Assessing and Treating Vulnerable Populations for Depressive Disorders
Introduction
Depressive disorder is a marked condition in which a person experiences persistent sadness and loss of interest (Watson et al., 2020). Most people with depressive disorders also experience other related mental health problems, such as anxiety. These mental health conditions can have a significant impact on the quality of life for someone who suffers from them. Depressive disorder is also sometimes referred to as depression, although there are some subtle differences between these terms that may not be readily apparent.
Depressive Disorder Causes and Symptoms
According to Rao (2013), the depressive disorder causes can be many. Some of these include genetics, biologically: (hormonal fluctuations, brain chemistry and mood disorders). Genetics: This might be the cause of your depression if it is present in family members, or if you have had a traumatic experience as an infant or child. The way people handle stress may also play a role here. Biologically: Hormonal fluctuations, brain chemistry and mood disorders can lead to depression — most commonly seen in women during their periods or people with bipolar disorder (American Psychiatric Association, 2013).. There are many different symptoms of depression. For example: persistent sadness; loss of interest in activities; weight changes (loss or gain); insomnia or excessive sleeping; fatigue; decreased energy; indecisiveness. Signs of depression are there to help you know if you might have this disorder so that you can contact your doctor for treatment options.
How depression is diagnosed for adolescents, why is this population considered vulnerable
There is a high prevalence of mood disorders in adolescents. They are among the leading causes of disability worldwide, affecting nearly 6 million young people annually. There is a lot of uncertainty about how to identify youth at high risk for these disorders because many mental health issues are not outwardly visible. The diagnostic approach for identifying these youth has changed over time and in some cases, this may lead to misdiagnosing depression. Some are considered at-risk because their psychiatric symptoms don’t meet the traditional criteria for an adult diagnosis, or they don’t have visible signs like fear or anxiety that can be seen by others (e.g., children with trauma histories) ( Magellan Health, 2013). Others are considered at-risk because they have a genetic predisposition or are victims of abuse. Still other youth are at-risk because they have a combination of these factors which increases their vulnerability to mental health disorders.
Medication treatment options for depression including risk vs benefits; side effects among adolescents
There are three primary classes of medication treatment options for depression which can be used before or in combination with psychological therapies (Howland, 2008a). These include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotic drugs (AADs). The tricyclic antidepressants have been prescribed for depression since the 1960s. They can be used alongside psychotherapy or alone in moderate to severe cases of depression. The TCAs work by inhibiting the reuptake of both norepinephrine and serotonin, which increases their availability in synapses. TCAs are also thought to have an effect on the limbic system of the brain which influences emotions and mood.
Selective serotonin reuptake inhibitors (SSRIs) are a type of medication which was initially intended to treat obsessive compulsive disorder (Howland, 2008b). However, over the last 20 years, they have been prescribed for depression in controlled trials as well. They work by enhancing the effects of serotonin in the brain and increasing its synaptic release. In addition to this, they also influence serotonin receptors in various parts of the brain including: hypothalamus, pituitary gland, enteric neurons and limbic system. SSRIs are generally more effective than TCAs in their treatment of depression and common side effects include drowsiness, sensitivity to light and nausea.
Atypical antipsychotic drugs (AADs) work by reducing serotonin activity in the brain. This is achieved by blocking its uptake into receptor sites in the brain and has been used to treat a number of conditions such as Alzheimer’s disease, depression and schizophrenia (Howland, 2008b).. The negative side effects associated with AAD use include weight gain, increased risk of type 2 diabetes and heart diseases. This may be related to their interaction with certain genes which can influence metabolism. Mood elevator drugs such as trazodone are also used to improve the symptoms of depression. However, they are not widely prescribed due to the risk of dependency which can occur after prolonged use.
FDA approvals for the vulnerable population of adolescents
The first generation of antidepressants that were approved by the FDA was tricyclic antidepressants. It was discovered that patients with depression would respond better to an antidepressant when it contained three separate active ingredients – an MAO (monoamine oxidase) inhibitor (which blocks dopamine, norepinephrine, serotonin and epinephrine from being released), a tricyclic antidepressant (which blocks norepinephrine from being released) and a tetracyclic antidepressant (which blocks epinephrine from being released) (U.S. Food & Drug Administration. (n.d.).
The second generation of antidepressants was the SSRI/SNRI group. The SSRI/SNRI antidepressants are commonly known as TCA’s or Tricyclic Antidepressants. The first generation of SSRI’s were used for mild to moderate depression (U.S. Food & Drug Administration. (n.d.). They have less side effects than the tricyclic antidepressants and have been found to be more effective for treating depression. These are the SSRIs fluoxetine (aka Prozac), paroxetine (aka Paxil), sertraline (Zoloft) and escitalopram (Lexapro).
The third generation of antidepressants is the newest class called Serotonin and Norepinephrine reuptake inhibitors, popularly known as SNRIs (Baek et al., 2016). These are the antidepressants venlafaxine (Effexor), duloxetine (Cymbalta), milnacipran (Savella) and levomilnacipran (Fetzima or Buspar). This group of antidepressants is effective for treating the irritability, agitation and anger associated with bipolar disorder and has a very low risk of causing mania.
Medication considerations of medication examples prescribed
Some of the medications that can be prescribed to adolescents suffering from depressive disorder include Amitriptyline, Bupropion and Citalopram. These include Amitriptyline, which is a tricyclic antidepressant (TCA) (Fava,& Papakostas, 2016). This medicine may also be effective at treating anxiety and nerve pain. Atypical antidepressants such as Bupropion are available in prescription only form and are used to help control weight. They act as an appetite suppressant, causing weight loss by reducing active feelings about food through mechanism that does not involve eating fewer calories.
Legal considerations, ethical considerations, cultural considerations, social determinants of health
When considering legal and ethical implications for this topic, the first consideration is confidentiality as per HIPAA laws. If a treatment plan includes sharing information with parents or guardians, then written consent should be given by the parent or guardian before proceeding with therapy sessions. During therapy sessions, issues of confidentiality must be addressed. If parents are to be present at the sessions, then their presence must be discussed prior to their attendance. The therapist should encourage parents to ask questions about the patient’s condition and treatment plans.
The second consideration is confidentiality as per medical records laws. Medical records pertaining to individual minors may contain information on other individuals, such as a child or parent’s diagnosis or treatment plans. Parents’ rights are also important considerations when considering ethical implications: usually, parents can have access to medical records of their children if they’re involved in treatment with a physician (Yasuda et al., 2008). Adolescents must remember that their parents are also affected by depression and that their parents may not seek treatment for the same reason as them. Parents should also be aware of the symptoms of depression and how to support their teenager if they suspect that they or their child may be depressed.
According to Rosengren et al. (2019), low socioeconomic status, limited access to healthcare, and lack of education in impoverished areas contribute to this high prevalence. Depression manifests in different forms with different consequences depending on the cultural context they are being experienced. The symptoms of depression may be interpreted differently by cultures foreign to the one felt them and can sometimes lead those afflicted with depression into mental health systems where they are not given treatment that would best suit their needs; for example in parts of India, rather than receiving medication or psychotherapy for their depressive disorder, those suffering may instead turn to ayurvedic treatments such as yoga or meditation and not receive any further treatment for their condition.
What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring
Labs, in particular, require more than just a single look at the results. If you’re a physician and your patient is an adolescent suffering from depression, monitoring labs may be a little more complicated than just checking their cholesterol level (Lorberg et al., 2019). It’s important, not only to monitor the level of depression symptoms, but also to monitor lab values because some adolescents may have worsening medical issues they don’t even know they have. Adolescents and adults both suffer from depressive disorder. Many patients with cases of depression also suffer from other medical issues that may go undiagnosed.
One such case is in an adolescent diagnosed with depression who experiences worsening of existing medical issues or the development of new ones (Ehntholt et al., 2018). Some of these medical problems may come and go, while others can have lasting effects on their lives and those around them if they are not treated properly. That’s why it’s so important to monitor labs when treating adolescents suffering from depressive disorder. Labs in a reference range that show normal values should be monitored regularly because they indicate the overall health of an individual while comorbidities require monitoring the closer they are or get to needing medical treatment.
Where to follow up in your local community for further information about Depressive disorder among adolescents
The National Alliance on Mental Illness is an organization with which aims to ensure access to care for all Americans living with mental illness and educate the public about what they can do to support those living with mental illnesses (World Health Organization, 2019). The National Suicide Prevention Lifeline is also a great resource for those who live near where you may be having trouble accessing information. They provide 24/7 support for individuals who are struggling emotionally and may have suicidal thoughts or tendencies, as well as provide information for what steps one might take if they’re worried that someone he or she knows may be at risk of suicide.
Provide 3 examples of how to write a proper prescription that you would provide to the adolescents patient suffering from depressive disorder or transmit to the pharmacy.
The patient’s diagnosis is major depressive disorder. Making sure to have the patient’s name, birthdate, medical record number, and current medications on hand, we can write a prescription for either:
- Sertraline 50mg by pill once daily
- Fluoxetine 20mg by pill once daily
- Escitalopram 10mg by pill once morning and evening
- Venlafaxine 5-75 mg by tablet twice per day
- Duloxetine 60mgs two or three times per
Conclusion
The main finding is that depressive disorders are a common problem in adolescents, affecting both boys and girls. A substantial proportion of adolescents experience major depressive episode during adolescence – even when they think they have it under control. Therefore, the support needed will require a multidisciplinary approach involving all the relevant professionals, including parents and other careers and health professionals who have an interest in this area. Most importantly, treatment should be adapted to each individual’s needs.
References
Baek, J. H., Nierenberg, A. A., & Fava, M. (2016). Pharmacological approaches to treatment- resistant depression. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 44–47). Elsevier.
Watson, R., Harvey, K., McCabe, C., & Reynolds, S. (2020). Understanding anhedonia: A qualitative study exploring loss of interest and pleasure in adolescent depression. European Child & Adolescent Psychiatry, 29(4), 489-499.
Ehntholt, K. A., Trickey, D., Harris Hendriks, J., Chambers, H., Scott, M., & Yule, W. (2018). Mental health of unaccompanied asylum-seeking adolescents previously held in British detention centres. Clinical child psychology and psychiatry, 23(2), 238-257.
Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J.Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 27–43). Elsevier.
World Health Organization. (2019). Mental health, disability and human rights: WHO QualityRights core training-for all services and all people: course guide.Rosengren, A., Smyth, A., Rangarajan, S., Ramasundarahettige, C., Bangdiwala, S. I., AlHabib, K. F., … & Yusuf, S. (2019). Socioeconomic status and risk of cardiovascular disease in 20 low- income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study. The Lancet Global Health, 7(6), e748-e760.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Howland, R. H. (2008a). Sequenced Treatment Alternatives to Relieve Depression (STAR*D).
Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21-24. https://doi.org/10.3928/02793695-20080901-06
Howland, R. H. (2008b). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21-24. https://doi.org/10.3928/02793695-20081001-05
Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-textbook of child and adolescent mental health. https://iacapap.org/_Resources/Persistent/a97650fb538f47bb697c47873b0e58d493684a0
7/A.7-Psychopharmacology-2019.1.pdf
Magellan Health. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. http://www.magellanhealth.com/media/445492/magellan- psychotropicdrugs-0203141.pdf
Poznanski, E. O., & Mokros, H. B. (1996). Child depression rating scale-Revised. Western Psychological Services.
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787-791. https://doi.org/10.1002/da.22171
Yasuda, S. U., Zhang, L. & Huang, S. M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417-423.
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
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Question 
For this assignment, you will develop a patient medication guide for treatment of depressive disorders in a vulnerable population (your choice for one vulnerable patient population to choose from: children, adolescents, older adults, dementia patients, pregnant women or one not listed of your choice!). Be sure to use language appropriate for your audience (patient, caregiver, parent, etc.). You will include non-copyright images and/or information tables to make your patient medication guide interesting and appealing. Limit your patient medication guide to 5 pages. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 3 scholarly supporting resources outside of your course provided resources.
Assessing and Treating Vulnerable Populations for Depressive Disorders
In your patient guide, include discussion on the following:
- Depressive disorder causes and symptoms
- How depression is diagnosed for the vulnerable population of your choice, why is this population considered vulnerable
- Medication treatment options including risk vs benefits; side effects; FDA approvals for the vulnerable population of your choice
- Medication considerations of medication examples prescribed (see last bullet item)
- What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring
- Special Considerations (you must be specific, not general and address at least one for EACH category; you must demonstrate critical thinking beyond basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health
- Where to follow up in your local community for further information
- Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.
APA Format
Min 5 pages
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