Outpatient Psychotherapy

Nikhil Patel is an 12-year-old Indian-American boy brought to you for an evaluation. Nikhil has been involved in outpatient psychotherapy for six months with a child therapist who provides cognitive-behavioral therapy (CBT).

Nikhil has had severe anxiety since age five. The psychotherapy seems to be only helping a little. Nikhil is still not able to go to school most days because he is very anxious. He often stays inside, refusing to go outside and play. He has become what is mother describes as “depressed.”

Answer the following questions from your perspective as his psychiatric nurse practitioner.

1. Based on the DSM-5, what symptoms would you expect to see for a diagnosis of generalized anxiety disorder (GAD)? How would you know if Nikhil has both GAD and a major depressive diagnosis?
2. What questions should you ask Nikhil’s parents relative to family history, school performance, and past treatment for Nikhil? What is your rationale for these questions?
3. What medication(s) would you recommend? Include dosing, titrating if appropriate, side effects, mechanism of action, metabolism, and excretion of the medication.
4. What information would you want from the therapist currently treating Nikhil? Do you think Nikhil should switch therapists, try a new therapy approach, or continue with the same CBT approach? Provide your rationale.