326.
Rec #1: Screen adolescents at high risk and those with CC of
mental health issues.
Rec #2: Screening should include interviews with patients and
their families.
Rec #1 Management: Educate entire family about depression.
Rec #2 Management: Create a comprehensive treatment plan
that includes referral, follow-ups, education, and
collaboration. Should include goals for functioning in each
aspect of patient’s life.
Rec #3 Management: Identify and manage referrals to support
in the community. Manage and collaborate on specialist’s
treatment plan.
Rec #4 Mangement: Create a safety plan.
GLAD-PC.ORG for algorithm/toolkit of
the AAP
Critique of Care
Appropriate screening and referral was made early on for
this patient, and the PCP had established a collaborative
relationship with the specialist early on, including
management specialist’s treatment plan. After the
patient’s inpatient discharge and follow-up to primary
care, a primary care treatment plan was established,
including frequent visits and screening.
Both the patient and the family partnered with the PCP
for care. A safety plan was established that included the
specialist’s emergency process. In general, though the
specific toolkit algorithm was not applied, all aspect of
the major recommendations were addressed in care.