D343 Task 2 Applied Practice Case Example

Applied Practice Case: A 17-Year-Old Asks for Depression Treatment Without Telling Her Parents

Student Name

Leavitt School of Health, Western Governors University

D343: Foundations of Advanced Psychiatric Mental Health Practice, Task 2

Course Instructor

Month Day, Year

Applied Practice Case: A 17-Year-Old Asks for Depression Treatment Without Telling Her Parents

The Situation

A composite 17-year-old high school senior comes alone to the community mental health center where the psychiatric-mental health nurse practitioner (PMHNP) described in the role analysis works. She reports four months of low mood, poor sleep, loss of interest in soccer and falling grades. Her Patient Health Questionnaire-9 score is 17, in the moderately severe range. She denies a suicide plan or intent but reports passive thoughts that 'everyone would be better off' twice in the past month. She asks to start treatment, including 'the pills my friend takes,' and asks that her parents not be told, because her father 'thinks therapy is for weak people.' She has private insurance through her parents.

The request sits at the edge of the PMHNP's authority in three ways: whether a minor may consent to her own treatment in this state, whether that consent extends to medication, and how far confidentiality can be promised to someone under 18 with suicidal thoughts.

Decision One: Can She Consent to Treatment?

In the composite state, the mental health code allows minors aged 16 and older to consent to outpatient mental health counseling without parental consent, but requires parental consent for psychotropic medication until age 18 unless the minor is emancipated. She is not emancipated. The PMHNP therefore decides that she can consent today to evaluation, psychotherapy and safety planning, but not to an antidepressant. The PMHNP explains this to her plainly and without apology, because a clear answer protects the relationship better than a vague one. This decision applies the boundary identified in the role analysis: authority comes from state law, and the law draws the line here, not the clinician's judgment.

Decision Two: What Can Be Kept Confidential?

Professional standards call for protecting confidentiality while also assessing and responding to risk (American Psychiatric Nurses Association [APNA] & International Society of Psychiatric-Mental Health Nurses [ISPN], 2022). The PMHNP completes a structured suicide risk assessment and finds passive ideation without plan, intent, prior attempts or access to firearms at home. The PMHNP decides that confidentiality can be maintained for now, and tells her exactly where its limits are: if she develops a plan or intent, or if the PMHNP believes she is at imminent risk, her parents or emergency services will be contacted to keep her safe. A written safety plan is completed together, naming warning signs, coping steps, two trusted adults, the crisis line and the clinic's number.

There is also a practical confidentiality problem. Her insurance statements go to her parents, and a claim for a mental health visit may reveal the service. The PMHNP asks the billing office about the state's confidential communications option for insured minors and, in the meantime, schedules her first sessions under the center's sliding-fee program so that no claim is filed without her knowledge.

Decision Three: How to Approach Medication

Moderately severe depression in an adolescent is often treated with a combination of psychotherapy and a selective serotonin reuptake inhibitor, but medication requires parental consent in this state, and antidepressants in young people carry a boxed warning about increased suicidal thinking early in treatment, which calls for close monitoring and family involvement (U.S. Food and Drug Administration [FDA], 2018). The PMHNP decides not to press for medication today. Instead, the PMHNP starts weekly cognitive behavioral therapy, explains that medication may help later and would need a parent's consent, and invites her to think about which parent might be more open. With her agreement, the PMHNP offers to hold a joint session in two to three weeks in which she can decide how much to share.

Because this is a new situation involving a minor, the PMHNP discusses the case, without identifying her, with the collaborating psychiatrist at the next chart review, as the collaborative agreement expects for complex cases.

The Theory in Practice

Peplau described the nurse-patient relationship as moving from orientation through a working phase to resolution, with trust established in orientation making the later work possible (Peplau, 1991). This first visit is orientation. The PMHNP's decisions, being honest about legal limits, keeping what can be kept private and not forcing the parent conversation, are designed to build enough trust that she returns next week. If the relationship fails at this stage, the risks she carries will go unmonitored. The PMHNP also takes on the teacher role Peplau describes, explaining depression as a treatable condition and not a weakness, which directly answers the message she has heard at home.

Ethical Principles Weighed

Respect for autonomy supports her right to seek help and to shape how her parents are involved. Beneficence supports effective treatment, which may eventually include medication and family support. Nonmaleficence requires watching closely for suicidal thinking. Justice supports access to care for a young person who might otherwise go without it because of a parent's views or the cost of a visit. The decisions above balance these principles rather than choosing one: treatment begins now within the law, confidentiality is kept within stated safety limits, and family involvement is pursued through her own choices rather than imposed.

Documentation and Follow-Up

The PMHNP documents the minor-consent basis for treatment, the risk assessment and safety plan, the confidentiality discussion and its limits, the decision to defer medication and the reason, and the consultation plan. A follow-up visit is booked in one week, with a phone check in three days. If her symptoms worsen, if she develops a plan, or if she decides to involve a parent, the plan will change accordingly and the change will be recorded.

What the Case Shows About the Role

This case shows that scope is not only a list of what a PMHNP may do but a set of limits that must be applied in real time, often while a young person is waiting for an answer. The PMHNP could legally offer therapy, safety planning and confidentiality within limits, and could not legally start medication. Working inside that boundary, rather than around it, still produced a meaningful plan: treatment began the same day, risk was assessed and documented, and a path to fuller treatment was left open for the patient to take. The role analysis made these decisions possible to reach quickly and to explain clearly.

References

American Psychiatric Nurses Association & International Society of Psychiatric-Mental Health Nurses. (2022). Psychiatric-mental health nursing: Scope and standards of practice (3rd ed.). American Nurses Association.

Peplau, H. E. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. Springer.

U.S. Food and Drug Administration. (2018). Suicidality in children and adolescents being treated with antidepressant medications. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications