w 9 Respond to 2 pple

2

Respond to charlen and  Luma

· Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders.

· Justify your suggestions with at least two references to the literature. 

2 references and 2 citations for Charlen

2 references and 2 citations for Luma

Charlen

Clinical Practice Guidelines for Bipolar Disorder

There are no current clinical practice guidelines that can sufficiently guide providers/physicians on the treatment of peripartum bipolar disorder (Sharma, & Sharma, 2017). There are however, clinical guidelines to assist with treating bipolar disorder. For a manic episode where the client is not already taking long-term medication, the British Association for Psychopharmacology found haloperidol, olanzapine, risperidone or quetiapine effective for short-term reduction of symptoms (Goodwin et al., 2016). They also mention valproate as an alternative treatment, but not in women who may become pregnant as it has teratogenic and reduced intellectual developmental risks associated with its use, but mentions aripiprazole, and other dopamine antagonists and partial agonist such as lithium and carbamazepine as other options (Goodwin et al., 2016). For an acute depressive episode in which the client isn’t already on a long-term treatment, the British Association for Psychopharmacology recommends lurasidone, quetiapine, or olanzapine, as dopamine antagonists have an advantage of being anti-manic treatments (Goodwin et al., 2016).

Risk Assessment

There are many factors to consider when trying to determine whether or not medication should be used to treat pregnant women who have bipolar disorder. Some things to consider would be the client’s personal preference, previous episodes of peripartum psychosis, comorbidities, the client’s social network, and previous response to medications or mood stabilizers (Psychiatry Advisor, 2018).

Treatment of Bipolar Disorder in Pregnant Women

One non-pharmacological intervention for treating people with bipolar disorder, pregnant or not, would be psychotherapy. According to a literature review done by Novick and Swartz (2019), different adjunctive evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT), family focused therapy (FFT), psychoeducation, and interpersonal and social rhythm therapy (IPSRT) can speed up the time to remission, prolong time of recurrence, and can improve outcomes. The British Association for Psychopharmacology suggests considering electroconvulsive therapy (ECT) in clients that are highly suicidal, treatment resistant, psychosis, or experiencing severe depression during pregnancy (Goodwin et al., 2016). One FDA approved drug that I might recommend for this client population would be quetiapine. According to Stahl (2013), in regards to prescribing medication in bipolar pregnant women, he believes it might be wise to treat them with an atypical antipsychotic during pregnancy. Discontinuing medication or choosing not to treat this disorder can cause the pregnant women to either become hypomanic/manic or in a depressive state which can ultimately affect the health of the baby. According to Babu, Desai, and Chandra (2015), there is more data of quetiapine use in pregnant women than the other atypical antipsychotics and in two recent studies, there was no evidence of any increased risk of malformations in babies that were exposed to olanzapine, risperidone, quetiapine, and clozapine. Things that should be monitored when taking quetiapine would be impaired glucose tolerance, maternal hyperglycemia, weight gain, and an increase in birth weight (Babu et al., 2015).

References

Babu, G. N., Desai, G., & Chandra, P. S. (2015). Antipsychotics in pregnancy and lactation. Indian Journal of Psychiatry, 57(2), 303–307. https://doi.org/10.4103/0019-5545.161497

Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T. R. H., Cipriani, A., Coghill, D. R., Fazel, S., Geddes, J. R., Grunze, J. R., Holmes, E. A., Howes, O., Hudson, S., Hunt, N., Jones, I., Macmillan, I. C., McAllister-Williams, H., Miklowitz, D. M., Morriss, R.,… Young, A. H. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British association for psychopharmacology. Journal of Psychopharmacology, 30(6), 495-553. DOI: 10.1177/0269881116636545

Novick, D. M., & Swartz, H. A. (2019). Evidence-based psychotherapies for bipolar disorder. https://doi.org/10.1176/appi.focus.20190004

Psychiatry Advisor. (2018). The risks and difficulties of managing bipolar disorder during pregnancy. https://www.psychiatryadvisor.com/home/bipolar-disorder-advisor/the-risks-and-difficulties-of-managing-bipolar-disorder-during-pregnancy/

Sharma, V., & Sharma, S. (2017). Peripartum management of bipolar disorder: What do the latest guidelines recommend? Expert Rev Neurother, 17(4), 335-344. doi: 10.1080/14737175.2017.1243470

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed). New York, NY: Cambridge University Press.

2 hours ago

Luma

Week 9 Discussion Main Post: Treating MDD in Pregnant Women

COLLAPSE

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Treating Depression During Pregnancy

Psychosocial stressors, psychological and physiological changes during pregnancy make pregnant women highly vulnerable to mental health disorders (Konstantinou et al., 2020; Liu et al., 2017). Mental health symptoms and existing treatments for these symptoms during pregnancy pose risks to maternal and fetal wellbeing, as well as childhood development (Sadock et al., 2015). Therefore, treatment of mental health disorders in pregnancy involves several decision-making challenges that involve careful consideration of risks, benefits, side effects, and potential adverse reactions of treatments to maternal, fetal, and child wellbeing after birth (Sadock et al., 2015). The purpose of this discussion post is to explore treatment options for managing depressive disorders during pregnancy and discuss clinical decision-making challenges that psychiatric mental health nurse practitioners (PMHNPs) consider when treating depressive symptoms during pregnancy.

Treatment Considerations

Depressive symptoms such as increased suicidality, insomnia, anhedonia, hopelessness, and helplessness compromise maternal and fetal welfare during pregnancy and contribute to unstable emotional states postpartum (Shen et al., 2017). However, existing treatment options pose the risk of low birth weight, pre-term birth, neonatal intensive care unit (NICU) admission postpartum, and adverse child development after birth (Molenaar et al., 2020; Shen et al., 2017). Treatment of major depressive disorder (MDD) symptoms during pregnancy involve careful consideration of risks, benefits, side effects, and potential adverse effects of treatment alternatives, including non-treatment to maternal, fetal, and child welfare (Molenaar et al., 2020). PMHNPs consider the duration and severity of depressive symptoms, safety, effectiveness, and potential risks of treatment options when managing MDD in pregnancy.  

Pharmaceutical Treatment Options

FDA Approved Treatments

There are no clear guidelines for the treatment of depressive symptoms during pregnancy (Stahl, 2013). The Food and Drug Administration (FDA) approves the use of some antidepressants to treat moderate to severe symptoms of depression during pregnancy to prevent worsening of depressive symptoms, poor self-care, self-harm, and the risk of substance abuse during pregnancy (Molenaar et al., 2020; Shen et al., 2017; Stahl, 2013). Selective serotonin reuptake inhibitors (SSRIs) are the most often used compared to first-generation tricyclic antidepressants due to higher validity and tolerability (Shen et al., 2017; Stahl, 2021).

Sertraline, the most prescribed SSRI worldwide, is commonly used to manage moderate to severe depressive symptoms during pregnancy (Shen et al., 2017; Stahl, 2021). Despite high treatment efficacy and tolerability, sertraline (and other SSRIs) cross the placenta and fetal blood-brain barrier posing significant risks to fetal health and wellbeing (Konstantinou et al., 2017). Sertraline use during pregnancy (especially during the first and third trimesters) increases the risk of cardiovascular defects, congenital malformations, and fetal anomalies (Shen et al., 2017).

Off-Label Treatment

Potential risks of congenital malformations during the first trimester and risks of prematurity, low birth weight, and possible neurodevelopmental abnormalities create hesitancy among pregnant mothers and clinicians around the use of antidepressants during pregnancy (Molenaar et al., 2020; Stahl, 2013). Off-label pharmacological options for managing depression during pregnancy include L-methyl folate, folate, and omega-3-fatty acids (Stahl, 2013; Liu et al., 2017).

Omega-3-fatty acids are nutritional compounds that the body cannot synthesize (Liu et al., 2017). Present-day evidence indicates low omega-3-fatty acid levels in MDD patients and a higher incidence of MDD in people with low concentrations of omega-3-fatty acids (Liu et al., 2017).  A meta-analytic study of the use of omega-3-fatty acids in managing acute MDD in pregnant women showed high treatment efficacy and safety due to the absence of maternal and fetal side effects (Liu et al., 2017). However, the scarcity of available evidence and the limited number of patients in which treatment of MDD during pregnancy using omega-3-fatty acid monotherapy has been investigated calls for more research studies and consideration of other treatment options.

Non-Pharmacological Treatment Options

The low acceptability of pharmaceutical treatments during pregnancy due to potential fetal and maternal risks warrants the need for clinicians to explore non-pharmaceutical treatment options for MDD during pregnancy (Konstantinou, 2020). Psychotherapy is recommended for mild cases of depression during pregnancy to minimize the risk of maternal and fetal exposure to pharmaceutic agents (Stahl, 2013). Other non-pharmacological treatments such as non-invasive neurostimulation strategies should be considered in cases of moderate to severe depression when psychotherapy alone is not potentially effective (Stahl, 2013). The advantage of neurostimulation strategies includes rapid treatment of depression without systemic medication exposure to the fetus, increased efficacy in managing treatment-resistant depression, and greater acceptability to pregnant women who prefer non-pharmacologic treatment options due to fears regarding fetal safety (Konstantinou et al., 2020). Potential shortcomings of using neurostimulation strategies include the risk of fetal exposure to anesthetics, muscle relaxants & risk of maternal seizures (Konstantinou et al., 2020). Maternal risks from neurostimulation treatments include the risk of exposure to accidental seizures, maternal discomfort, headaches, and scalp pain during pregnancy (Konstantinou et al., 2020).

Implications to PMHNP Role

Managing depressive symptoms during pregnancy poses clinical decision-making challenges for PMHNPs and other clinicians. PMHNPs should consider the clinical presentation of depression during pregnancy on a case-by-case basis and carefully consider the risks and benefits of treatment and non-treatment options to maternal and fetal wellbeing during and after pregnancy (Stahl, 2013). Additional treatment considerations for PMHNPs include symptom severity and duration (Konstantinou et al., 2020; Molenaar et al., 2020).

It is vital for PMHNPs to discuss treatment options, risks, benefits, side effects, and potential adverse reactions, including the possibility of non-treatment to facilitate informed decision-making and promote patient autonomy. When treating depressive symptoms during pregnancy, risk management analysis should consider legal and ethical obligations of PMHNP practice and maternal and fetal wellbeing during pregnancy, postpartum, and during childhood years (Kostantinou et al., 2020; Liu et al., 2017). Treatment of depressive symptoms in pregnant women involves challenging clinical decision-making and requires consistent collaboration between the patient and interdisciplinary treatment team members to ensure safe and effective outcomes of maternal and fetal outcomes.

 

References

Konstantinou, G. N., Vigod, S. N., Mehta, S., Daskalakis, Z. J., & Blumberger, D. M. (2020). “A systematic review of non-invasive neurostimulation for the treatment of depression during pregnancy.” Journal of Affective Disorders, 272, 259–268. doi:10.1016/j.jad.2020.03.151

Liu Wei-Hong, Zhang Cheng-Gui, Gao Peng-Fei, Liu Heng, & Yang Jian-Fang. (2017). Omega-3 Fatty acids as Monotherapy in Treating Depression in Pregnant Women: a Meta- Analysis of Randomized Controlled Trials. Iranian Journal of Pharmaceutical Research, 16(4), 1593–1599.

Molenaar, N. M., Bais, B., Lambregtse-van den Berg, M. P., Mulder, C. L., Howell, E. A., Fox, N. S., Rommel, A.-S., Bergink, V., & Kamperman, A. M. (2020). The international prevalence of antidepressant use before, during, and after pregnancy: A systematic review and meta-analysis of timing, type of prescriptions and geographical variability. Journal of Affective Disorders, 264, 82–89. doi:10.1016/j.jad.2019.12.014

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry (11th ed.). Wolters Kluwer.

Shen, Z., Gao, S., Li, S. X., Zhang, T., Liu, C., Lv, H., Zhang, Y., Gong, T., Xu, X., Ji, C., Wu, Q., & Li, D. (2017). Sertraline use in the first trimester and risk of congenital anomalies: a systemic review and meta-analysis of cohort studies. British Journal of Clinical Pharmacology, 83(4), 909–922.

Stahl, S. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4 th ed.). Cambridge University Press: Cambridge, MA

Stahl, S. (2021). Prescriber's guide: Stahl's essential psychopharmacology (7th ed.). Cambridge University Press: Cambridge, MA.

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