Learning Goal: I’m working on a nursing multi-part question and need an explanation and answer to help me learn.
CC (chief complaint): “There has been a lot going on, but I won’t hurt myself.”
HPI: G.W. is a 12-year-old female who presents with symptoms of worthlessness, guilt, panic, chest tightness, and expressed suicidal ideation with self-injurious behaviors.The patient is seen with her mother for psychiatric evaluation following a 5-day inpatient hospitalization.She denies suicidal or homicidal ideation during intake, denies auditory or visual hallucination.She reports recent suicidal ideation with plan to hang herself which was the reason for her hospitalization, but states “it was all a misunderstanding”. She reports a history of cutting via scissors for over one year; reports last incident was one month ago. Was unable to provide frequency when most acute but reported she cuts when feeling stressed, punished, or overwhelmed at home or school. The patient endorses depressive symptoms of hypersomnia, negative view of self, hopelessness, helplessness, worthlessness, guilt, and passive suicidal ideation stating she thinks about what it would be like if she “was not here or alive anymore”. She reports poor appetite and poor concentration or focus while in class. Patient identified no concerns regarding completion of ADLs and identified that she does well taking care of herself. Patient additionally noted experiencing excessive worry, hypervigilance, panic attacks, over-thinking and impulsivity as symptoms related to anxiety and panic – mother attested to this, also.
Substance Current Use: Patient has no known history of substance abuse and other addictive behaviors.
Familial Psychiatric History:Depression in mother, anxiety in older sister. No other familial psychiatric history reported or known.No relevant familial or personal medical history reported.
VS: Temp: 97.1; BP 110/68; RR 17; P 65; HT 5’4”; WT 150lbs
Patient is an 12-year old female who presents looking her stated age. The patient is cooperative during the assessment and answers all questions appropriately. Patient aox4 (person, place, time and situation). Patient appears well-nourished and well-kept, there is no evidence of abnormal activity. Patient denies suicidal or homicidal thoughts, denies auditory or visual hallucinations.No evidence of delusional thinking. Patient with clear and logical speech, no tics or self-injurious behaviors noted. Patient is alert and oriented, recent and remote memories in tact. Concentration is appropriate, there is no evidence of looseness of association or flight of ideas.Patient’s mood is flat, affect is appropriate to mood.Patient’s judgement and insight intact and age appropriate.
Mental Status Examination:
G.W.’s presentation is consistent with that of major depressive disorder.The core features of depression are fatigue or sleep disturbance, anxiety, neurocognitive and sexual dysfunction, and loss in pleasure or interest in activities (Bains, & Abdijadid, 2021).Specifically, the loss of interest in activities will result in forgetfulness or hopelessness, and decreased feelings in self-worth.During the assessment, our patient reports she feels she “pretty much ruined everything” and feels her parents and sister “hate” her.Learning that she has been experiencing difficulties with falling or staying asleep further confirms her diagnostic criteria for depression.Also, since she has a family history of depression (depression in her mother), it is possible our patient also suffers from depression.If we can help improve her depression which is the first likely cause of her symptoms, we can then help in alleviating her anxiety symptoms.In my experiences in clinical and working at the bedside, if we can help alleviate depressive symptoms, we, in turn, help in reducing anxiety and panic symptoms at the same time.
My preceptor and I did discuss possible initiation of Zoloft for G.W.’s mood, but since her mother reported she has been on Prozac herself and finds it effective, we chose Prozac instead of the Zoloft. Prozac is first line antidepressant recommended for patients 8 years and older and has been proven to be most effective in treating adolescent depression (Gonzales & Green, 2020).Prozac 10mg daily will help with both reducing depressive and anxiety symptoms for G.W. as it is an SSRI and will work by blocking the absorption of serotonin in her brain.Regulating the amount of serotonin helps brain cells to transmit their messages to one another, which results in a more stable, better mood.In prescribing Prozac, I did educate the mother about co-morbidities that are involved with depression (i.e., substance use or abuse), but if I were to assess G.W. again, I would have focused on the risk of poor self-function and self- identity.Also, I would have discussed gene testing with the patient and her mother to assess which medications genetically would work best for G.W..Gene sight psychotropic testing will analyze how G.W.’s genes may affect medications prescribed to her.Along with antidepressants, I would encourage G.W. to partake in psychotherapy, activities to improve her overall function (i.e., exercise, developing new hobby, better sleep habits, etc.).Referring G.W. to outpatient therapy services and encouraging her to attend groups or participate in cognitive behavioral therapy will help in the reduction of her symptom and improve her overall mood.
The FDA advises that we “prescribe the smallest quantity of pills possible to help reduce the risk of deliberate or accidental overdose” (p.38). Careful monitoring by parents or guardians and health providers is important for any child taking an antidepressant because of increased suicidal thoughts during the first few months of treatment or when dosage is either increased or decreased (Gore, Chugh, & Gautam, 2017). Symptoms of self-harm or suicidal ideation are sometimes difficult to see, so it is important to educate parents about signs of worsening depression (i.e., talk of suicide or dying, suicide attempt or self-injurious behaviors, agitation, aggression, restlessness, impulsiveness, etc.) (Gore, Chugh, & Gautam, 2017). Also, it is crucial parents and guardians are aware that most adverse effects of antidepressants present and are most severe early in treatment. If I were to do this intake differently, I would have asked the patient more questions about herself injurious behaviors (i.e., why did she start cutting at a young age? Did she start cutting again because of her new school? Because her best friend moved away? Is this only home related?).
The importance of drug safety and efficacy in pediatric or adolescent population gains less attention as compared to other ages (i.e., adolescent, adult). I believe there is a need for legal obligation for pharmaceutical companies to perform trials on children if they intend to develop use in the pediatric population. Childhood illness or disease may be different than their adult equivalents so there may be more risk in therapy or treatment as compared to the benefit.
If I could re-do this evaluation, I would have asked the patient’s mother to step out of the room to assess and interview G.W. alone.G.W. revealed how she was feeling, but I do feel if her mother was not present, she may have opened up more and answered questions more in depth. I did not ask her specifically about her diet or appetite, so I would include this next time in her evaluation. Having her mother involved in her treatment is critical for improvement, but, also, asking her father or sister about G.W.’s mood would benefit her treatment, too.As providers and prescribers, it is our duty to educate our patients, as well as those family members of theirs who are involved in their care.
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