Discussion: Foundational Neuroscience1

Discussion: Foundational Neuroscience1

A Sample Answer For the Assignment: Discussion: Foundational Neuroscience1

Depressive disorders are a source of considerable disease burden to the global population. The disorders affect productivity, lower the quality of life of the affected populations, and cause premature mortalities. Pharmacological interventions are the mainstream treatments for depressive disorders. Nurse practitioners should be aware of the safety, indications, and monitoring of different populations prescribed medications for depressive disorders. Therefore, this essay examines the medications used in treating major depression in children and adolescents, considerations, monitoring, follow-up, diagnosis, and its causes and symptoms.

Causes and Symptoms

            Major depression in children and adolescents is an important public health concern since it affects 5% of 12-year-olds and 17% of 17-year-olds in America. Psychological, biological, and environmental factors cause major depression in children and adolescents. Some of the biological risk factors associated with major depression include overweight, female sex, having a family history of depression, early puberty in girls, chronic illness, and polymorphisms that affect dopamine, serotonin, or monoamine oxidase genes. Some of the psychological factors that cause major depression in this population include dysfunctional emotional regulation, body dissatisfaction, low self-esteem, negative thinking, and substance abuse (Boaden et al., 2020; Farley, 2020). Environmental causes of major depression among children and adolescents include bullying, victimization, exposure to traumatic events, parental rejection, and dysfunctional families.

            Children and adolescents affected by major depression present to the hospital with a range of symptoms. They include hypersomnia or insomnia, weight gain or loss, difficulty concentrating, lack of interest and pleasure, easy irritability, and feeling sad or hopeless. Patients also report difficulties in making decisions, feeling guilty, and suicidal thoughts, plans, or attempts (Dwyer & Bloch, 2019; Selph & McDonagh, 2019). The symptoms affect the patient’s normal functioning in areas such as academic and social activities.

Diagnosing the Disorder and Why the Population is Considered Vulnerable

            Screening tools such as PHQ-A are used in the diagnosis of major depression in children and adolescents. The screening tool helps healthcare providers rate the client’s depressive symptoms and rule out other potential causes such as generalized anxiety disorder and bipolar disorder. Major depression can present with symptoms that are seen in other conditions such as hypothyroidism. As a result, healthcare providers must perform laboratory investigations such as thyroid function tests to rule out other comorbidities. The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) also guides the diagnosis of major depression in children and adolescents.

The DSM-5 manual sets the criteria that must be met for a diagnosis of major depression to be made (Selph & McDonagh, 2019). For example, patients should report symptoms such as being depressed almost every day most of the time, lack of interest and pleasure, changes in appetite and weight, being hopeless or guilty, having difficulties concentrating and making decisions, and symptoms affecting normal functioning.

            Children and adolescents are considered a vulnerable population. Firstly, children and adolescents are not mature enough to make safe decisions about issues that affect their health. Children and adolescents rely on others for decision-making and support. As a result, they are at risk of harm and practices that affect their health outcomes. Children and adolescents are also highly vulnerable to social, emotional, and physical changes. Exposure to negative experiences such as abuse, or violence can alter significantly their normal development and progression to adulthood. This makes them a vulnerable group to other health problems based on their environmental exposures.

Children and adolescents also have immature body systems and organs. This means that, unlike adults, children and adolescents are prone to harm from medications used for different conditions. Their risk of developing side and adverse effects due to immature organs involved in drug metabolism and elimination is higher than in adults (Farley, 2020). Therefore, they are considered a vulnerable population and caution must be taken when treating mental health problems that affect them.

Medication Treatment Options and Examples

            The Food and Drug Administration (FDA) has approved escitalopram and fluoxetine for use in treating major depression in children and adolescents. The guidelines recommend the use of fluoxetine in children who are aged eight years and older while escitalopram is used for patients who are aged 12 years and above. The other FDA-non-approved antidepressants used for treating major depression in this population include paroxetine, sertraline, citalopram, and fluvoxamine (Feeney et al., 2022). Bupropion and mirtazapine might also be considered despite the lack of adequate evidence that supports their use in the population.

            Antidepressants have the benefit of managing the depressive symptoms of major depression. The improvement in symptoms results in enhanced functioning, well-being, and quality of life. Antidepressants also reduce the risk of symptom relapse among children and adolescents with major depression. However, practitioners should be aware of the risks associated with antidepressants. They include predisposing patients to suicidal thoughts, plans, or attempts. Patients might also suffer from a negative self-image from weight gain associated with antidepressants (Boaden et al., 2020; Dwyer & Bloch, 2019). Patients and their families should also be educated about anticipated side effects such as insomnia, sedation, sexual dysfunction, gastrointestinal upset, hyperhidrosis, and dry mouth.

Monitoring

            Close patient monitoring should be done for children and adolescents prescribed antidepressants. Firstly, children and adolescents should be monitored for suicide risks. Antidepressants are associated with the adverse effect of increasing the risk of suicide in patients. Laboratory investigations such as a lipid panel and complete blood count should be performed periodically. Antidepressants are associated with side effects such as weight gain. Patients should be assessed for cardiovascular risks such as hyperlipidemia with weight gain (Hazell, 2022). Blood pressure and weight should also be assessed regularly, and patients advised on effective interventions to promote healthy weight gain.  

Healthcare providers should also monitor children and adolescents for pediatric behavioral activation syndrome. The syndrome can be diagnosed based on symptoms such as mania, hyperactivity, and agitation. Patients should also be monitored for serotonin syndrome. Serotonin syndrome develops among patients with dual antidepressant therapy (Zhou et al., 2020). Patients with serotonin syndrome present to the hospital with symptoms that include hypertension, diarrhea, sweating, hyperthermia, and tachycardia.

Special Considerations

            Several considerations influence drug therapy for children and adolescents diagnosed with major depression. Firstly, ethical considerations influence the selected treatments. Ethical principles such as autonomy and non-maleficence guide the practitioner’s decisions. Autonomy entails protecting a client’s right to self-determination. Healthcare providers ensure informed consent is obtained from the parents and legal custodians of the children and adolescents when treating major depression (Dwyer & Bloch, 2019). They also make decisions that are associated with optimum benefits such as a reduction in symptoms of major depression and minimum risk of patient harm.

            Legal considerations also affect the treatment of major depression in children and adolescents. Healthcare providers must ensure data privacy and confidentiality when treating major depression in children and adolescents. They should ensure that unauthorized parties do not access the patient’s data. Informed consent should be obtained before sharing the information with other healthcare providers. Healthcare providers must also make decisions in the client’s best interest to prevent negligence in their practice. Nurse practitioners should also be aware of the effect of culture on treatment outcomes in children and adolescents with major depression. Cultural practices associated with mental health problems such as stigma and isolation lower treatment utilization and adherence (Zhou et al., 2020). Healthcare providers must advocate the adoption of strategies that address stereotypes related to mental health problems in their communities.

            Social determinants of health also influence major depression among children and adolescents. Children and adolescents born to poor families are likely to experience barriers in accessing their needed mental healthcare services due to issues such as cost. Income and education levels also influence the access to and utilization of mental health services by this population (Sokol et al., 2019). Therefore, addressing social determinants of health would result in increased access to mental healthcare services for children and adolescents.

Follow-Up

            Antidepressants take between two and six weeks to produce the desired effects in managing depressive symptoms. Therefore, patients should be followed up after two weeks to assess their response to treatment and identify any issues that should be addressed for optimum treatment outcomes. Patients should also be linked with social support groups for mental health problems to help them learn effective ways to cope with their conditions.

Examples of Proper Prescription

Name: L.L.

Age: 12 years

Diagnosis: Major depression

Treatment: Oral sertraline 25 mg OD for two weeks

Refills: none

Follow-up: after two weeks

Name of the prescriber and DEA number:

Name: Y.Y.

Age: 14 years

Diagnosis: Major depression

Treatment: Oral escitalopram 25 mg once daily for two weeks

Refills: none

Follow-up: two weeks

Name of the prescriber and DEA number:

Name: L.A.

Age: 17 years

Diagnosis: Major depression

Treatment: Oral Fluoxetine 25 mg once daily for two weeks

Refills: none

Follow-up: two weeks

Name of the prescriber and DEA number:

Conclusion

            In summary, major depression in children and adolescents is the selected depressive disorder of focus in this assignment. FDA-approved and non-approved antidepressants are used in treating major depression in children and adolescents. Healthcare providers should weigh the benefits and risks of the available treatment. Legal, ethical, and cultural considerations and social determinants of health inform treatment decisions in children and adolescents diagnose with major depression.

References

Boaden, K., Tomlinson, A., Cortese, S., & Cipriani, A. (2020). Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment. Frontiers in Psychiatry, 11. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00717

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26-42F.

Farley, H. R. (2020). Assessing mental health in vulnerable adolescents. Nursing2023, 50(10), 48. https://doi.org/10.1097/01.NURSE.0000697168.39814.93

Feeney, A., Hock, R. S., Fava, M., Hernández Ortiz, J. M., Iovieno, N., & Papakostas, G. I. (2022). Antidepressants in children and adolescents with major depressive disorder and the influence of placebo response: A meta-analysis. Journal of Affective Disorders, 305, 55–64. https://doi.org/10.1016/j.jad.2022.02.074

Hazell, P. (2022). Antidepressants in adolescence. Australian Prescriber, 45(2). https://doi.org/10.18773/austprescr.2022.011

Selph, S. S., & McDonagh, M. S. (2019). Depression in Children and Adolescents: Evaluation and Treatment. DEPRESSION IN CHILDREN AND ADOLESCENTS, 100(10).

Sokol, R., Austin, A., Chandler, C., Byrum, E., Bousquette, J., Lancaster, C., Doss, G., Dotson, A., Urbaeva, V., Singichetti, B., Brevard, K., Wright, S. T., Lanier, P., & Shanahan, M. (2019). Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics, 144(4), e20191622. https://doi.org/10.1542/peds.2019-1622

Zhou, X., Teng, T., Zhang, Y., Giovane, C. D., Furukawa, T. A., Weisz, J. R., Li, X., Cuijpers, P., Coghill, D., Xiang, Y., Hetrick, S. E., Leucht, S., Qin, M., Barth, J., Ravindran, A. V., Yang, L., Curry, J., Fan, L., Silva, S. G., … Xie, P. (2020). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: A systematic review and network meta-analysis. The Lancet Psychiatry, 7(7), 581–601. https://doi.org/10.1016/S2215-0366(20)30137-1

1. Explain the agonist-to-antagonist spectrum of action of psychopharmacologic agents, including how partial and inverse agonist functionality may impact the efficacy of psychopharmacologic treatments.

The agonist spectrum can be explained best as a scale from agonist to inverse agonist; with natural neurotransmitters being an agonist or drugs that stimulate the receptors for that action. Partial agonist follows the agonist because of drugs that stimulate the same receptors on a lower gradation of the spectrum (Stahl, 2021). The next level on the spectrum is the antagonist blocking the action of the agonist (Stahl, 2021).

The final function is the inverse agonist has two behaviors: (1) block the agonist, and (2) lower the level of activity below the starting point in absence of an agonist (Stahl, 2021). The best way to explain a partial agonist is to present a medication used in the treatment of depression. Vilazodone is a serotonin reuptake inhibitor, which causes a rise in serotonin at the synaptic cleft by preventing the re-uptake of serotonin at the presynaptic axon terminal (Comprodon & Roffman, 2016).

However, Vilazodone also signals the 5HT1A presynaptic receptors and causes a decrease in the production of serotonin acting as a partial agonist (Baumgartnera et al., 2020). The outcome of partial and inverse agonists can be a marked increase or decrease in the concentration of a drug from the inhibition or excitation of the drug’s receptors (Comprodon & Roffman, 2016).     

2. Compare and contrast the actions of g couple proteins and ion gated channels.

Two of the four methods of signal transduction involve neurotransmitters rather than hormones or neurotrophins (Stahl, 2021). G-coupled proteins and ion-gated channels are similar because they are stimulated by drugs that cause neurotransmitters to activate genes inside of the cell when a phosphate is added to the cAMP protein (Stahl, 2021).

Although they have similarities, the first, G-coupled proteins, cause a slow neuronal effect as a result of its action with cAMP and protein kinase A (Comprodon & Roffman, 2016). The second, ion-gated channels, cause a rapid neuronal effect on the membrane potential as a result of calcium and a kinase called CaMK (Comprodon & Roffman, 2016).

3. Explain how the role of epigenetics may contribute to pharmacologic action.

Epigenetics describes the heritable action of DNA when gene function changes from one generation to the next because of the influence of the external milieu (Comprodon & Roffman, 2016). DNA can be affected by experiences triggering phenotype modifications rather than genotype changes medications (Quevedo et al., 2022). Stress, such as physical abuse in children, is positively correlated with the development of borderline personality disorder (Comprodon & Roffman, 2016; Quevedo et al., 2022).

The downstream effect of neuroplasticity can result in changes at the genetic level resulting in DNA sequencing variations (Quevedo et al., 2022). Once the chromatin’s structure is modified, the encoding of proteins may alter the original behavior of synaptic uptake of drugs causing changes of pharmacological action, such as enhanced or diminished responses to medications (Quevedo et al., 2022). The increased or decreased action at the receptor site may enhance or inhibit the action of a drug and cause an unexpected outcome.

4. Explain how this information may impact the way you prescribe medications to patients. Include a specific example of a situation or case with a patient in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.

Epigenetic changes are crucial to understand when prescribing medications to patients who have suffered trauma (child abuse, substance misuse, malnutrition, etc.) resulting in DNA silencing or activation (Comprodon & Roffman, 2016). The stress response to physical, emotional, or sexual abuse can cause increased DNA methylation in various tissues in the body, namely blood, saliva, and brain tissue (Quevedo et al., 2022).

Therefore, the PMHNP should be well versed in the biomechanics of a medication for appropriate and effective prescribing. One example is the higher reactivity of the HPA axis to adverse childhood experiences stimulating Corticotropin Releasing Hormone (CRH), which triggers the release of adrenocorticotropin hormone from the pituitary gland (Quevedo et al., 2022). A corticotropin releasing hormone antagonist may be ineffective if one’s mental health is severely affected by a history of abuse. Therefore, the PMHNP should consider an alternative medication to a CRH antagonist.

References

Baumgartnera, K., Doeringb, M., & Schwarz, E. (2020). Vilazodone poisoning: A systematic review. Clinical Toxicology, 58(5), 360–367.               https://doi.org/10.1080/15563650.2019.1691221

Links to an external site.

Camprodon, J. A., & Roffman, J. L. (2016). Psychiatric neuroscience: Incorporating pathophysiology into clinical case formulation. In T. A.        Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (pp.        1–19). Elsevier.

Quevedo, Y., Booij, L., Herrera, L., Hernández, C., & Jiménez, J. P. (2022). Potential epigenetic mechanisms in psychotherapy: A pilot                study on DNA methylation and mentalization change in borderline personality disorder. Frontiers in Human Neuroscience.                              https://doi.org/10.3389/fnhum.2022.955005

Great post, very informative, and that was a great example agonist medication and how the process works. Affinity is the property of a drug that describes its ability to bind to a receptor and depends on both the structure and receptor of the drug. Each affinity is unique for every drug receptor pair.  Differential affinity for different receptor subtypes allows for receptor selectivity.

Selectivity is generally considered to be a valuable drug property, however, there is an argument to be made for non-selectivity  for therapeutics especially for neuropsychiatric diseases, such as schizophrenia because of redundancy inherent in neural circuitry, may require action at multiple systems for therapeutic effects because adverse effects are often attributed to off-target drug actions (Berg & Clarke, 2018).

Schizophrenia occurs in about 1% of the population and is highly debilitating socially and economically. Unfortunately, schizophrenia is poorly understood despite decades of study. Schizophrenia is associated with impaired performance across a range of measurable parameters, including neuron volume and number, synaptic connectivity, neurochemical balance, and sensory gating (Focking et al., 2019) You are right, it is caused by some phenotypic variations due to epigenetic modifications, but researchers are unsure of the exact why.

Berg, K. A., & Clarke, W. P. (2018). Making Sense of Pharmacology: Inverse Agonism and Functional Selectivity. The international journal of neuropsychopharmacology, 21(10), 962–977. https://doi.org/10.1093/ijnp/pyy071

Focking, M., Doyle, B., Munawar, N., Dillon, E. T., Cotter, D., & Cagney, G. (2019). Epigenetic Factors in Schizophrenia: Mechanisms and Experimental Approaches. Molecular neuropsychiatry, 5(1), 6–12. https://doi.org/10.1159/000495063

Discussion: Foundational Neuroscience1

Having a strong knowledge in foundational neuroscience is a bonus for a psychiatric mental health nurse practitioner. In order to diagnose and treat clients, you must not only understand the pathophysiology of psychiatric disorders, but also how medications for these disorders impact the central nervous system. These concepts of foundational neuroscience can be challenging to understand. Therefore, this Discussion is designed to encourage you to think through these concepts, develop a rationale for your thinking, and deepen your understanding by interacting with your colleagues.

Learning Objectives

Students will: Analyze the agonist-to-antagonist spectrum of action of psychopharmacologic agents Compare the actions of g couple proteins to ion gated channels Analyze the role of epigenetics in pharmacologic action Analyze the impact of foundational neuroscience on the prescription of medications

Learning Resources for NURS 6630 Discussion Foundational Neuroscience1

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Required Readings Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library.

nervous system. These concepts of foundational neuroscience can be challenging to understand. Therefore, this Discussion is designed to encourage you to think through these concepts, develop a rationale for your thinking, and deepen your understanding by interacting with your colleagues.

For this Discussion, review the Learning Resources for NURS 6630 Discussion Foundational Neuroscience1 and reflect on the concepts of foundational neuroscience as they might apply to your role as the psychiatric mental health nurse practitioner in prescribing medications for patients.

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