NR-606- MIDTERM EXAM Questions and Answers

NR-606- MIDTERM EXAM Questions and Answers What are barriers to seeking mental health care in children & adolescents? Children- Although children and adolescents may seek help, they usually drop out before treatment is effective due to poverty, language barriers, living in communities with lack of resources, stressors such as family issues, violence in the community, unstable housing, unemployment and food insecurity. Adolescents- Many parents lack an access to sufficient care for their children or themselves during perinatal. Parents and adolescents are reluctant to receive care due to the stigmas or negative perceptions towards mental health services. What are some barriers that pregnant women are faced with when attempting to seek care for mental health? Perinatal- cost, scheduling conflicts and high staff turnover rate causes issues for families seeking care. Less than 15% of women get treated for PPD. Explain the sensorimotor stage (ages 0-2) according to Piaget. Children experience the world through their senses and motor responses. The goal of this stage is object permanence. Explain the pre-operational stage (ages 2-7) according to Piaget. Children think symbolically and think very concrete. They learn to use words or pictures to represent objects. They are egocentric and have difficulty seeing things from others' perspectives. Pre-operational thinking is very concrete. So think very straight forward when you are teaching them: "You know how its hard for you to sit still and pay attention in school? This medicine will help you" . Imagination is still strong however abstract thinking is difficult. Think Ade's responses. THE ABSENCE OF OBJECT PERMANENCE. Explain the concrete-operational stage (ages 7-11) according to Piaget. Children begin to think more logical and organized about concrete events. They begin to reason inductively, from specific information to principles. Using similes within teaching is great for this group. "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." Time, space, and quantity is understood however not as separate concepts. Explain the Formal-operational stage (ages 12 and up) according to Piaget. Adolescents and young adults begin to reason abstractly and can consider hypothetical problems. They begin to think more about moral, philosophical, ethical, social, and political issues. "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your friends and parents. Do you have any concerns about taking the medication?" They begin to start planning at this age. -50% of lifetime mental illnesses begin at the age of 14. -50% of children ages 8-15 are not treated for mental illnesses How does consent work with children? Parents may decide whether to allow treatment if the child is unable to provide true informed consent (Preston et al., 2021). Although children may not be able to give legal consent, they should be included in discussions about medication and treatment whenever possible. Child input into treatment decisions may encourage treatment adherence. Positive experiences with providers and treatment can help instill the perception that treatment is beneficial, which can support positive mental health behaviors in the future. What should be included in the consent form and documentation when discussing information (such as taking psychotropic drugs) with pregnant patients? Informed consent should include side effects possible/rare side effects to mother and baby regardless of incidence the patient's decision to continue or discontinue treatment potential risks of continuing or discontinuing treatment Referral to perinatal psychiatrist if the patient is at high risk or on a high-risk medication. What are some points that PMHNP should take into consideration when prescribing medications for children? Metabolism, Excretion, Side effects Metabolism- Children have a higher metabolism than adults and may require higher dose of medication per body weight. When they reach puberty in adolescents is when the medication is usually titrated down because they are reaching a metabolism of an adult. Excretion- Children are going to excrete medications quicker due to high metabolism. Ensure to use proper prescribing protocol per weight. Again, may need higher doses than adults. Side effects- Children may not understand that they are experiencing side effects so the PMHNP must ensure to educate and include the child in prescribing education as well as be keen to side effects that the child may or may not describe. (Listen to the parents as well). Allow children to participate in the treatment plan PMHNP are mandatory reporters and MUST report any forms of child abuse, neglect or suspicions of such to the authorities. There are federal and state guidelines that we are expected to follow. What is this federal guideline called? The Child Abuse Prevention and Treatment Act What are some prescribing considerations for women who are pregnant? The physiologic changes that occur during pregnancy impact the pharmacokinetics of many medications. An increase in blood plasma level may increase the distribution volume of certain medications. Hormonal changes in CYP450 enzyme activations may increase or decrease drug metabolism. Increased renal blood flow and glomerular filtration rate may speed the excretion of medications. Monitoring of serum drug levels can help inform drug dosing for some medications; generally, however, providers must rely on careful symptom monitoring and adjust dosages as necessary to achieve optimal symptom management at the lowest beneficial dose (Payne, 2020). _______ stigma includes policies, regulations, or laws that intentionally or unintentionally lead to discrimination. This stigma can limit access to resources and other opportunities, thereby impacting the well-being of the stigmatized group. A program policy that prohibits individuals from using specific forms of prescribed medication for addiction (MAT) treatment is an example of structural stigma. Institutional or structural stigmas _____ stigma is when Individuals working in [medication-assisted treatment] MAT experience discrimination and prejudice from other healthcare professionals, especially abstinent treatment professionals who disagree with the use of medications to treat opioid use disorders. This discrimination and prejudice stem at times from stigma toward addiction diagnoses, and at other times toward unique features of MAT itself. The experiences of addiction treatment professionals illustrate how medical interventions can mark clients and professionals in ways that affect client care, and thus must be added to the scope of destigmatization efforts" (p. 324). Interventional stigmas _______ stigma encompasses the attitudes, beliefs, and behaviors of groups or individuals which form a stereotype that creates an emotional reaction or prejudice and results in discrimination. A stereotypic belief that individuals choose to use alcohol or other drugs and blame them for their substance use disorder is an example of this stigma. Public stigma _______ stigma refers to the shame individuals internalize about negative stereotypes. For individuals affected by SUDs, this stigma may lead to feelings of being flawed or unworthy of love or connection. It may also prevent them from seeking help. self-stigma Name some risk factors for maternal mental health disorders: lack of social support familial/personal history of depression pregnancy complications poor relationship quality smoking unintended pregnancy life complications chronic physical conditions prior pregnancy with infant/fetal loss What is the DSM-5 criteria for maternal depression? The patient has to have at least 5 symptoms for a two week period to be diagnosed with MDD. Peripartum onset is a specifier that is used if the depression occurs during pregnancy UP TO the first four weeks after birth. What are some symptoms of maternal depression? low mood, anxiety, avoiding people, negative thoughts, fatigue, guilt and difficulty focusing, feeling like one "lost themselves", insecurity, anhedonia, feeling overwhelmed, lack of control over emotions, weight loss, indecisiveness, recurrent suicidal ideation, psychomotor agitation specific concerns about the baby or parenting, including a sense of numbness or disconnection from the baby or guilt about not being a good mother As a PMHNP, what scale is used to screen for depression in pregnant women? Discuss the scale ratings The Edinburgh Postnatal Depression scale- It can used during pregnancy and after delivery. A score cutoff of 10 is in the indicator of depression. Discuss the scoring for the EPD scale along with the PMHNP interventions · Less than 8: Depression not likely: continue support · 9-11: Depression possible. Re-screen in 2-4 weeks · 12-13: Fairly high possibility of depression: monitor, support and educate. Refer to PCP · 14+: POSITIVE SCREENING. IMMEDIATE DISCUSSION, REFER TO PMHNP OR SPECIALIST How often should the PMHNP screen with the EPD scale? At every wellness appointment post pregnancy 1, 2, 4 week and the 6 month. What is the pharmacological and non-pharmacological treatment for maternal depression? SSRI is the first line treatment ONCE Bipolar is ruled out. Tricyclics can also be used and are deemed safe for treatment. omega-3 fatty acids may aid with depressive symptoms CBT Interpersonal Therapy ECT for treatment resistant depression ______ is an IV drug that is known to treat depression in pregnant women. This drug will take 60 hours to administer at a healthcare facility. The mother has to enrolled in a risk evaluation and mitigation strategy program. Braxanolone What is a HUGEEEEE side effect of SSRI's to the fetus that our patient's should be counseled on? SSRI & SNRI common adverse effect is neonatal withdrawal syndrome. Neonatal withdrawal syndrome or post natal abstinence syndrome- affects up to 30% of babies whose mothers take these medications and symptoms include tremors, high pitched cry and disturbed sleep. These symptoms usually peaks from 2-4 days after birth. THERE IS NO EVIDENCE THAT TAPERING DOSAGES or DISCONTINUING MEDICATIONS WITHIN THE LAST TRIMESTER WILL DECREASE HARM TO THE BABY. What is the first line treatment for depression in a breastfeeding mother? The first-line treatment for a breastfeeding mother with mild to moderate depression is psychotherapy. For more severe depression, antidepressants may be considered. Is it safe for mother a breastfeed while taking an SSRI? YES she can! They have low transmission rates through the breast What are the main symptoms of neonatal withdrawal symptom? tremors high pitched cry and disturbed sleep! Why is it important to NOT stop or decrease an SSRI during pregnancy? THERE IS NO EVIDENCE THAT TAPERING DOSAGES or DISCONTINUING MEDICATIONS WITHIN THE LAST TRIMESTER WILL DECREASE HARM TO THE BABY. This could do more harm to the mother. What is the DSM-5 criteria for maternal anxiety? Remember that with peri-partum onset will mean that the symptoms started during pregnancy up until 4 weeks after delivery EXCESSIVE WORRY about their pregnancy and delivery complications, infant well-being, and maternal or partner illness. irritability, difficulty sleeping, difficulty, tension, concentrating, and easy fatiguability. Pt should have 3 or more symptoms What is a HUGE risk factor for a woman to be diagnosed with perinatal anxiety disorder? A previous diagnosis of an anxiety disorder What is the pharmacological and non-pharmacological treatment for anxiety within pregnant women? SSRI's are the FIRST line treatment. SNRI's, buproprion, and tricyclics are considered safe. Non-pharmacological: CBT interpersonal therapy Why are benzodiazepines not considered the first-line or even second-line treatment amongst pregnant women? Benzodiazepines may be taken with caution for anxiety during pregnancy; however, a risk of newborn toxicity must be considered and monitored if used. Symptoms include sedation, floppy muscle tone, and potential breathing issues at birth. What is the DSM-5 diagnosis of peri-natal PTSD? Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred FOR MORE THAN 1 MONTH & causes significant distress. 1.) Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2.) Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3.) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. 4.) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s 5.) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 6.) 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 1. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Negative cognition: forgetfulness or negativism towards life or situations. Detachment or enstrangement What are risk factors for women to develop peri-natal PTSD? previous trauma history of sexual abuse complications with past pregnancies, traumatic births or labor experiences, instrument-assisted vaginal births or cesarean sections peri-partum depression, and previous mental illness What is the FIRST LINE treatment to treating peri-natal PTSD? FIRST LINE TREATMENT: PSYCHOTHERAPY!!!!!! Second-line: SSRI may be used for co-morbid depression Non-pharmacological: expressive writing, EMDR, CBT What are some non-pharmacological treatments for peri-natal PTSD? Non-pharmacological: expressive writing, EMDR, CBT What is the DSM-5 diagnosis of peri-natal bipolar I disorder? The presence of Bi-polar I: Mania present, depressive symptoms are less likely. Debilitating, usually hospitalization. Hallucinations and delusions occur. Increased self-esteem or expressions of grandiosity • Lesser need for sleep • Increased talkativeness • Onset of racing thoughts • Increased propensity to be easily distracted • Increased activity that is goal-directed • Increased activity in areas that have a high potential for negative consequences What is the DSM-5 diagnosis of peri-natal bipolar II disorder? Bipolar II- 1 hypomania episode that lasts for at least 4 days with 1 depressive episode. Usually does not require hospitalization. Childbirth can trigger hypomania and a severe depressive episode may follow several weeks later. Hypomania is usually more likely to occur in the initial stage of postpartum and is usually missed due it seeming like "the joys of pregnancy". Then severe depression weeks later. The following criteria from the DSM-5 (APA, 2013) are necessary for a diagnosis of bipolar II disorder: at least one hypomanic episode and at least one major depressive episode. To meet the criteria for a hypomanic episode, there must be a distinct period of increased mood irritability that is persistent and not normal for the individual. Also present in hypomania is an increased activity or energy level that lasts at least 4 consecutive days and is present for most of the day. During this period of increased activity and irritability, at least three of the following symptoms must persist to a significant degree: Increased self-esteem or expressions of grandiosity • Lesser need for sleep • Increased talkativeness • Onset of racing thoughts • Increased propensity to be easily distracted • Increased activity that is goal-directed • Increased activity in areas that have a high potential for negative consequences Remember: Childbirth can bring on hypomania & it can be masked by the joys of childbirth. Assess for other symptoms! REMEMBER:::: Clients with bipolar disorder may present during the depressive phase of the illness and may not report any symptoms of hypomanic or manic episodes. The provider must obtain a careful history from the client and/or family members to differentiate between bipolar disorder and depression. Bipolar disorder should be ruled out as a cause of depression before prescribing medication as certain antidepressant medications can precipitate a manic episode or induce rapid-cycling bipolar depression, which may contribute to the increased incidence of death by suicide in children and adults younger than 25. What is the pharmacological treatment for perinatal bipolar I disorder during a manic phase? LITHIUM- FOR MANIA LAMICTAL (LAMOTRIGINE)-maintenance What are your education points to teach your patient diagnosed with perinatal bipolar disorder who is on lithium or lamictal? Lithium- lithium CAN CAUSE cardiac malformations and the risk increases with higher doses. Always assess serum lithium levels before tapering or discontinuing medication. Benefits outweigh the risks with this medication. So, you may not want to stop the medication but def monitor and educate. Mom will need to BOTTLE FEED, this medication has a high transmission through breast milk. If the client chooses to breastfeed then the baby should be monitored for hypotonia and cyanosis and signs of toxicity. Lamictal- CAN cause cleft lip/cleft palate. You will need to BOTTLE feed your baby due to the high risk of medication transmission through breast milk. Mood stabilizers in pregnancy- Discontinuation of psychotropic medications for pregnancy is associated with a relapse rate of 80-100% for clients who take mood stabilizers. Its cheaper to keep her! What are some education points for a woman who wants to take Depakote (valproic acid) and Carbamezapine? THESE MEDICATIONS ARE TERATOGENIC AND SHOULD NOT BE TAKEN WHILE PREGNANT. Valproic acid can be taken POST-PREGNANCY and women can breastfeed while taking, howeverrrr serum drug levels MUST BE monitored. What is the DSM-5 criteria for perinatal psychosis? The DSM-5-TR (APA, 2022) recognizes perinatal psychosis as a "brief psychotic disorder with peripartum onset" when symptoms present suddenly during pregnancy or within the first 4 weeks after birth and last at least one day but no more than one month. The patient needs to only have ONE of the following symptoms What are s/s of perinatal psychosis? ·Postpartum psychosis presents with at least one of the following symptoms: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior (Stephen & Lui, 2021). Suicide and infanticide are primary concerns. Hallucinations or delusions related to the infant are common. For example, women may experience delusions that someone will harm or kill their infant, that the infant is the devil, or that the infant belongs to someone else. They may experience command hallucinations to harm or kill their infants which may seem reasonable or appropriate to the client (Beck, 2021). THIS IS A PSYCHIATRIC EMERGENCY AND THE MOMMY NEEDS IMMEDIATE HOSPITALIZATION. In PPP, however, intrusive thoughts of harming the infant are ego-syntonic or consistent with the woman's reality. Women with PPP do not experience distress surrounding these thoughts, and they feel comfortable discussing them with others. Because they experience delusions and hallucinations (Spinelli, 2005), there is an increased likelihood that psychotic women will act on such thoughts. What is the treatment for perinatal psychosis? IMMEDIATE HOSPITALIZATION. ECT Pharmacological: mood stabilizers antipsychotics: Risperidone (Risperdal), Quetiapine (Seroquel) antidepressants benzodiazepines What are the TWO huge risk factors for perinatal psychosis? A previous diagnosis of Bipolar disorder LACK OF SLEEP Lets talk antipsychotics for perinatal psychosis. A patient has been taking Zyprexa (Olanzapine) for the PP psychosis. What are some education points for the patient? Zyprexa (Olanzapine) can increase the possibility of the fetus to have neonatal withdrawal syndrome, gestational diabetes and musculoskeletal disorders. Lets talk antipsychotics for perinatal psychosis. A patient has been taking Quetiapine (Seroquel) for the PP psychosis. What are some education points for the patient? This medication can increase the risk for gestational diabetes. Mom gains weight, the baby weight will increase. Mom CAN breastfeed while taking this medication. What is the DSM-5 criteria for perinatal OCD? Presence of obsessions, compulsions, or both: 1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety or distress- OBSESSIONS 2.) Repetitive behaviors (e.g., hand washing, ordering checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly.1. SAME2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. The obsessions or compulsions are time consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. What are some s/s of perinatal OCD? Common obsessions relate to fears of contaminating the baby, the need for exactness, thoughts of aggression towards the infant, and fears of infant death, while common compulsions include repetitive handwashing and checking the infant (Beck, 2021). If intrusive thoughts involve fears of acting aggressively toward the infant, mothers fear being left alone with the infant or may distance themselves from the infant to avoid acting on the thoughts. Defined obsessions as "recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress." Compulsions were defined as "repetitive behaviors (e.g., hand washing, ordering of objects, re-checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly" (APA, 2013, p. 237). With compulsive acts, a person attempts to decrease anxiety or prevent a dreaded event. The obsessions and compulsions are distressing and occur more than 1 hour per day. O.C.D. continued.... In postpartum OCD, these intrusive thoughts are ego-dystonic or not considered within the woman's reality (Wenzel, 2011). The thoughts cause great distress and women are uncomfortable talking with others about them. Women with OCD are often afraid of being left alone with their infants and are hypervigilant in protecting them. Most women with postpartum OCD are terrified of revealing their thoughts of harming their infants to anyone because of shame, guilt, and fear that the infant will be taken away from them (Wenzel, 2011). When women finally share their thoughts, they often tell clinicians they would never act on them. In fact, women usually describe elaborate plans to avoid situations in which the intrusive thoughts might occur. For example, if a woman experiences repetitive thoughts of cutting her infant with a knife, she may have all the sharp objects and knives removed from her home and kept in a location unknown to her. Women in the peripartum period are approximately 1.5-2 times more likely to experience OCD compared to the general population, and up to 47% of women with OCD experience their first onset during the peripartum period. How would you treat perinatal O.C.D., pharmacologically and non-pharmacologically? First line treatment would be an SSRI, like Fluoxetine. CBT with psycho-education Cognitive restructuring Exposure with response prevention What are the baby blues? Symptoms that can last from days to weeks post delivery due to the drastic drop in hormones after the placenta is delivered. However, IT WILL NOT CAUSE IMPAIRMENT. The best treatment is self care, emotional support and reassurance from family and friends, eat well, ask for help, get great amount of rest. Does baby blues cause impairment? NOOOOOO Perinatal mental illness is associated with adverse outcomes for both the pregnant client and infant, including preterm birth, low birth weight, and a higher incidence of maternal substance use. What are some complications of smoking during pregnancy? Low birth weight ectopic pregnancy fetal mortality, placenta privia, placental abruption, still birth and pre-term labor. Smoking-related effects on neonates include sudden infant death syndrome and birth malformations such as oral clefts and neural tube defects, whereas effects on infants, children, and adolescents include asthma, cognitive impairment, lower respiratory illness, attention deficit hyperactivity disorder (ADHD), and central nervous system tumors As a PMHNP, what are pharmacological and non-pharmacological treatments for pregnant women who have tobacco use disorder? PMHNP should advise clients to discontinue tobacco use during pregnancy and may perform or refer clients for psychotherapy and support. After reviewing the risks and benefits with the client, nicotine replacement therapy (NRT), bupropion, or a combination of these interventions may be initiated (Ramsey et al., 2021). Higher doses of NRT may be required in pregnant clients due to the metabolic changes of pregnancy. Use of immediate-release preparations of NRT such as GUM or an INHALER rather than a slow-release preparation can help minimize infant exposure during pregnancy and breastfeeding. What are some complications of ALCOHOL during pregnancy? Health problems associated with alcohol use disorder include an increased risk for miscarriage, stillbirth, congenital anomalies, low birth weight, small for gestational age, and preterm delivery (Prince & Ayers, 2022). Lifelong effects of alcohol use disorder on children include fetal alcohol spectrum disorders (FASDs), neuro-developmental and central nervous system deficits, speech and language challenges, cognitive and behavioral deficits, impaired executive functioning, and psychosocial difficulties in adulthood (May et al., 2020). How would you treat alcohol use disorder in a pregnant client? Behavioral therapy and harm reduction counseling may assist clients to discontinue or decrease alcohol use. Although acamprosate and naltrexone are commonly used in medication-assisted treatment (MAT) in nonpregnant adults, little information is available from well-controlled studies on safe use during pregnancy. Inpatient treatment is recommended for clients at risk for moderate, severe, or complicated alcohol withdrawal as indicated by a score of more than 10 on the CIWA scale. What is the scoring scale for CIWA? 1-9- mild 10-20 moderate 20+= delirium tremens Although the public may consider cannabis harmless, it is associated with adverse pregnancy outcomes and fetal effects, including preterm labor, low birth weight and small for gestational age deliveries, and adverse effects on fetal and adolescent brain growth, executive functioning skills, behavioral problems, and academic achievement (Prince & Ayers, 2022). . Cocaine use during pregnancy is linked with poor pregnancy-related outcomes including premature rupture of membranes, placental abruption, preterm birth, low birth weight, and small for gestational age deliveries, as well as long-term effects in children and adolescents including lower short-term memory, child and adolescent delinquent behavior, earlier age of sexual activity, and substance use (Prince & Ayers, 2022). What is a huge education point when treating pregnant patients with opioid use disorder? clients should be advised to avoid the abrupt discontinuation of opioid use as opioid withdrawal during pregnancy can risk harm to both the mother and infant. How would you treat OUD in pregnant patients? Methadone and buprenorphine are the most prescribed MAT for OUD in pregnancy. Dosing may be increased during the second and third trimesters due to increased blood volume and metabolism. Clients who initiate treatment during pregnancy or who become pregnant while using MAT should continue treatment through pregnancy, labor, delivery, and the postpartum period. Is methadone and bubrenorphine safe for the baby of a breastfeeding mother?? YESSSS What is the DSM-5 criteria for depression in children? It is a depressive episode lasting for two weeks with at least 5 of these symptoms: Depressed or irritable mood for more days than not, anhedonia, significant weight loss/gain insomnia or hypersomnia more days than not psychomotor agitation or retardation fatigue more days than not feelings or worthlessness or excessive guilt impaired concentration (accompanied by a drop in grades) recurrent thoughts of suicide or death Irritability social withdrawal low self -esteem themes of suicide death or self-destructing appearing in play VEGETATIVE SYMPTOMS: sleep disturbance or poor appetite. School failure loneliness sadness low energy vague-non-specific physical complaints running away from home boredom extreme sensitivity to rejection or failure reckless behavior/acting out difficulty with relationships substance abuse or abuse Feeling misunderstood clinginess to parents. What are the depression screening for children 12-18 years old? According to the USFTA, depression screening is recommended for children 12-18 years old using the PHQ-9A. Lets discuss the PHQ-9A depression score results: 0-4 No or Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression What is the GLAD-PC and how does it aid with diagnosis and recognition of childhood depression? The GLAD-PC is a clinical assessment flowchart that aids providers with interventions and assessment guidelines for patients that land on the mild, moderate or severe depression. What is the treatment for depression in children? CBT + SSRI! Prozac is FDA approved to treatment of depression within children. It is low cost, effective and has a low side effect profile. Prozac has a long half-life which is one of the reasons why symptoms are so low unlike other SSRI's. What are some guidelines when you prescribe an SSRI for adolescents? START LOW and go slow as you titrate. The patient should be assessed every 1-2 weeks to see if symptoms are improving or worsening BEFOREEEE titrating or keeping the same. CONTINUE TO ASSESS FOR SUICIDALITY. SSRI's have a black box warning for suicide. Assess for activation, switching, emotional disinhibition/apathy What is the most common side effect that adolescents complain of when taking SSRI's? It is considered a late onset-effect Emotional disinhibition: a lack of control over emotions, which can lead to maladaptive emotional distress. Inappropriate behavior, impulsivity, risk-taking. This is a LATE onset-side effect. Bupropion can be added to aid with these symptoms. Apathy (lack of interest, enthusiasm or concern) and emotional blunting is also another side effect. Bupropion can also help because it will active the dopamine transmitter system. It happens because of the downstream effect of serotonin on dopamine. (SSRIs primarily work by increasing serotonin levels, which can, in some cases, disrupt the balance of other neurotransmitters like dopamine, potentially contributing to a reduced ability to experience strong emotions.) What medication can be given to aid in treatment of emotional disinhibition or apathy? bupropion What is activation when a patient is taking an SSRI? The is an ACUTE SIDE EFFECT. This can occur in the within a few hours of taking the first dose OR when dosages are increased. The patient can present with anxiety, initial insomnia, and agitation. Parents need to be educated on activation and how it is important to notify the PMHNP immediately. It will usually subside within two weeks. Providers sometimes can prescribe a benzo (Ativan 0.125 mg). When does activation usually occur? During the first hours if the initial dose OR it can occur after titration How long does it usually take activation symptoms to resolve? Two weeks! What is the best way to avoid activation when patients are taking SSRI's? But the best way to avoid activation is to start LOW and titrate SLOW. If activation occurs during a titration up, you can titrate back down to the original dose and when you begin to titrate up, use even a smaller dosage How long should a patient be treated with an antidepressant before discontinuation? A patient should be consistently on the SAME DOSE OF MEDICATION for 6 months at one time with complete remission of symptoms THEN the medication can be discontinued. What is switching and how can it occur when taking SSRI's? This can occur when the medication has been taken for two weeks or more. Switching shows up when the antidepressant invokes mania or hypomania in a person who is bipolar. Why is it soo important for unipolar depression to be properly diagnosed and effectively treated? 1.) Most children diagnosed in early childhood and late adolescence. More than half diagnosed with late MDD will be diagnosed with bipolar disorder in adulthood. 2.) MDD can be misdiagnosed and this can lead to one being placed on an SSRI. If they truly have bipolar disorder, the SSRI can induce a manic episode and lead them to more issues.