Mood disorders can impact every facet of a human being’s life, making the most basic activities difficult for patients and their families. This was the case for 13-year-old Jeanette, who was struggling at home and at school. For more than 8 years, Jeanette suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues.

As a PNP working with pediatric patients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.

 

LEARNING OBJECTIVES

Students will:

·        Assess patient factors and history to develop personalized plans of antidepressant therapy across the lifespan

·        Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric, adult, and older adult patients requiring antidepressant therapy

·        Synthesize knowledge of providing care to pediatric, adult, and older adult patients presenting for antidepressant therapy

·        Analyze ethical, legal, and social implications related to prescribing antidepressant therapy to patients across the lifespan

 

Assignment- NOTE YOU ONLY HAVE ONE ASSIGNMENT FOR WEEK 4. THE OTHER ASSIGNMENT YOU SHOULD NOTICE, IS FOR WEEK 6. I AM GIVING YOU THREE WEEKS TO PREPARE FOR THIS VERY LARGE ASSIGNMENT. IF I WERE YOU, I WOULD START THIS ONE VERY EARLY

1.     Knowledge Check- this is the only assignment for week 4

This Knowledge Check will test your knowledge on the videos presented each week. These videos and quizzes will help prepare you for the midterm and final exams later in the course. 

To prepare:

View all of the Required Learning Resources media.

Looking ahead to Week 6

·        if I were you, I would start working on this very BIG assignment during week 4 and 5

In Week 6, you will “argue” your case for a specific medication for a patient case scenario. Assigned medication categories, as well as whether you will take the pro or con position are as follows:

 

Cases:

Patient 1:

Malcolm is a 9-year-old male in the 4th grade at the public elementary school. Malcolm
has recently been diagnosed with ADHD, combined presentation. Malcolm struggles
with being fidgety and hyperactive; he often gets into trouble at school for blurting out
answers, getting out of his desk when he should not be, and hitting other children when
upset. Malcolm also has a hard time focusing on anything other than video games at
home. His parents report homework takes “all night” though it should only take 30
minutes. Malcolm has assigned chores but often gets distracted. For example, Malcolm
was to take out the trash but got distracted in the driveway while taking out the trash
and left the full bag in the driveway. He often misplaces the combination code for the
lock on the house door.

Patient 2:
Jessica is a 32-year-old female that was recently diagnosed with ADHD. She was
referred to your office by the psychologist that completed the ADHD assessment.
Jessica has always struggled in school and jobs. She is often “written up” at her job for
not completing tasks that are assigned to her. She becomes easily distracted by her
other co-workers. She finds herself spending a lot of time conversing with colleagues.
Her colleagues are frequently annoyed with her for constantly talking to them and
interrupting their work and tasks. Jessica is here to discuss medication options to treat
ADHD.

If your last name begins with:

A-D- Amphetamine and Pro’s patient 1

E-H- Amphetamines Con’s Patient 1

I-L- Methylphenidate Pro’s Patient 2

M-O- Methylphenidate Con’s Patient 2

P-R- Alpha Adrenergic Agonists Pro’s patient 2

S-T- Alpha Adrenergic Agonists Con’s Patient 2

U-W- Non-stimulants Pro’s Patient 1

X-Z- non-stimulants Con’s Patient 1

 

Pro	Con
Amphetamine	Amphetamine
Methylphenidate	Methylphenidate
Alpha Adrenergic Agonist	Alpha Adrenergic Agonist
Non-Stimulant	Non-Stimulant

Once you are assigned your medication and stance (pro or con), begin considering the following questions in terms of your assigned argument to prepare for this debate:

·        What is the proposed mechanism of action of the medication(s). Why or why not might this be the most appropriate for the patient?

·        What are the advantages or disadvantages to your class of medication (options for different administration, length of duration, etc.)?

·        What are the advantages or disadvantages of the other medication options?

·        What possible side effects or considerations need evaluation?

·        Provide one example for each consideration—legal, ethical, and social implications—for prescribing the medication category.

Note: You will need to research both the pros and the cons of the medication category to support and defend your stance, as prescribed for the patient-specific case.

 

 

Assignment part 2

Answer the following questions using the patient examples described above.

Patient 1

·        What are the concerns of the patient remaining on the opioid medication and clonazepam?

·        How might you educate the patient about these risks and concerns?

The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

·        How would you instruct the patient to taper off clonazepam?

·        What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.

·        How would you start the new recommended psychotropic medication for the patient?

·        Discuss one legal, ethical, or social consideration with the treatment plan.

Patient 2

·        The patient reports withdrawal symptoms when previously tapering off the alprazolam. What symptoms are common withdrawal symptoms from this medication?

·        Provide the patient education of withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt patient should seek medical attention.

·        Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?

·        What is the dose you would prescribe and how would you taper off the medication?

Patient 3

·        Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.

·        Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breast feed for 6 months postpartum.

·        The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.

·        The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.

Patient 4

·        Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?

·        How would you evaluate the patient for these side effects?

·        The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?

·        Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.

 

 

Examples:

 

Patient Examples:

Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.

Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.

Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.

Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”