Erica Daniels-Dottir is a 13-year-old Caucasian female who was admitted today to an inpatient adolescent psychiatric unit for suicidal ideation and reports of severe depression.

QUESTION

Directions
Review the case study and then answer the questions that follow.
Case Study
Erica Daniels-Dottir is a 13-year-old Caucasian female who was admitted today to an inpatient adolescent psychiatric unit for suicidal ideation and reports of severe depression. She has no other significant medical problems. You are at a meeting with Erica and her mothers, Sally Daniels and Thea Sindridottir. Erica has had severe mood swings, irritability, and dangerous and impulsive behavior. This is her third suicide attempt in the past two months.
Questions
From your perspective as Erica’s psychiatric nurse practitioner, answer the following questions in a two- to three-page double-spaced paper (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

ANSWER THE FOLLOWING QUESTIONs, RUNNING HEAD,2016-2020 REFERENCES PLEASE
1. You are assigned to complete a psychiatric evaluation on Erica. Identify the clinical presentation and symptoms you would expect to see if you were to make a diagnosis of Major Depression.
2. What lab tests would you order? Discuss the rationale for each test.
3. Erica’s mothers want to know how their daughter could be depressed enough to require psychiatric hospitalization. What information would you need from Erica’s mothers relative to family, Erica’s current and past functioning, and the rationale for needing inpatient psychiatric treatment rather than outpatient treatment at this time?
4. Erica’s mothers tell you they do not want to medicate her. How do you discuss medication treatment with parents of teenagers and of younger patients? How young is too young? At what age do you consider the child’s opinion? (Optional: Imagine Sally and Thea are divorced, and one of them wants medications and the other does not. How do you mediate that conversation?)
5. Identify pharmacological and non-pharmacological interventions you might recommend. Include a specific recommendation of a psychotropic medication (include starting dose and side effects to monitor). Provide the rationale for these recommendations. Identify how the drug you select is metabolized and its mechanism of action.
6. How would you know when Erica would be ready for a safe discharge relative to symptom presentation and functioning? What are the potential complications if these symptoms are not well managed?

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ANSWER

 To make a diagnosis of Major Depression, the following clinical presentations and symptoms may be expected

Depressed mood most of the day, nearly every day, as observed by others or reported by the individual.

Markedly diminished interest or pleasure in almost all activities.

Significant weight loss or weight gain, or a decrease or increase in appetite.

Insomnia or hypersomnia nearly every day.

Psychomotor agitation or retardation nearly every day.

Fatigue or loss of energy.

Feelings of worthlessness or excessive or inappropriate guilt.

Diminished ability to think or concentrate, or indecisiveness.

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt.

 The lab tests that may be ordered to assess Erica’s condition and rule out any underlying medical factors contributing to her symptoms may include

Complete blood count (CBC): This can help identify any abnormalities such as anemia or infections.

Thyroid function tests: Thyroid imbalances can contribute to mood disturbances, so checking the levels of thyroid hormones (T3, T4, and TSH) is important.

Basic metabolic panel: This evaluates kidney and liver function, electrolyte balance, and blood glucose levels.

Vitamin D levels: Low levels of vitamin D have been associated with depression, so checking this may be beneficial.

The rationale behind these tests is to exclude any potential underlying medical conditions that could mimic or exacerbate depressive symptoms.

To better understand Erica’s situation and determine the need for inpatient psychiatric treatment, information from Erica’s mothers regarding the following areas would be helpful

Family history: Information about the presence of mental health disorders in the family can provide insights into potential genetic or familial risk factors.

Current and past functioning: Details about Erica’s daily functioning, academic performance, social interactions, and any recent significant life events or stressors can help assess the severity and impact of her symptoms on her overall functioning.

Previous treatment attempts: Knowing if Erica has received any prior outpatient treatment, such as therapy or medication, and the outcomes of those interventions can inform the decision for inpatient treatment.

The rationale for inpatient psychiatric treatment would depend on the severity and acuity of Erica’s symptoms, the level of distress and impairment they cause, and the potential risk for self-harm or suicide. If Erica’s symptoms are severe, and she poses a significant risk to herself, intensive monitoring and a structured treatment environment provided by inpatient care may be necessary.

When discussing medication treatment with parents of teenagers and younger patients, it is important to provide them with accurate information about the benefits and potential risks of medication. The decision to use medication should be based on a thorough evaluation of the individual’s clinical condition and should consider the potential impact on their overall well-being.

The age at which a child’s opinion is considered can vary depending on the individual’s maturity level and capacity to participate in the decision-making process. In general, it is important to involve adolescents in discussions about their treatment and take their preferences into consideration, especially when they demonstrate the capacity to understand the implications of different treatment options.

In the scenario where Sally and Thea have differing opinions about medication, it is crucial to facilitate open and respectful communication between them. This may involve discussing the potential benefits and risks of medication, addressing any concerns or misconceptions, and exploring alternative treatment options. Mediation might involve facilitating a dialogue that allows both parents to express their concerns and viewpoints while aiming for a collaborative decision that prioritizes the best interests of the child.

For pharmacological interventions, selective serotonin reuptake inhibitors (SSRIs) are commonly used for treating depression in adolescents. A specific recommendation may be fluoxetine (Prozac), starting at a low dose of 10 mg per day, which can be gradually increased based on the response and tolerability. Common side effects to monitor include gastrointestinal disturbances, initial activation or increased anxiety, and potential changes in mood or suicidal ideation, which should be carefully monitored.

Fluoxetine is primarily metabolized by the liver, mainly through the CYP2D6 enzyme. Its mechanism of action involves inhibiting the reuptake of serotonin, thereby increasing serotonin levels in the brain and potentially improving mood.

Non-pharmacological interventions that can be recommended include individual therapy, such as cognitive-behavioral therapy (CBT), which can help Erica develop coping skills and address negative thought patterns. Family therapy may also be beneficial to improve communication, address family dynamics, and provide support to Erica’s mothers.

Determining when Erica would be ready for a safe discharge would involve ongoing assessment of her symptom presentation and functioning. It would be important to monitor the improvement of depressive symptoms, reduction in suicidal ideation, stabilization of mood, and restoration of daily functioning and social engagement.

Potential complications if these symptoms are not well managed include an increased risk of further suicide attempts, worsening of depressive symptoms, impaired social and academic functioning, strained family relationships, and overall diminished quality of life. Regular monitoring and appropriate interventions can help minimize these risks and support Erica’s recovery.