CASE STUDY 3

The Importance of Physical and Mental Health in Preparing for Pregnancy

Breeze, a 34-year-old female diagnosed with Bipolar Affective Disorder (BAD), presents with the desire to start a family. She has Type-2 diabetes, is currently overweight, smokes, and has a moderate alcohol intake. She has a history of depression in which she has been hospitalised. Breeze has been prescribed carbamazepine to manage her BAD, insulin to manage her diabetes, and currently has an Implanon for birth control. Breeze's previous prescription of lithium and fluoxetine has caused weight gain, which subsequently has resulted in her diagnosis of Type-2 diabetes. It is well documented that the long-term use of antipsychotic drugs, antidepressants, and mood stabilisers can increase weight gain (Shi et al., 2017). Studies have also reported that obesity or being overweight is one of the main causes of Type-2 diabetes, with poor diet and insufficient physical activity (Rudland et al., 2020). The complex relationships between mental health, treatment for mental health, and physical health are highlighted in this case.

Critical Health Issues

There are several critical health issues that Breeze will need to consider during perinatal care. One of the main risks is managing her BAD. Continuation of carbamazepine medication during her pregnancy has been reported to significantly increase the rate of congenital anomalies, increase the risks of fetal abnormalities and neural tube defects (Boyce & Buist, 2016). However, if Breeze stops taking her medication during pregnancy, she will have an increased risk of episodes of depression or mania (Boyce & Buist, 2016). Research also suggests that women with BAD are at an increased risk of relapse following childbirth, where risks are further increased when unmedicated (Boyce & Buist, 2016).

Of significant risk is the management of Type-2 diabetes and pregnancy. Adverse pregnancy outcomes are primarily associated with glycaemia levels in women with Type-2 diabetes (Rudland et al., 2020). It is advised that optimal glycemic levels should be achieved and maintained prior to conception to reduce the risk of congenital anomalies (Rudland et al., 2020). Breeze is currently classified as "overweight," with a BMI of 25.86. Being overweight increases maternal and fetal morbidity and malformations and can increase hypertension disorders, increase the risk of caesarean delivery, miscarriage, and postoperative complications (Rudland et al., 2020).

Other health concerns include smoking and alcohol intake. Smoking poses a significant threat to the development of the unborn child. The toxins in tobacco may increase the risk of miscarriage, congenital disabilities, and sudden infant death (Oskarsdottir et al., 2017).

Assessment and Intervention Plan

Breeze's care plan will reflect the interrelationship of her physical health. It will address the modifiable risk factors to improve the outcomes for mother and child. Family and social support are of great importance. Research suggests that partners and family play a pivotal role in support for women during the perinatal period, where greater support is associated with lower rates of postnatal depression in first-time mothers (Lever Taylor et al., 2019).

Due to Breeze's critical health issues, a multidisciplinary team specialising in the care of women with diabetes and mental health disorders is required (Boyce & Buist, 2016; Rudland et al., 2020). It may include her local GP, Obstetrician, Psychiatrist, Endocrinologist, and the support of her partner. Breeze requires pre-pregnancy planning and counselling to ensure that she and her partner are fully educated about the potential risks associated with pre-existing diabetes and mental health in pregnancy (Sharma et al., 2020). A collaborative decision-making process with Breeze and her partner will discuss the potential risks and benefits of treatment, provide advice about the risk of relapse during pregnancy, and discuss the potential risks and benefits of pharmacological treatment and the risks associated with stopping her medication during pregnancy.

Her care plan will be a stepped process that focuses on her physical health:

· Psychological assessment

· Pharmacotherapy review

· Advice for smoking/alcohol cessation

· Lifestyle changes, including modifications to diet and exercise

Goals include:

· Diet and nutrition

· Exercise Program

· Psychological review

· Glucose monitoring to achieve optimal glycaemia before conception

· Pre-pregnancy goal weight

The importance of adapting lifestyle changes to improve physical health is essential if considering pregnancy. The quality of nutritious food consumed by mothers during pregnancy can have a lasting impact on the child's health and wellbeing at birth and later in life (Langley-Evans, 2015). Nutritional deficits in pregnancy are associated with an increased risk of cardiovascular disease, metabolic syndrome, and Type-2 diabetes (Langley-Evans, 2015).

During the perinatal period, women who have previously experienced mental health disorders are at an increased risk of vulnerability and are more likely to become ill. The risks for developing antenatal depression or postnatal depression are also increased (Sharma et al., 2020). The focus of Breeze's care plan is to ensure she at optimal physical and mental health before becoming pregnant.

Planned Referrals

Clinical recommendations suggest pre-conception counselling as an integral part of managing BAD during and after pregnancy (Sharma et al., 2020). A referral to an Obstetrician is provided. An Obstetrician will provide Breeze and her partner with critical education and advice on pre-conception considerations, including optimal health, nutrition, exercise, smoking, and alcohol intake. A referral will also be made to an Endocrinologist to advise and manage Breeze's Type-2 diabetes and glycemic levels prior to pregnancy.

With her current BAD diagnosis, Breeze will be referred to a Psychiatrist to discuss her treatment options. This involves educating Breeze on the risks of taking carbamazepine in pregnancy, her choices, and options to consider if she was to discontinue her medication on conception.

A referral will be made to One Door Mental Health, providing exercise physiology, dietician, and health and wellbeing services (One Door Mental Health, n.d.). Studies have shown the positive effects that exercise can have for depressive symptoms and mood, improving aerobic capacity and muscle strength leading to improved physical wellbeing (Pedersen & Saltin, 2015). Physical activity can also reduce fat mass and induce weight loss if combined with a decreased calorie intake (Pedersen & Saltin, 2015). There are many benefits of physical exercise for Type-2 diabetes, said to significantly improve metabolic control where a combination of aerobic training and resistance training is optimal (Pedersen & Saltin, 2015).

Community Resources

The Frankston Bipolar Support Group runs a monthly meeting at the local community centre. The purpose of the group is to connect with other people who have been diagnosed with BAD. The group provides peer support to share knowledge, information, and coping methods (Bipolar Australia, 2019).

Narrative Description of Outcomes

This plan is focused on achieving optimal physical health for Breeze before conception. It considers the critical health issues that are associated with BAD, Type-2 diabetes, and being overweight. Planning for pregnancy with the high risks associated with Breeze's diagnosis is pivotal to management and positive outcomes for mother and child. There are no timelines to achieving these goals, as success will be defined when Breeze reaches optimal and maintained glycemic levels, healthy pre-pregnancy weight, good nutrition, good mental health, reduced or cessation of smoking and alcohol. Breeze is encouraged to participate in at least 30 minutes of physical activity daily, ideally combining aerobic and resistance training. This is a long-term goal, and it may take some time to increase physical capacity. It is anticipated that the desire to have a healthy child will provide the necessary motivation for Breeze and her partner to make the necessary lifestyle changes required for optimal physical and mental health.

The Physical and Mental Impacts of Lifestyle for Depression

Dion, a 55-year-old male currently suffering from depression, presents with multiple health issues. Dion acquired a lower back injury at work as a concrete worker, which subsequently has confined him to office work and impacted his ability to participate in physical activity. Dion has been prescribed antidepressants to manage his depression. He is a heavy drinker and smoker and was recently forced to close and sell his business due to a construction downturn. His wife has recently left him.

Critical Health Issues

Dion has several critical health issues that are predominantly associated with poor physical health and his addictive behaviours, smoking, and alcohol intake. Critically, Dion shows symptoms of Metabolic Syndrome with reported high triglyceride levels, hypertension, and lack of physical activity, increasing risks for cardiovascular disease, diabetes, and stroke. (Mottillo et al., 2010). Hypertension, or high blood pressure, can also be linked to excessive alcohol intake, however in Dion's case, a combination of alcohol abuse, smoking, lack of physical exercise, and stress (Gao et al., 2017; McClintock & Bogner, 2017). Dion's elevated liver function test indicates the onset of alcoholic liver disease. Further to this, smoking significantly increases the risks for liver disease compared with non-smokers (Aberg et al., 2018).

Additionally, after acquiring a lower back injury from work and the social impacts of Dion losing his business, Dion was diagnosed with depression and currently takes Zoloft, an antidepressant medication. Research suggests when physical activity is restricted through injury, and movement is limited, psychological stress can occur. Workplace injuries can negatively impact a person's mental health due to the financial pressures of income changes (Gu et al., 2020).

Dion also presents with sexual dysfunction. Research suggests that sexual dysfunction can be a common side effect of antidepressant medications, particularly selective serotonin reuptake inhibitors (Thakurdesai & Sawant, 2018). However, physical health, drug and alcohol consumption, relationship issues, and poor self-esteem are also significant contributors to sexual dysfunction and performance (Thakurdesai & Sawant, 2018).

Other critical health concerns include heavy smoking and drinking, where his GP has advised Dion that he needs to stop smoking immediately. He currently smokes up to twenty cigarettes a day, coupled with heavy consumption of alcohol and poor diet. He is now living on his own with no support.

Assessment and Intervention Plan

The care plan for Dion will be a biopsychosocial approach. Treatment will be a combination of pharmacotherapy, psychotherapy, social support, and lifestyle changes. Cognitive Behavioural Therapy (CBT) is the most researched and recognised treatment for depression. For a large percentage of patients, a combination of antidepressants and CBT is most effective (Malhi et al., 2021). The priority in Dion's care plan is to address the perpetuating factors that are affecting his physical and mental health, cessation of smoking, and alcohol. Excessive intake of nicotine and alcohol contributes to Dion's hypertension increasing cardiovascular risks such as heart attack, heart failure, and stroke (Gao et al., 2017). Research suggests that cigarette smoking is also one of the leading preventable causes of hypertension (Gao et al., 2017).

Dion's injury has increased his risk of physical inactivity, which increases depressive symptoms. Exercise has been proven as an effective treatment for depression, and Dion's plan will include an exercise physiologist (Malhi et al., 2021). To address Dion's alcohol problem, he will be provided with a comprehensive clinical assessment that will ascertain alcohol consumption patterns, family factors, relationships, occupational and psychological problems that may be contributing to his addiction. There will be a review of Dion's antidepressant medication due to the side effects. A common side effect of SSRIs is fatigue and sedation; however, alcohol can enhance these effects (Malhi et al., 2021). The benefits of sleep are currently linked to positive outcomes for mood disorders (Malhi et al., 2021). The GP provides Dion with education on the importance of getting adequate sleep and ensuring he has good sleep hygiene.

Dion's care plan will be a stepped care approach that involves:

· Advice for smoking/alcohol cessation

· Lifestyle changes, including modifications to diet and exercise

· Psychological intervention

· Pharmacotherapy review

· Review sexual dysfunction

Goals include:

· Smoking cessation

· Alcohol cessation

· Exercise program specific to Dion's injury

· Diet and nutrition

· Addressing psychosocial factors contributing to depression

· Connection with family, community support

Planned Referrals

A referral will be made to a psychologist for CBT. CBT will support his treatment for depression and cessation of smoking and alcohol. Many studies support the efficacy of CBT in the treatment and management of addictive behaviours (Sudhir, 2018). Dion has agreed to attempt nicotine replacement therapy to assist in quitting smoking. Nicotine replacement therapy is said to be effective when used in conjunction with behavioural interventions (Peckham et al., 2017).

Nutrition can play a crucial role in the severity of depression, where people suffering from mental disorders are notably deficient in a diet consisting of nutritional content, including essential vitamins and minerals and omega-3 fatty acids (Malhi et al., 2021). There has been increasing evidence supporting the Mediterranean Diet, high in vegetables, fruit, fish, grains, and low in animal fat (Malhi et al., 2021).

A referral will be made to One Door Mental Health, providing exercise physiology, dietician, and health and wellbeing services (One Door Mental Health, n.d.). Regular physical activity is reported to positively affect depressive symptoms and mood (Pedersen & Saltin, 2015). One Door Mental Health delivers programs specifically designed for those suffering or living with mental illness, focusing on diet, nutrition, and physical exercise tailored to each individual (One Door Mental Health, n.d.).

Community Resources

That's the Thing About Fishing is a non-for-profit organisation designed to support people who have a disability and mental illness. It encourages social interaction and uses fishing as a therapeutic intervention. Dion may rediscover his passion for fishing and act as a distraction to keep him busy while trying to quit smoking and alcohol (That's the Thing About Fishing, 2017).

Narrative Description of Outcomes

This plan focuses on addressing the significant lifestyle changes required to impact Dion's physical and mental health. It aims to build resilience to enable Dion to adapt to life challenges and improve his overall wellbeing. It will be a stepped process where the benefits of smoking and alcohol cessation, diet, and exercise, sleep, combined with psychological intervention, should positively affect Dion. CBT treatment will occur weekly, over an eight to twenty-week period, depending on treatment response. A view for stopping antidepressant medication once Dion has been in remission for approximately nine months to a year will gradually be withdrawn over an extended period (Malhi et al., 2021). It is anticipated that Dion is motivated to implement the necessary lifestyle changes as he does not want to lose his wife, whom he has been together with for over 20 years.

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