NRNP 6675 Week 9 Discussion: Prescribing for Older Adults and Pregnant Women

Prescribing for Older Adults and Pregnant Women

After assessing and diagnosing a patient, PMHNPs must take into consideration special characteristics of the patient before determining an appropriate course of treatment. For pharmacological treatments that are not FDA-approved for a particular use or population, off-label use may be considered when the potential benefits could outweigh the risks.

In this Discussion, you will investigate a specific disorder and determine potential appropriate treatments for when it occurs in an older adult or pregnant woman.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare:

Choose one of the two following specific populations: either pregnant women or older adults. Then, select a specific disorder from the DSM-5-TR to use.

Use the Walden Library to research evidence-based treatments for your selected disorder in your selected population (either older adults or pregnant women). You will need to recommend one FDA-approved drug, one non-FDA-approved “off-label” drug, and one nonpharmacological intervention for treating the disorder in that population.

By Day 3 of Week 9

Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your chosen disorder in older adults or pregnant women.

Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?

Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.

Support your reasoning with at least three current, credible scholarly resources, one each on the FDA-approved drug, the off-label, and a nonpharmacological intervention for the disorder.

Read a selection of your colleagues’ responses.

By Day 6 of Week 9

Respond to at least two of your colleagues on 2 different days who selected different disorders. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply , you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply !

This topic is closed for comments.

SO

Safurat Olaniba-Adebisi

Jan 29, 2023 10:56pm

Reply from Safurat Olaniba-Adebisi

Discussion week 9

Response 2

Thank you for your post. Your post is very interesting and highly educative.

According to Jahan et al., 2021, class C drugs are safe for use in treating pregnant women safe to use while expecting or nursing a baby. Therefore, Bupropion (Wellbutrin) and Duloxetine (Cymbalta) are an appropriate drug of choice for the pregnant woman. Nonpharmacological treatment is psychotherapy-CBT.

References

Jahan, N., Went, T. R., Sultan, W., Sapkota, A., Khurshid, H., Qureshi, I. A., & Alfonso, M. (2021). Untreated depression during pregnancy and its effect on pregnancy outcomes: A Systematic Review.

SO

Safurat Olaniba-Adebisi

Jan 28, 2023 10:32pm

Reply from Safurat Olaniba-Adebisi

Discussion week # 9

Depression in an elderly patient.

The DSM criteria for Depression in the elderly. We must have five or more symptoms present for at least two weeks and at least either one of 1- depressed mood 11 loss of interest/ pleasure need to be present.

The five symptoms are Fatigue or loss of interest, insomnia/ hypersomnia, thought of death, or SI.

FDA-APPROVED ANTIDEPRESSANTS FOR THE ELDERLY

Sertraline is FDA-approved drug, and a safe medication for the elderly due to its tolerability rate, it can be used alone or as an adjunct with another medication possibly SSRI’s .In the journal analysis, it was noted that Sertraline has efficacy and tolerability for different kinds of depression as in other medications, Sertraline has some side effects, such as EPS, dystonia, parkinsonism, and dyskinesia. Therefore, patient education is necessary for better outcomes.

The off-label drug for depression in an elderly is Seroquel, “Quetiapine is an atypical antipsychotic approved for treating schizophrenia, bipolar depression, and mania but is frequently used in an off-label manner to control the behavioral and psychological symptoms of dementia in elderly patients with dementia.”(Ganzetti et al., 2021).

Thanks

Safurat

Kately Anne Sylvia

Jan 28, 2023 4:14pm

Reply from Kately Anne Sylvia

Week 9: Special Considerations Related to a Vulnerable Population

Kately Anne Sylvia

College of Nursing- PMHNP, Walden University

NRNP 6665: PMHNP Across the Lifespan II

Dr. Madeleine Reyes

January 29, 2023

Week 9: Special Considerations Related to a Vulnerable Population

Introduction

This purpose of this discussion is to address special considerations related to a vulnerable population; this population is older adults with major depressive disorder (MDD). The discussion will include the following: one, a recommendation for a Federal Drug Administration (FDA) approved drug, an off-label drug and a non-pharmacological intervention for treating older adults with MDD. Two, a risk assessment will be identified to help to inform the treatment decision making, and the risks and benefits of the FDA-approved medication and the off-label medication will be addressed. Last, the clinical practice guidelines of MDD for the older population will be discussed.

FDA-Approved Drug, Off-Label Drug and a Non-Pharmacological Intervention

Later-life depression occurs in older adults who are 60 years or older (Sozeri-Varma, 2012 as cited in Robertson et al., 2019). Also, depression often goes undetected or is inadequately treated in older adults (Kok & Reynolds, 2017). Antidepressants are usually the first line approach to treatment for MDD. However, an off-label medication and a non-pharmacological intervention may significantly help the patient with their symptoms of depression. A FDA-approved medication therapy for older patients with MDD that will be chosen is one of the selective serotonin reuptake inhibitors (SSRI) called fluoxetine. An off-label drug that will be selected for MDD in older adults is modafinal. Last, a non-pharmacological intervention chosen for this population is interpersonal psychotherapy (IPT). IPT focuses on stressful life events “that are associated with the onset, exacerbation, or perpetuation of current symptoms, while helping patients to connect with social supports and to improve the quality of their relationships (Ravitz & Watson, 2014; Weissman et al., 2007, as cited in Cuijpers et al., 2016).

A Risk-Assessment & the Risks and Benefits of the FDA-Approved and Off-Label Drug

A risk assessment I would use to inform my treatment decision making is the Beers Criteria (BC). BC is a tool that evaluates drugs for “potentially inappropriate medication (PIM) in older adults” (Khamis et al., 2019). PIM is the benefits of the medication must outweigh a drug’s potential for adverse effects; the BC goal is to decrease the PIM to improve the quality and safety of care to older adults (Khamis et al., 2019).

The benefits of SSRIs is they have a better safety profile than other classes of antidepressants “including fewer antimuscarinic and cardiotoxic side effects, rarely fatal in overdose, less dosage titration, once daily administration and greater patient adherence (Mottram et al., 2006; National Institute for Health and Care Excellence [NICE], 2009; Taylor et al., 2018, as cited in Robertson et al., 2019). Some of the more serious risks associated with SSRIs in older adults with co-morbidities are some of the following: first, SSRIs increase the risk of gastrointestinal bleeding, history of bleeding or using such drugs as non-steroidal anti-inflammatory drug (NSAID) or warfarin (Anglin et al., 2014; Jiang et al., 2015; NICE, 2009; Taylor et al., 2018, as cited in Robertson et al., 2019).

According to Kaser (2018), cognitive problems are persistent in depression such as memory, concentration and decision making problems, and cognitive problems do not respond to anti-depressant medications. The off-label drug, modafinal, has been found to have beneficial effects in cognitive functioning (Kaser, 2018). In a study by Kaser (2018), it “showed feasibility of modafinal use to address decision-making problems in depression,” and showed “decision-making cognition can lead to better outcomes in depression.” Side effects that are more common and do not need medical attention are anxiety, nausea, nervousness and headache (Mayo Clinic, 2023). Some side effects that are less common, but most likely will need immediate medical care are the following: black stool, blurred vision, chest pain, clumsiness, confusion, problems with memory, shortness of breath, shaking, troubling voiding, unusual bleeding, and unusual weakness (Mayo Clinic, 2023).

Clinical Practice Guidelines

The clinical practice guidelines from the American Psychological Association (APA) Guideline Development Panel recommend for the initial treatment of MDD for older adults is the following: “1. Either group life review treatment or Group Cognitive Behavioral Therapy (either alone or added to usual care) over no treatment.” or “2. Combined pharmacotherapy and IPT over IPT alone” (APA, 2019, p 13). For the pharmacotherapy, the panel recommends a second-generation antidepressant because of decreased potential for side effects. The strength of recommendation for use of this initial therapy for MDD in older adults is that APA recommends it for use (2019, p. 14). APA has other therapies, but the strength of the recommendations are “conditional recommendation for use,” and “Insufficient evidence for a recommendation” (APA, 2019, p. 14). Furthermore, for the prevention of recurrence of MDD in older adults APA recommends either the following: “combination interpersonal psychotherapy and pharmacotherapy” or “combination supportive care and pharmacotherapy” (APA, 2019, p. 17). The strength of the recommendation for the prevention of recurrence of MDD in older adults is that APA recommends this for use (2019, p. 17).

Conclusion

Vulnerable populations such as older adults have unique mental health needs compared to younger and middle aged adults. Psychiatric Mental Health Nurse Practitioners (PMHNP) need to be aware of all the drug-to-drug interactions associated with poly-pharmacy because of the co-morbidities the older adult patient’s have that may cause potential harm. Moreover, it is recommended for older adults with MDD to take SSRIs because they have a better safety profile, and to start interpersonal psychotherapy (IPT), which is recommended by APA. An off-label drug such as modafinal can be tried because of its’ positive effects on cognitive functioning in older adults, and a non-pharmacological intervention such as IPT should be started because it helps patients connect with social supports and to improve the quality of their relationships. Furthermore, it is important for PMHNPs to know if the benefits outweigh the risks when taking antidepressants for MDD. Beers Criteria (BC) is a risk assessment that is to decrease the potentially inappropriate medication (PIM) to improve the quality and safety of care to older adults. Last, clinical practice guidelines should be used to verify if the best treatment is initiated and maintained for older adults with MDD to ensure best patient outcomes.

Reference s

American Psychological Association. (2019). APA clinical practice guideline for the treatment of depression across three age cohorts . chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.apa.org/depression-guideline/guideline.pdf

Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. The American Journal of Psychiatry, 173 (7). doi.org/10.1176/appi.ajp.2015.15091141

Khamis, S., Abdi, A. M., Uzan, A., & Basgut, B. (2019). Applying Beers criteria for elderly patients to assess rational drug use at a university hospital in Northern Cyprus. J Pharm Bioallied Sci, 11 (2). doi: 10.4103/jpbs.JPBS_208_18

Kok, R. M., & Reynolds, C. F. (2017). Management of depression in older adults: A review. JAMA, 317 (20). doi:10.1001/jama.2017.5706

Mayo Clinic. (2023). Modafinal (oral route). https://www.mayoclinic.org/drugs-supplements/modafinil-oral-route/side-effects/drg-20064870?p=1

Robertson, L., Bertolini, F., Meader, N., Davies, S. J. C., Barbui. C., Gilbody, S., & Churchill, R. (2019). Antidepressants for major depression disorder in older people: A network meta‐analysis. Cochrane Database of Systematic Reviews, 9 . doi:10.1002/14651858.CD013394. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727180/

Kaser, M. (2018, November 8). Computational approach to reinforcement learning in patients with remitted depression: Results from a double-blinded, randomised, placebo-controlled study [Video]. The Academy of Medical Sciences. Youtube. https://www.youtube.com/watch?v=eerHwrg_6YM. Links to an external site. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.apa.org/depression-guideline/guideline.pdf

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Tina Baker

Jan 26, 2023 7:15pm

Reply from Tina Baker

WK9Assgn+Baker+T6675.docx

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Colette Affiah

Jan 26, 2023 5:35pm | Last reply Jan 27, 2023 12:36am

Reply from Colette Affiah

Initial Post-Colette Affiah

According to antidepressants, risk can be decreased and the medication more tolerable if the dose is started slowly and titrated slowly up to a tolerable level. Depression in the elderly, according to Robertson et al. (2019), affects the mood and causes anhedonia are lack of pleasure in once-enjoyed activities. Depression also causes low appetite and feeling worthless or hopeless. Pt. also has sleep disturbance, and some patients have an increased rate of suicidality. The elderly, considered adults aged 60 and above, have what is considered later-age depression. As noted by Robertson et al., depression affects 7.5% of women and 5.5% of men aged 55 to 74. The elderly population is prone to taking at least four or more medications for other health issues so drug to drug or drug to disease, as noted by Robertson et al. (2019), so careful dosing becomes a priority in the dosing and treatment plan for the elderly living with Major Depression disorder. According to Robertson et al., antidepressants should be prescribed to the elderly with consideration to their age, physical health, and drug-drug interactions. Depression, as postulated by Robertson et al., is because by the decrease of the monoamines, which include serotonin, norepinephrine, and dopamine, the key brain mood regulators. By taking serotonin, the activities of serotonin become enhanced, allowing for mood regulation for elderly patients.

FDA-APPROVED ANTIDEPRESSANTS FOR THE ELDERLY

Sertraline, an FDA-approved medication, is a Selected Serotonin reuptake Inhibitor and is recognized for treating Major Depression Disorder. According to Lenze & Ajam (2019), in the systematic review and the meta-analysis of comparative studies of antidepressants in older adults, the key finding was that SNRIs but not SSRIs were associated with adverse events versus placebo during acute treatment. Sertraline also has its risk and benefits in the treatment of MDD. Lenze & Ajam (2019) noted that Sertraline is safe for the elderly with a good tolerability rate, adding that it is significantly used in patients aged 65 and over and sometimes in combination with other central nervous system-active agents. The studies by Alexopoulos (2011) noted that the sertraline efficacious rate was higher than that of the placebo effect. Though Alexpoulos (2011) noted that for all types of depression, Sertraline was rated highest for efficacy and tolerability, the new studies have differed in the results, which may be partly due to the low doses of Sertraline prescribed to ensure tolerability and low incidence of side effects. Even with the efficacy of Sertraline also comes with some side effects, including extrapyramidal symptoms like dystonia, parkinsonism, and dyskinesia. As such, there must be followed up scheduled to monitor for the presence of these symptoms. As speculated by Edinoff et al. (2021), the most concerning adverse reaction are the side effect of hyponatremia, which is common in the elderly. According to Edinoff et al. (2021), serotonin may increase the antidiuretic hormone, thereby causing the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

OFF-LABEL MEDICATION FOR DEPRESSION

Seroquel is an off-label to treat depression, and studies show that using this medicine in low doses has good tolerability and efficacy in patients with depression. Seroquel, an antipsychotic according to Rowe (2007), can improve low mood, which is a significant problem with depression. As noted by Muller et al. (2020), Quetiapine, an antipsychotic drug used for schizophrenia and bipolar disorder, is usually prescribed to the elderly with an indication of depression. The side effect of this medication is that even in very low doses, it can cause serious adverse drug events of hip fractures, orthostatic hypotension, and pneumonia. Muller et al. (2020), in the study of Seroquel in nursing homes of Southern Switzerland, also stated that this medication is used in the presence of dementia, a common problem among the elderly, and is linked with increased risk for mortality. Mueller et al. (2020) also stated that the anonymous data collected during September and November 2016 in 15 nursing homes from either electronic or paper documentation. Out of the total of 1173 patients analyzed, Muller et al. Stressed that 379 patients were prescribed Seroquel. As noted by Muller et al. (2020), the side effects of Seroquel consist of impaired cognitive and functional capabilities. The Clinician is therefore faced with the challenges of ensuring that the elderly safety and tolerance level are maintained while treating the psychological condition of Major Depression Disorder.

According to Park et al.(2014), in the study of the evidenced-based, non-pharmacological treatment guideline for depression in Korea, Cognitive behavioral therapy was stated can be effective for the treatment of depression in mild to moderate depression. Park et al. (2014) state that the non-pharmacological considered by the clinical psychiatrist could provide a good adjunct to the pharmacological approach to producing successful stories of improvement in depressed patients. As clinicians, the success of treating depressed patients is to encourage the patient’s involvement in cognitive behavioral therapy. According to the World Health Organization (WHO), between 2015 and 2050, Gramaglia et al. (2021) noted that the estimated number of older adults that would be diagnosed with MDD is almost estimated to double to 22%. Moreover, Gramaglia et al. (2021) postulated that cognitive behavioral therapy effectively treats MDD in the elderly.

References

Alexopoulos GS. Pharmacotherapy for late-life depression. J Clin Psychiatry. 2011 Jan;72(1):e04. doi: 10.4088/JCP.7085tx2cj. PMID: 21272511; PMCID: PMC3314291.

Edinoff AN, Akuly HA, Hanna TA, Ochoa CO, Patti SJ, Ghaffar YA, Kaye AD, Viswanath O, Urits I, Boyer AG, Cornett EM, Kaye AM. Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review. Neurol Int. 2021 Aug 5;13(3):387-401. doi: 10.3390/neurolint13030038. PMID: 34449705; PMCID: PMC8395812.

Lenze EJ, Ajam Oughli H. Antidepressant Treatment for Late-Life Depression: Considering Risks and Benefits. J Am Geriatr Soc. 2019 Aug;67(8):1555-1556. doi: 10.1111/jgs.15964. Epub 2019 May 29. PMID: 31140584; PMCID: PMC6684410.

Müller L, Noseda R, Bertoli R, Bissig M, Ceschi A. Off-label use of quetiapine in nursing homes: Does medical specialty of prescribing physicians play a role? Br J Clin Pharmacol. 2020 Jul;86(7):1444-1445. doi: 10.1111/bcp.14232. Epub 2020 Feb 25. PMID: 32100324; PMCID: PMC7318997.

Robertson L, Bertolini F, Meader N, Davies SJC, Barbui C, Gilbody S, Churchill R. Antidepressants for major depression disorder in older people: a network meta‐analysis. Cochrane Database Syst Rev. 2019 Sep 5;2019(9):CD013394. doi: 10.1002/14651858.CD013394. PMCID: PMC6727180. NRNP-6675 Week 9: Discussion – Prescribing for Older Adults and Pregnant WomenNRNP-6675 Week 9: Discussion – Prescribing for Older Adults and Pregnant Womenand discussion thread from Colette Affiah

NJ

Neethu John

Jan 25, 2023 11:05pm | Last reply Jan 26, 2023 2:15pm

Reply from Neethu John

Anxiety disorders are prevalent in pregnant women with equal or higher incidence and are often underdiagnosed (Lemon, Vanderkruik, Arch, & Dimidjian, 2020). The first line treatment for generalized anxiety disorder amony pregnant women is cognitive behavioral therapy which has good results, but patients who still need medications should take caution but has to consult the provider for options for medications. Survey shows majority of women that have taken antidepressants stop at the time of pregnancy and the abrupt discontinuation of SSRI’s can harm in many ways and the discontinuation must be discussed with the provider (Lemon, Vanderkruik, Arch, & Dimidjian, 2020). Escitalopram is an SSRI that is approved for use in pregnancy if the benefit outweighs the risks (FDA, 2017). A study conducted with seven full term pregnant women with escitalopram did not show any major fetal harm and had normal Apgar scores upon delivery. Infants who were exposed to escitalopram also did not show any major health problems as well (Bellantuono, Bozzi & Orsolini, 2013). There are drugs that has not been approved by the FDA but is still the first line treatment for some conditions. The drugs that have not been FDA approved does not have enough research and studies behind it. Off the label drugs can be as effective as FDA approved drugs. Since FDA approved drugs are based on vast research, it is considered to be a safer option with the back up of studies. When off the label drugs are used, it is like they are not studied properly and thus considered with more impact (Wittich, Burkle, &Lanier, 2012).

Reference

Bellantuono, C., Bozzi, F., & Orsolini, L. (2013). Safety of escitalopram in pregnancy: A case series. Neuropsychiatric disease and treatment. Retrieved, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3772871/

FDA. (2017). Lexapro (escitalopram oxalate).

Lemon, E., Vanderkruik, R., Arch, J. J., & Dimidjian, S. A. (2020). Treating anxiety during pregnancy: Patient concerns about pharmaceutical treatment. Maternal and Child Health Journal, 24(4), 439–446. https://doi.org/10.1007/s10995-019-02873-7

Wittich, C. M., Burkle, C. M., & Lanier, W. L. (2012, October). Ten common questions (and their answers) about off-label drug use. Mayo Clinic proceedings. Retrieved, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538391/

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Solange Ndah Missibi

Jan 25, 2023 11:01pm | Last reply Jan 27, 2023 4:05pm

Reply from Solange Ndah Missibi

WK 9 Discussion

Selected Disorder: Major Depressive Disorder (MDD) in Pregnant Women

Major Depressive Disorder (MDD) is widespread in pregnant women and lactating mothers due to hormonal changes, physical limitations, social and economic impact, and stress. According to the American Congress of Obstetricians and Gynecologists (ACOG, 2021), about 14-23% of pregnant mothers nationwide are affected by depression annually, and often goes untreated and can result in high suicide tendencies, substance abuse, poor maternal medical health, fetal growth and birth weight, poor interpersonal relations as well as increase risk of premature birth (American Congress of Obstetricians and Gynecologists, 2021). The risk of injury to the fetus also increases during treatment with some antidepressants resulting in congenital disabilities and withdrawal symptoms in the newborn (Mayo Clinic, 2020).

When treating depression in pregnant women, the decision to prescribe or treat is strictly case-by-case basis based on the patient’s symptoms and severity, as there are currently no FDA-approved antidepressant drugs totally safe for use in this population (Gorun, 2018). Antidepressant drugs may have neonatal consequences; however, untreated depression has been shown to have more maternal and fetal consequences (MGH, 2018). Therefore, the patient and clinician must decide whether to initiate or continue therapy for depression during pregnancy.

One selected drug of choice is Fluoxetine. Approximately 1.1 million pregnant women with depression in 2016 were treated with an antidepressant, with the most commonly prescribed being SSRIs such as Sertraline, Citalopram, Escitalopram, and Fluoxetine with the exception of Paroxetine (Centers for Disease Control and Prevention (CDC), 2017).

Risks and Benefits of Fluoxetine

Fluoxetine, like most antidepressants, falls into Category C, meaning not enough well-controlled studies in humans due to the risk in this group, but potential benefits may warrant the use of the drug in pregnant women despite potential risks (MGH, 2018). Fluoxetine has been linked with maternal weight changes, neonatal syndrome like jitteriness, irritability, respiratory problems, low Apgar score, hypoglycemia, convulsions, as well as premature birth and neonatal persistent pulmonary hypertension with increased risk seen in late gestational use (Mayo Clinic, 2020).

Risk Assessment

Risk assessments crucial in treatment decision-making and choice of medication in pregnancy should be patient-centered as it greatly depends on the presenting symptoms and severity, poor response to psychotherapy, and patient’s medical history (MGH, 2018). According to the CDC, pregnant women with severe depressive symptoms with suicidal ideations, functional difficulties, and weight loss ought to stay on their drug regime (CDC, 2017). Another risk assessment is the high potential for relapse, worsening symptoms, increased risk of suicidal ideation, and worsening maternal physical health after drug discontinuation. If the decision is made to start treatment, the clinician should titrate the drug beginning with the lowest dose possible with close maternal and fetal monitoring (MGH, 2018). Depression and suicide screening tools such as the PHQ-9 for the severity of depression symptoms and the Columbia Suicide Severity Rating Scale (C-SSRS) for screening for the risk of suicide is essential in treatment planning.

Non-Pharmacologic Treatment

One of the most common and evidence-based non-pharmacologic treatments for depression is light therapy and psychotherapy (Rodriquez, 2019). Cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) has been recommended as a first-line treatment for depression in pregnant women and most other population groups of patients, with extensive research backing its efficacy or effectiveness and the low associated risk involved. (Rodriquez, 2019). CBT helps change negative thought processes and behavioral patterns, as well as teaches effective stress-coping strategies (Rodriquez, 2019).

OFF-LABEL DRUG

According to the National Center for Complementary and Integrative (NCCIH), one “off-label” drug used in treating depression in pregnant women is S-Adenosyl-methionine (SAMe) dietary supplements naturally found in the body and shown to alleviate depression symptoms (Cuomo et al., 2020). However, most studies were not of the highest scientific because they were short and done over a few weeks (Cuomo et al., 2020).

One risk of taking SAMe is that despite its benefits, studies on the long-term safety of SAMe and its safety for use during pregnancy have not been established according to the NCCIH; hence pregnant patients must talk to their doctor before taking any supplement, including SAMe (Cuomo et al., 2020).

CLINICAL PRACTICE GUIDELINES AND RECOMMENDATIONS

Due to the risk associated with the treatment of depression in pregnant women, the decision to treat and drug choice depends on the patient’s symptoms and severity, relapse potential, drug safety, gestation stage, medical history, and preferences. Psychotherapy might be initiated first due to the low risk to the mother and baby. If drugs must be initiated, the lowest therapeutic dosage possible is advised, and drug dosage may require an increase in the second half of pregnancy (American Congress of Obstetricians and Gynecologists, 2021). Medications are labeled and classified by the FDA into (A, B, C, D, and X) categories based on drug safety in pregnancy, and there is currently no available antidepressant in category A or B (MGH, 2018). Meanwhile, Category D, such as paroxetine, has strong evidence of fetal risk from human studies; potential benefits may permit use despite potential risks (MGH, 2018).

References

American Congress of Obstetricians and Gynecologists. (2021). Depression during pregnancy. Retrieved from https://www.acog.org/search#q=depression%20in%20pregnancy&sort=relevancy

Centers for Disease Control and Prevention. (2017). Antidepressant prescription claims among reproductive-aged women with private employer-sponsored insurance-United States 2008-2013. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6503a1.htm?s_cid=mm6503a1_w Links to an external site.

Cuomo, A., Beccarini Crescenzi, B., Bolognesi, S., Goracci, A., Koukouna, D., Rossi, R., & Fagiolini, A. (2020). S -Adenosylmethionine (SAMe) in major depressive disorder (MDD): a clinician-oriented systematic review. Annals of general psychiatry , 19 , 50. https://doi.org/10.1186/s12991-020-00298-z

Gorun, A. (2018). Choosing and discussing SSRIs for depression in pregnancy: A basic guide for residents. Retrieved from https://ajp.psychiatryonline.org/doi/10.1176/appi.ajprj.2018.130602

Mayo Clinic. (2020). Antidepressants: Safe during pregnancy? Retrieved from https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-byweek/indepth/antidepressants/art-20046420 Links to an external site.

MGH Center for Women’s Mental Health. (2018). Psychiatric disorders during pregnancy: Weighing the risks & benefits of pharmacologic treatment during pregnancy. Retrieved from https://womensmentalhealth.org/specialty-clinics/psychiatric-disorders-duringpregnancy/

Rodriguez, T. (2019). 5 non-pharmacological treatments for depression. Retrieved from https://medshadow.org/5-treatments-for-depression-without-meds/

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Safurat Olaniba-Adebisi

Jan 25, 2023 10:58pm | Last reply Jan 27, 2023 9:28pm

Reply from Safurat Olaniba-Adebisi

Discussion week # 9

PRESCRIBING FOR OLDER ADULTS

Hello professor and fellow colleagues, The disorder that usually affects the geriatrics is dementia. Alzheimer’s disease is the most common type of dementia. People with dementia have problems with reasoning, judgement, problem solving, memory, communication and visual perception beyond typical age-related vision changes. (CDC,2022).

Alzheimer’s disease is caused by changes in the brain transmitters and it’s hereditary – runs in the family. The treatment depends on the underlying cause. Neurodegenerative dementia such as Alzheimer’s has no cure but medication to protect the brain or manage the anxiety. Such medication is Namenda.

Namenda reduces the actions of chemicals in the brain that may contribute to the symptoms of Alzheimer’s disease. Namenda is used to treat moderate to severe dementia of the Alzheimer’s type. Side effect of headache, dizziness, and bloating.

References

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of

psychiatry (11th ed.). Wolters Kluwer

CDC.2022

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NE

Ndidi Joan Egemonu

Jan 25, 2023 10:49pm | Last reply Jan 27, 2023 1:10pm

Reply from Ndidi Joan Egemonu

WEEK 9 Main DQ

Older adults are often affected by a decline in cognition due to Alzheimer’s and dementia. According to DSM-5 331.83 (31.84), a neurocognitive decline in older adults, also known as Alzheimer’s disease, is the cause of about 60 to 80 percent of dementia. Dementia impairs the mental ability to perform activities of daily living. It is not a disease; instead, a cluster of symptoms that impacts and alters the ability and subsequent deterioration of memory, reasoning, functioning, and logical thinking in the affected person. Alzheimer’s disease is one cardinal cause of dementia. As a cluster of symptoms, dementia can be mixed, resulting in the occurrence of multiple brain changes at the same time. Alzheimer’s disease, also called senile dementia, is a progressive disease that damages and impedes memory and other vital functions. As the number one cause of dementia, its pathology affects brain cell connections, and the brain cells degenerate and die, destroying memory and other vital mental functions. Alzheimer’s disease causes memory loss and confusion and has no cure. The goal of medication and management strategies is to improve symptoms and delay their ravaging advancement temporarily.

FDA-approved drug:

The Food and Drug Administration approves the following medications in the USA to help slow the progression of Alzheimer’s disease and improve memory and cognitive functioning, donepezil, galantamine, rivastigmine, memantine, and donepezil/memantine combination). Due to the progressive nature of Alzheimer’s disease, the efficacy of the above five medications will depend on the stage of the disease. According to FDA, in mild to moderate or moderate to severe Alzheimer’s disease, Aricept (donepezil) has been approved to be more effective. The National Institute on Aging, according to research, believes that Aricept (donepezil), galantamine (Razadyne), and rivastigmine (Exelon) may assist in slowing down behavioral symptoms in the interim and delay worsening symptoms.

One non-FDA-approved “off-label” drug:

Medications that fall under antipsychotics, antidepressants, anti-anxiety, and mood stabilizers can be used to alter the brain waves, thereby improving brain function. A drug like Seroquel can change a patient’s mood, perception, and consciousness with Alzheimer’s disease. The pharmacist can dispense such medicines because the FDA did not approve them, provided there is enough evidence documented, other than trial or experimental purposes, to prove that it is acceptable within reasonable health care clinical practice standards.

One nonpharmacological intervention for treating Alzheimer’s Disease.

Alzheimer’s disease progresses for the worse with time; therefore, a multi-dimensional approach to slow its progress is a sound clinical decision. Some nonpharmacological interventions that could be used include cognitive stimulation therapy, validation therapy, and reality reorientation, with reminiscence therapy as a holistic approach.

Explain the risk assessment you would use to inform your treatment decision-making.

Using the Mini-Mental Examination (MMSE), a set of eleven questions to validate a patient’s cognitive impairment will guide my decision-making. Other assessment tools that could be used include the Bristol Activities of Daily Living Scale (BADLS) and Genetic assessment risk factors obtained through comprehensive family history. There are many clinical guidelines that real-life modifications can help prevent the cause of the disease, delay disease progression, or even improve its ravaging side effects. Such lifestyle modifications include regular exercise, both physical and mental, moderate alcohol intake, and avoidance of tobacco and head injuries. A conflicting outcome does exist in the vascular studies that a systolic blood pressure below 140 mmHg is also associated with an increased risk for Alzheimer’s disease. A randomized study of the Guidelines for Neurocognitive disorder treatment conducted by Furey and Wilkins (2019) used three cholinesterase inhibitors, donepezil, rivastigmine, and galantamine, approved by the U.S. Food and Drugs as a baseline for the study of dementias. The treatment efficacy is based on the type of dementia, such as Alzheimer’s disease, vascular dementia, and other dementias, and whether it is mild, moderate, or severe. The participants who received Aricept (donepezil) proved to have more cognitive functioning and slowed the progression of their dementias than those who received placebos.

Most of the information to consider is that interdisciplinary and shared clinical decisions are crucial in the treatment of Alzheimer’s disease. It is what will guide pharmaceutical companies to comply and dispense a medication approved by FDA for one aliment when it is meant to be used as a non-approved for what it is prescribed for. It is also essential to verify the ethical and legal implications of prescribing “off-label medications for the patient’s benefit.

Reference

American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia Links to an external site. Links to an external site. . https://doi.org/10.1176/appi.books.9780890426807

American Psychiatric Association (APA) 2013., Diagnostic and statistical manual of mental disorders 5 th ed. DSM-5. American Psychiatric Publishing Washington, DC / London, England

Furey, K. & Wilkins, K. (2019). Prescribing “Off-Label”: What Should a Physician Disclose?

AMA J Ethics. 2016;18(6):587-593. DOI 10.1001/journalofethics.2016.18.6.ecas3-1606.

Patterson et al. (2008).Diagnosis and treatment of dementia: 1. Risk assessment and primary prevention of Alzheim er’s disease. CMAJ 2008;178:316-21. www.cmaj.ca/cgi/content/full/178/5/548/DC1 Links to an external site.

Rabins, P.V. et al., (2014). Guide watch (October 2014): Practice guidelines for treating patients with Alzheimer’s disease and other dementias. APA Guideline

Watch; https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimerwatch.pd Links to an external site. American Psychiatric Association. (2020). Geriatric telepsychiatry Links to an external site. Links to an external site. [Video]. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/geriatric-telepsychiatry Links to an external site.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11 th ed.). Wolters Kluwer.” Chapter 33, “Geriatric Psychiatry”

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Kimberly Mary Baldor

Jan 25, 2023 8:37pm | Last reply Jan 26, 2023 12:47pm

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Willie Feagin

Jan 25, 2023 8:31pm | Last reply Jan 26, 2023 12:46pm

Reply from Willie Feagin

Prescribing for Older Adults and Pregnant Women

The DSM-5 diagnosis that affects older adults is a major depressive disorder. Depression is a huge public health issue due to its severe implications (Gabriel et al., 2020). Older adults are more likely to suffer from subsyndromal depression. This type of depression doesn’t always meet the full criteria for major depression. However, it can lead to major depression if left untreated. Depression in older adults can reduce the quality of life, and increases the risk of suicide and is linked to an increased risk of morbidity, an increased risk of suicide, poorer physical, cognitive, and social functioning, and increased self-neglect, all of which are linked to an increased risk of mortality (Gabriel et al., 2020). `

FDA-approved, Off label, and non-pharmacological intervention

Antidepressants have been shown to reduce the risk of depression recurrence in adults, justifying prolonged antidepressant maintenance therapy for most if not all patients. However, older depressed adults may be at increased risk for antidepressant adverse effects (Diniz & Reynolds, 2014). Historically, TCAs were the first‐line treatment for MDD, but other antidepressants have since been developed that have a better safety profile. SSRIs are generally used as first‐line therapy as they have several advantages over TCAs, including fewer antimuscarinic and cardiotoxic side effects, rarely fatal in overdose, less dosage titration, once-daily administration, and greater patient adherence (Robertson et al., 2019). Sertraline is a medication used to manage and treat major depressive disorder. It is in the SSRI class of medications. Sertraline is an antidepressant medication within the selective serotonin reuptake inhibitors (SSRIs) class. Sertraline is an antidepressant with primarily inhibitory effects on presynaptic serotonin reuptake (“Sertraline,” 2022). The FDA has authorized sertraline as a treatment for elderly patients with severe depression. The results of several carefully planned trials show that sertraline (50-200 mg/day) is effective in treating a major depressive disorder in elderly individuals (> or =60 years of age) (Chen & Shan, 2019). One off-label medicine chosen is fluoxetine, which is useful in treating older people with dementia and depression symptoms. Fluoxetine is the off-label drug chosen because it is effective in treating depression symptoms in older persons (Wang et al., 2021). Psychotherapy may be beneficial for LLD due to specific psychological conditions in old age and a low risk of side effects. Cognitive-behavioral therapy (CBT) is a successful and long-lasting treatment for late-life depression (Gabriel et al., 2020).

Risk and Benefit Assessment

Fortunately, numerous antidepressants have been effective in elderly patients suffering from MDD without psychotic symptoms. While selecting an antidepressant, it is advised that the best side effect profile and the lowest risk of drug-drug interactions be considered. Sertraline, for example, has lesser anticholinergic effects than previous antidepressants and is thus well tolerated by people with cardiovascular disease. Nausea, dry mouth, sleeplessness, somnolence, agitation, diarrhea, excessive perspiration, and, less commonly, sexual dysfunction are common adverse effects of SSRIs (Gabriel et al., 2020). It is critical to monitor sodium levels one month after commencing SSRI treatment, especially if the patient is also taking other drugs that have the potential to cause hyponatremia, like diuretics (Gartlehner et al., 2017). Fluoxetine is not related to the withdrawal syndrome reported with other SSRIs. Fluoxetine should not be shunned in the geriatric population, and in some cases, it may be the medicine of choice. Because of its long half-life and chronic negative effects, fluoxetine is generally not recommended for usage in the elderly. Paroxetine is also not normally suggested for use in the elderly since it has the most anticholinergic impact of any SSRI, comparable to that of the tricyclics desipramine and nortriptyline (Gabriel et al., 2020).

Clinical Guidelines

Clinical practice guidelines do exist for Major Depressive Disorder (MDD). The American Psychiatric Association (APA) and the American Medical Association (AMA) both have guidelines for the treatment of MDD. These guidelines generally recommend a combination of medication and psychotherapy as the first-line treatment for MDD. The APA’s guidelines recommend selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line medication options for MDD. They also suggest that psychotherapy, specifically cognitive-behavioral therapy (CBT), be used in conjunction with medication. The AMA’s guidelines similarly recommend SSRIs or SNRIs as first-line medication options and also suggest the use of psychotherapy, specifically cognitive-behavioral therapy (CBT), as an adjunctive treatment. When making recommendations for the treatment of MDD, it is important to consider the patient’s specific symptoms and medical history, as well as any comorbid conditions or risk factors. It’s also important to monitor the patient’s response to treatment and adjust as necessary. When elaborating on the treatment of MDD, it is important to note that medication and psychotherapy are not the only treatment options available. Electroconvulsive therapy (ECT) is also an effective treatment option for MDD, particularly for patients who have not responded to other treatments or who have severe or life-threatening symptoms. Another important aspect to consider when treating MDD is the patient’s preference and the availability of treatment options. For example, some patients may prefer to avoid medication due to side effects or personal beliefs, in which case psychotherapy alone may be a better option. Additionally, in some rural or low-income areas, access to mental health professionals may be limited, making teletherapy or self-help resources more appropriate options. It’s also important to consider comorbid conditions and risk factors, such as substance abuse, when treating MDD. Patients with comorbid substance abuse may require specialized treatment and support. It’s also important to monitor the patient’s response to treatment and adjust as necessary. This includes regularly checking the patient’s symptoms and side effects, as well as monitoring the patient’s progress in psychotherapy. If a patient is not responding to treatment, it may be necessary to adjust the medication dosage, switch to a different medication, or add or change the type of psychotherapy. It’s also important to provide support and education to the patient and their family, which can help to improve treatment adherence and outcome. In the absence of clinical practice guidelines, the general approach to the treatment of MDD is a combination of medication and psychotherapy. The choice of medication should be based on the patient’s specific symptoms and medical history, and the choice of psychotherapy should be based on the patient’s preference and the availability of the therapist. It’s also important to monitor the patient’s response to treatment and adjust as necessary.

The elderly may be more prone to depression due to psychological or biological reasons. As they get older, older people experience significant losses including losing a companion, their jobs, their social status, and their physical and mental abilities (Robertson et al., 2019). Due to physiological changes due to advanced age, the elderly may be more susceptible to drug therapy. Older individuals could need more cautious dose adjustments and be more vulnerable to the negative effects of drugs (Gartlehner et al., 2017). Elderly people commonly get medication for a variety of reasons, and drug interactions are a worry. Tricyclic antidepressants are no longer recommended as first-line therapy for elderly patients because of the possibility of side effects such as postural hypotension, which can cause falls and fractures, irregular cardiac conduction, and anticholinergic effects. The latter includes symptoms including delirium, urination, dry mouth, retention, and constipation (Van Poelgeest et al., 2021). Alzheimer’s disease, Parkinson’s disease, and cardiovascular issues are just a few of the illnesses that tricyclic antidepressants can make worse (Laird et al., 2019). Because they are less anticholinergic, nortriptyline and desipramine are the best alternatives when tricyclic is used as a second-line treatment. The starting dose of an antidepressant should be half that of a younger adult once it has been decided on for an elderly patient to minimize side effects. Age-related alterations in hepatic metabolism, coexisting medical conditions, and drug-drug interactions are believed to be the root of antidepressant adverse effects in the elderly. It should instead be the goal to progressively increase the dosage at 1- to 2-week intervals until it reaches an average therapeutic level (Gabriel et al., 2020). The average therapeutic dose is frequently lower than that recommended for younger individuals because of how aging affects hepatic metabolism, but there are many individual variations as well, it is now known. Some patients will require a greater therapeutic dosage than usual. Assume that a typical therapeutic dosage is used for 2 to 4 weeks and no appreciable improvement is observed. The dosage should be raised until there is a clinical improvement, serious adverse effects, or until the maximum dosage is achieved (Gabriel et al., 2020). Therefore, scheduling frequent follow-up sessions is essential to monitor therapeutic response, assess side effects, and modify dosage as necessary. Additionally, it’s critical to watch out for any indications of depression getting worse, agitation, or anxiety, as well as the risk of suicide, particularly in the beginning stages of therapy (Buckman et al., 2018). There is no proof that older people who use antidepressants have more suicidal thoughts.

References

Al-Azayzih, A., AlAmoori, R., & Altawalbeh, S. M. (2019). Potentially inappropriate medications prescribing according to beers criteria among elderly outpatients in jordan: A cross sectional study. Pharmacy Practice , 17 (2), 1439. https://doi.org/10.18549/pharmpract.2019.2.1439 Links to an external site.

Diniz, B. S., & Reynolds, C. F. (2014). Major depressive disorder in older adults: Benefits and hazards of prolonged treatment. Drugs & Aging , 31 (9), 661–669. https://doi.org/10.1007/s40266-014-0196-y Links to an external site.

Gabriel, F., de Melo, D., Fráguas, R., Leite-Santos, N., Mantovani da Silva, R., & Ribeiro, E. (2020). Pharmacological treatment of depression: A systematic review comparing clinical practice guideline recommendations. PLOS ONE , 15 (4), e0231700. https://doi.org/10.1371/journal.pone.0231700 Links to an external site.

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., Gaynes, B. N., Viswanathan, M., Patel, S., & Lohr, K. N. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: Review of systematic reviews. BMJ Open , 7 (6), e014912. https://doi.org/10.1136/bmjopen-2016-014912 Links to an external site.

Robertson, L., Bertolini, F., Meader, N., Davies, S., Barbui, C., Gilbody, S., & Churchill, R. (2019). Antidepressants for major depressive disorder in older people: A network meta-analysis. Cochrane Database of Systematic Reviews . https://doi.org/10.1002/14651858.cd013394 Links to an external site.

Ruberto, V. L., Jha, M. K., & Murrough, J. W. (2020). Pharmacological treatments for patients with treatment-resistant depression. Pharmaceuticals , 13 (6), 116. https://doi.org/10.3390/ph13060116 Links to an external site.

Sertraline. (2022).

van Poelgeest, E. P., Pronk, A. C., Rhebergen, D., & van der Velde, N. (2021). Depression, antidepressants, and fall risk: Therapeutic dilemmas—a clinical review. European Geriatric Medicine , 12 (3), 585–596. https://doi.org/10.1007/s41999-021-00475-7 Links to an external site.

Wang, J., Jiang, F., Yang, Y., Zhang, Y., Liu, Z., Qin, X., Tao, X., Liu, T., Liu, Y., Tang, Y., Liu, H., & Cotes, R. O. (2021). Off-label use of antipsychotic medications in psychiatric inpatients in china: A national real-world survey. BMC Psychiatry , 21 (1). https://doi.org/10.1186/s12888-021-03374-0 Links to an external site.

American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia Links to an external site. Links to an external site. . https://doi.org/10.1176/appi.books.978089

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Francis Archangel

Jan 25, 2023 7:08pm | Last reply Jan 28, 2023 3:33pm

Reply from Francis Archangel

Main Question Post

Treatments for a Disorder in Older Adults

In this discussion, a neurocognitive disorder is selected as a focus in older adults. Alzheimer’s disease is a neurocognitive disorder that shows cognitive decline or impairment in older adults (American Psychiatric Association [APA], 2022). Dementia of the Alzheimer’s type is a major neurocognitive disorder that is typically diagnosed in individuals older than 65 years (Sadock et al., 2015). Older adults with dementia may experience delusions, depression, and intellectual disorientation (Sadock et al., 2015). Donepezil is a Food and Drug Administration (FDA) approved drug for dementia-related cognitive symptoms (Alzheimer’s Association, 2023). Donepezil is one of the drugs that can help control Alzheimer’s disease progression. Donepezil can be given to all stages of Alzheimer’s disease. Olanzapine is an antipsychotic drug used as an off-label in treating Alzheimer’s disease (Alzheimer’s Association, 2023). Olanzapine may be prescribed to control agitation in an individual with Alzheimer’s disease (Alzheimer’s Society, 2023). Individuals with dementia can be referred to a speech-language pathologist (SLP) for non-pharmacological interventions. SLP sessions for dementia will focus on controlling or improving the individual’s memory, attention, problem-solving, and thinking skills. (American Speech-Language-Hearing Association [ASHA] 023). SLPs will help the individual with dementia to learn important information, and they may also teach the family or caregivers how to best communicate with the patient. (ASHA, 2023).

Risk Assessments

Before prescribing medications, it is critical to consider the patient’s health in all aspects. The provider must understand how a particular drug could affect every organ system. The provider must be knowledgeable about drug interactions, potential side effects, adverse reactions, management of drug side effects or adverse reactions, and critical laboratory tests. The provider must conduct regular follow-up appointments to evaluate pharmacological and non-pharmacological interventions and possible modification of the management plan. The provider must assess the competency of the patient, family, and caregivers to participate in the treatment and their access to health. People with low health literacy typically need help understanding the processes involved in healthcare, have problems providing accurate health histories, and have challenges in health management engagement (Stewart & DeNisco, 2019).

Risks and Benefits of FDA-Approved and Off-Label Drugs

The benefits of drugs, in general, are the relief from symptoms such as blood pressure abnormalities, infections, and pain (FDA, 2018). The risks of medicines, in general, are unexpected or unwanted effects or reactions, including abdominal pain or liver damage. The FDA approves a drug when it has been determined to be safe enough for a particular health condition that outweighs its risks (FDA, 2018). All medicines have side effects; however, if the drug is FDA-approved, the side effects are generally not critical and are safe for use as intended (FDA, 2019). FDA approval means the drug underwent and passed a clinical trial effective for its intended use. The labels for FDA-approved medicines also include information about their risks and benefits (FDA, 2018). Moreover, the labels of FDA-approved drugs also show indications for use (Congressional Research Service, 2021)

On the other hand, off-label drug use is also legal in the United States (American Cancer Society [ACS], 2015). When the FDA approves a drug, physicians can use it in any way when they consider it medically appropriate. Medications without FDA approval are not regulated (ACS, 2015). Providers may consider off-label prescriptions to incorporate the latest ideas or treatment approaches available (Congressional Research Service, 2021). Many insurance companies do not reimburse off-label drugs and mark them as experimental or investigational. Off-label use of drugs is a legal risk because it did not pass appropriate clinical trials and is not a standard of care that could result in poor patient outcomes (ACS, 2015).

Clinical Practice Guidelines for Alzheimer’s Disease

Clinical practice guidelines exist for Alzheimer’s disease. Donepezil is an FDA-approved drug for treating Alzheimer’s disease (Alzheimer’s Association, 2023). Donepezil can treat mild, moderate, and severe Alzheimer’s, which inhibits the breakdown of acetylcholine in the brain (National Institute on Aging [NIA], 2021). Individuals with Alzheimer’s disease have low levels of acetylcholine in the brain, which is important in sending messages between nerve cells. (Alzheimer’s Society, 2023). A higher level of acetylcholine in the brain may ease the symptoms of Alzheimer’s (Alzheimer’s Society, 2023). Donepezil is typically started in low dosages and is increased as determined necessary. However, higher doses of donepezil have a higher risk of side effects (NIA, 2021). Patients on donepezil must be monitored regularly due to potential side effects, including allergic reactions and abdominal upset. Behavioral symptoms of Alzheimer’s disease, such as agitation, restlessness, depression, wandering, and aggression, can be treated to provide patient comfort. Different anti-anxiety drugs, sleeping aids, antipsychotics, and anticonvulsants can be used to treat or control the behavioral symptoms of Alzheimer’s. In addition, managing the behavioral symptoms of Alzheimer’s will make it less complicated for the patient’s family to take care of them (NIA, 2018).

References

Alzheimer’s Association. (2023). Medications for memory, cognition, and dementia-related

behaviors. https://www.alz.org/alzheimers-dementia/treatments/medications-for- Links to an external site.

memory#:~:text=Donepezil%20(Aricept%C2%AE)%3A%20approved,moderate%20stag

es%20of%20Alzheimer’s%20disease.

Alzheimer’s Association. (2023). Treatments for behavior. https://www.alz.org/alzheimers- Links to an external site.

dementia/treatments/treatments-for-behavior

Alzheimer’s Society. (2023). Antipsychotics and other drug approaches in dementia care.

https://www.alzheimers.org.uk/about-dementia/treatments/drugs/antipsychotic- Links to an external site.

drugs#:~:text=The%20off%2Dlabel%20antipsychotics%20most,other%20symptoms%20

of%20these%20conditions.

Alzheimer’s Society. (2023). How do drugs for Alzheimer’s disease work?

https://www.alzheimers.org.uk/about-dementia/treatments/dementia-drugs/how-do- Links to an external site.

drugs-alzheimers-disease-

work#:~:text=In%20the%20brain%20of%20a,use%20acetylcholine%20are%20also%20lost.

American Cancer Society. (2015, March 17). Off-label drug use.

https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/off- Links to an external site.

label- Links to an external site. druguse.html#:~:text=Many%20insurance%20companies%20will%20not,experimental%

E2%80%9D%20or%20%E2%80%9Cinvestigational.%E2%80%9D

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental

disorders, fifth edition, text revision (DSM-5-TR).

American Speech-Language-Hearing Association. (2023). Dementia.

https://www.asha.org/public/speech/disorders/dementia/ Links to an external site.

Congressional Research Service. (2021). Off-label use of prescription drugs . chrome-

extension://efaidnbmnnnibpcajpcglclefindmkaj/https://sgp.fas.org/crs/misc/R45792.pdf

National Institute on Aging. (2021, July 8). How is Alzheimer’s disease treated?

https://www.nia.nih.gov/health/how-alzheimers-disease-treated

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

ed.). Wolters Kluwer

Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd

ed.) . Jones & Bartlett Learning.

United States Food and Drug Administration. (2018, June 18). Think it through; managing the

benefits and risks of medicines. https://www.fda.gov/drugs/information-consumers-and- Links to an external site.

patients-drugs/think-it-through-managing-benefits-and-risks-medicines

United States Food and Drug Administration. (2019, October 28 ). Frequently asked questions

about CDER. https://www.fda.gov/about-fda/center-drug-evaluation-and-research- Links to an external site.

cder/frequently-asked-questions-about-cder#:~:text=6.-

,Once%20FDA%20approves%20a%20drug%2C%20does%20this%20mean%20that%2

0the,effects%20are%20generally%20not%20serious.

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Pamela Mccleary

Jan 25, 2023 4:27pm | Last reply Jan 28, 2023 5:41pm

Reply from Pamela Mccleary

Women with bipolar disorder have a 50% increased risk for exacerbations during the perinatal period, so discontinuing treatment increases the risk of symptom worsening and changing their ability to function and engage in risky behaviors, including substance abuse and poor prenatal compliance (Clark, 2020). Another concern is that exposing a fetus to untreated bipolar disorder can lead to low birth weight, preterm birth, small gestational age, and microcephaly (Clark, 2020). During pregnancy, pharmacokinetics are altered, causing metabolism and elimination of medications to change substantially, requiring close monitoring of any treatment. Clinicians will need to adjust treatment throughout the pregnancy (Montiel et al., 2022

Lithium is still one of the best treatments for bipolar disorder, and if the client is stable on Lithium, consider continuing Lithium during the pregnancy. The risk for cardiac malformations, including Epstein’s anomaly, was less than previously reported; there is also a risk of increased birth weight, hypoglycemia tremor, and heart rate (Clarke, 2020). Mothers with hyperemesis, pre-eclampsia and renal insufficiency are at risk for Lithium toxicity and must be closely monitored. Completing an ultrasound at 16–20 weeks to rule out congenital malformations is also recommended (Clarke, 2020).

Invega (paliperidone) can be used off-label to treat bipolar disorder. There is a limited study available about the effects of its use during pregnancy. However, studies have shown no evidence of teratogenic or harmful impact on the mother or fetus (Onken et al., 2018). Since Invega is cleared renally, plasma levels depend on renal clearance, which increases during pregnancy. If Invega is tolerated well before pregnancy, current literature supports continuing the medication with frequent monitoring after reviewing the benefits versus risks of continued treatment.

There are clinical practice guidelines in place, but they are inconsistent internationally. Pregnancy has had limited studies and updates to guidelines due to the FDA having limited research information about pregnant women who use antipsychotic drugs. The guidelines recommend closely monitoring lithium levels, review of benefits versus risks, increasing monitoring in the third trimester, and not recommending breastfeeding (Malhi et al., 2017). If possible, stopping Lithium in the first trimester is also recommended. The recommendations are clear and concise and include the best practice so that I would incorporate them into my practice. However, there will always be a chance of a client that doesn’t fit into the guidelines, and as a practitioner, a review of the latest evidence-based research will be necessary to meet that client’s needs.

Risks versus benefits for both FDA-approved and off-label use would include considering the client’s symptoms and disease history. Untreated bipolar disease can lead to risky behaviors and general health neglect, and studies show increased fetal/infant health risks. Also, with untreated bipolar disorder, postpartum depression and difficulty stabilizing the mother’s mood becomes a concern. So maintaining some form of treatment during pregnancy may be the preferable course of care. If a client is pregnant or telling you they are considering pregnancy, reviewing each of their medications using evidence-based research is indicated to discuss the medication’s risks and benefits so that decisions can be made using current research findings. Increased assessment and monitoring of the mood and medication levels will also be part of the treatment plan. The decision to prescribe any medication during pregnancy should be thoroughly assessed, and medications should only be prescribed when the risk of untreated maternal disorder outweighs the potential risk to the fetus from exposure to the medication. Clinicians should prescribe the minimum effective dose. The close collaboration of care with the OB/GYN is essential.

Bright Light Therapy (BLT) is a non-pharmacological treatment for mood disorders, including bipolar disorder. BLT can be used alone or as adjunctive therapy, and results have been seen in as little as one week. If effective medication doses could be decreased, further reducing the risk of fetal injury. The therapy works by regulating the biological mechanisms and mediating dysregulation of the circadian rhythm by affecting the pineal gland light, which induces melatonin production and balances cortisol. This is a natural, noninvasive, and safe treatment option that can quickly and safely be incorporated into a treatment plan (Cuomo et al., 2023)

References

Clark, C. T. (2020). Psychotropic drug use in perinatal women with bipolar disorder. Seminars in Perinatology , 44 (3), 151230. https://doi.org/10.1016/j.semperi.2020.151230 Links to an external site.

Cuomo, A., Carmellini, P., Garo, M. L., Barillà, G., Libri, C., Spiti, A., Goracci, A., Bolognesi, S., & Fagiolini, A. (2023). Effectiveness of light therapy as adjunctive treatment in bipolar depression: A pilot study. Journal of Affective Disorders , 321 , 102–107. https://doi.org/10.1016/j.jad.2022.10.009 Links to an external site.

Grover, S., & Avasthi, A. (2015). Mood stabilizers in pregnancy and lactation. Indian Journal of Psychiatry , 57 (Suppl 2), S308. https://doi.org/10.4103/0019-5545.161498 Links to an external site.

Malhi, G. S., Gessler, D., & Outhred, T. (2017). The use of Lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. Journal of Affective Disorders , 217 , 266–2https://doi.org/10.1016/j.jad.2017.03.052

Montiel, C., Newmark, R. L., & Clark, C. T. (2022). Perinatal use of lurasidone for the treatment of bipolar disorder. Experimental and Clinical Psychopharmacology , 30 (2), 249–252. https://doi.org/10.1037/pha0000509 Links to an external site.

Onken, M., Mick, I., & Schaefer, C. (2018). Paliperidone and pregnancy—an evaluation of the German Embryotox database. Archives of Women’s Mental Health , 21 (6), 657–662. https://doi.org/10.1007/s00737-018-0828-z Links to an external site.

Uguz, F. (2020). Pharmacological prevention of mood episodes in women with bipolar disorder during the perinatal period: A systematic review of current literature. Asian Journal of Psychiatry , 52 . https://doi.org/10.1016/j.ajp.2020.102145 Links to an external site.

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OO

Ogechukwu Christiana Obiajulu

Jan 25, 2023 3:34pm | Last reply Jan 28, 2023 9:56pm

Reply from Ogechukwu Christiana Obiajulu

Week 9 Discussion

Prescribing for pregnant women

Schizophrenia is a developmental disease that is caused by an interaction of genetic susceptibilities combined with environmental insults .The genetic contribution is well-established, with up to a 10- fold increase in the risk of developing schizophrenia (Bates et al., 2018) . Schizophrenia is one particular DSM-5-TR disease that may have an impact on expectant mothers. Hallucinations, delusions, and disorganized thinking are all symptoms of the mental illness schizophrenia. Psychotherapy and antipsychotic medications are frequently used in the treatment of schizophrenia. The possible dangers and advantages of the medicine for both the mother and the growing fetus must be taken into account while treating pregnant women with schizophrenia (Bates et al., 2018).

FDA-approved drug

There are numerous therapies for schizophrenia in expectant mothers that are supported by evidence. Clozapine is one drug used to treat schizophrenia that has FDA approval. An antipsychotic drug called clozapine helps lessen hallucinations, delusions, and disordered thinking. Clozapine use during pregnancy, however, should be thoroughly monitored by a healthcare professional due to the drug’s increased risk of agranulocytosis (Uguz, 2020).

One off-label drug

Quetiapine, an antipsychotic drug that has not received FDA approval for use during pregnancy, provides an additional option for treating schizophrenia in expectant patients (Zheng et al., 2020). But compared to clozapine, quetiapine has been demonstrated to be beneficial in lowering schizophrenia symptoms and is linked to a lower incidence of agranulocytosis (Zheng et al., 2020). Last but not least, nonpharmacological treatments like psychotherapy can be effective in treating schizophrenia in expectant women (Gentile & Fusco, 2019)

T he risk assessment used to inform my treatment decision making .

Clinical practice guidelines provide direction for the management of schizophrenia in both pregnant women and older persons. According to these recommendations, antipsychotic drugs should be used as the first line of treatment for schizophrenia. Clozapine is advised as a first-line option for pregnant women, and quetiapine is advised as a second-line alternative. The recommendations make psychotherapy a second-line or adjunctive treatment for schizophrenia. Assessing risks to humans and the environment for remediation programs is technically feasible. The risk assessment will be based on the benefits and drawbacks that the drug has for the patient. Going through the drug leaflet, understanding the contraindications of the drug, knowing the drug interaction, and completing a wholesome psychiatric evaluation, as well as monitoring the drug effects, are all part of risk assessment.

Risks and benefits of the FDA-approved medicine

U.S Food and Drug Administration (FDA) -approved medicine has some risks and benefits towards an individual’s healthy life. Gourgari et al. (2017) analyzed that some FDA-approved drugs like sedatives and anti-anxiety medications can cause low blood pressure, slowed breathing, and memory problems which can be a considerable threat to a patient’s health. On the other hand, FDA-approved medicines can be of much benefit in that a patient is fully aware of their effectiveness and safe to consume. The U.S federal law requires drugs to be examined and proved to be safe for patients.

Risks and benefits of the off-label drug

Off-label drugs are drugs that have unapproved use. Off-label drugs are beneficial because they can be prescribed for a disease that is not approved to treat (Good & Gellad, 2016). For instance, antipsychotics approved to treat a particular type of mental condition can also treat a different kind of psychosis because it is not approved for a specific type. The risk associated with off-label drugs includes such a drug can cause a client to experience adverse body events like allergic response, drug interaction, and drug reaction (Good & Gellad, 2016).

Clinical practice guidelines for schizophrenic pregnant women

Clinician-developed clinical practice guidelines are statements that make recommendations for enhancing patient care. They are educated through a thorough study of the facts as well as an assessment of the benefits and risks of different care alternatives . Clinical practice guidelines do exist for the treatment of schizophrenia in pregnant women adults. Patients and Healthcare providers must look for side effects. Clinicians’ practice guidelines allow noncompliance and therapy-associated adverse effects when creating a thorough treatment plan to manage schizophrenia. The American Psychiatric Association’s (APA’s) clinical practice standards are critical in helping healthcare practitioners to select healthcare options for schizophrenic patients. The therapeutic procedures for schizophrenia are founded on proven medication and non-pharmacological therapies. To the guidelines, mentally ill persons like people with schizophrenia should be treated with an antipsychotic drug and their efficacy and adverse reactions should be monitored carefully (Avasthi et al., 2017)

References.

Avasthi, A., Grover, S., Chakrabarti, S., & Kulhara, P. (2017). Clinical Practice Guidelines for Management of Schizophrenia. Indian Journal of Psychiatry , 59 (5), 19. https://doi.org/10.4103/0019-5545.196972 Links to an external site.

Bates, V., Maharjan, A., Millar, J., Bilkey, D. K., & Ward, R. D. (2018). Spared motivational modulation of cognitive effort in a maternal immune activation model of schizophrenia risk. Behavioral Neuroscience , 132 (1), 66–74. https://doi.org/10.1037/bne000023 Links to an external site.

Gentile, S., & Fusco, M. L. (2019). Schizophrenia and motherhood. Psychiatry and Clinical Neurosciences , 73 (7), 376–385. https://doi.org/10.1111/pcn.12856 Links to an external site.

Good, C. B., & Gellad, W. F. (2016). Off-label Drug Use and Adverse Drug Events. JAMA Internal Medicine , 176 (1), 63. https://doi.org/10.1001/jamainternmed.2015.6068 Links to an external site.

Gourgari, E., Wilhelm, E. E., Hassanzadeh, H., Aroda, V. R., & Shoulson, I. (2017). A comprehensive review of the FDA-approved labels of diabetes drugs: Indications, safety, and emerging cardiovascular safety data. Journal of Diabetes and Its Complications , 31 (12), 1719–1727. https://doi.org/10.1016/j.jdiacomp.2017.08.005 Links to an external site.

Harris, M. G., Kazdin, A. E., Chiu, W. T., Sampson, N. A., Aguilar-Gaxiola, S., Al-Hamzawi,A., … & WHO World Mental Health Survey Collaborators. (2020). Findings from worldmental health surveys of the perceived helpfulness of treatment for patients with major depressive disorder JAMA psychiatry,77(8), 830-841

Uguz, F. (2020). The Use of Clozapine During Pregnancy And Lactation: A Case Report. Psychiatry and Clinical Psychopharmacology , 30 (2), 193. https://doi.org/10.5455/pcp.20200502080433 Links to an external site.

Zheng, L., Tang, S., Tang, R., Xu, M., Jiang, X., & Wang, L. (2020). Dose Adjustment of Quetiapine and Aripiprazole for Pregnant Women Using Physiologically Based Pharmacokinetic Modeling and Simulation. Clinical Pharmacokinetics , 60 (5), 623–635. https://doi.org/10.1007/s40262-020-00962-3

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PE

Preston Eyerman

Jan 25, 2023 12:42pm | Last reply Jan 26, 2023 12:45pm

Reply from Preston Eyerman

When treating schizophrenia in older adults, the safest approach is to always start at a low dosage and titrate slowly. One FDA-approved drug that is available for the treatment of schizophrenia is Abilify. When treating patients with antipsychotics, especially older adults, it is imperative to educate the patient and closely monitor them for side effects. Some of the more concerning side effects for this population include anticholinergic effects (such as urinary retention, constipation, and cognitive impairments) and orthostatic hypotension (which increases the risk for falls) and sedation (Marder, 2022). The benefits of using Abilify in patients with schizophrenia would be an improvement in psychotic symptoms. Though it takes about 2 weeks to achieve a steady-state, it may take up to 4-6 weeks to observe a desired response after an effective dose is reached (Marder, 2022).

In treatment resistant schizophrenia, Clozapine is typically the next suggested treatment modality. A patient is categorized as treatment-resistant if they are experiencing moderate symptoms, functional impairment, and have had at least two unsuccessful trials of antipsychotic treatment (Kane, Rubio, Kishimoto, & Correll, 2021). Antipsychotic treatment trials must have been at least six weeks at the highest tolerated dose. If clozapine is not an option, then the use of ECT to augment the current antipsychotic is recommended. This is based off of a meta-analysis of 11 random clinical trials that compared ECT augmentation of a non-clozapine antipsychotic versus treatment of a non-clozapine antipsychotic alone. The study found that the patients who augmented treatment with ECT had enhanced symptom improvement compared to those treated with antipsychotic monotherapy. The most common risks associated with ECT includes memory impairment and headache.

If the patient does not have a significant clinical response to ECT (after an 8-week trial of ECT 2-3 times per week), and clozapine therapy is not a possibility, then Lamotrigine is the next recommended choice of treatment (Kane, Rubio, Kishimoto, & Correll, 2021). This recommendation is based upon consistent, though limited, evidence supporting its use in this population. Three randomized studies have revealed a decrease in psychotic symptoms with the use of adjunctive lamotrigine (in combination with an antipsychotic) compared to placebo. Lamotrigine, a mood stabilizer, carries a boxed warning for potentially causing serious rashes. If a patient develops a rash, then the medication should be discontinued in hopes to avoid progression to a more serious form of the rash such as Stevens-Johnson syndrome or toxic epidermic necrolysis (Lamotrigine: Drug information, n.d.). Other risks include blood dyscrasias, suicidal ideation, and nausea.

Clinical guidelines do exist for the treatment of Schizophrenia. First-line treatment of a second-generation antipsychotic is typically recommended for acute psychosis and ongoing maintenance therapy. Second-generations are preferred over first generation due to their decreased risk for EPS production. Though these are the general guidelines, a first-line antipsychotic, such as Haldol, may be more appropriate in some cases such as during extreme agitation. This methodology excludes the use of clozapine as a first-line option. Though it has been proven to be more effective than other antipsychotics, Clozapine is reserved for treatment-resistant patients due to its associated side effects and necessity for frequent monitoring (Marder, 2022).

References

Kane, J., Rubio, J., Kishimoto, T., & Correll, C. (2021). Evaluation and management of treatment-resistant schizophrenia. Up to date . Retrieved from https://www.uptodate.com/contents/evaluation-and-management-of-treatment-resistant-schizophrenia?search=schizophrenia%20&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H1536388995 Links to an external site.

Lamotrigine: Drug information. (n.d.). Up to date . Retrieved from https://www.uptodate.com/contents/lamotrigine-drug-information?search=schizophrenia%20&topicRef=14808&source=see_link#F186309 Links to an external site.

Marder, S. (2022). Psychosis in adults: Initial management. Up to date. Retrieved from https://www.uptodate.com/contents/psychosis-in-adults-initial-management?sectionName=INITIAL%20MANAGEMENT&search=schizophrenia%20treatment&topicRef=14805&anchor=H4035521878&source=see_link#H498310159 Links to an external site.

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CC

Chasity Cooper

Jan 25, 2023 11:16am | Last reply Jan 26, 2023 12:45pm

Reply from Chasity Cooper

Treating Depression in Pregnant Women

Chasity Cooper RN,BSN

PMHNP Care Across the Lifespan II

Dr.Reyes

1/25/22

Treating Depression in Pregnant Women

Many pregnant women experience increased sadness and cognitive changes during pregnancy. Especially, if they are unaccepting of the bodily changes or unable to complete their normal daily routines. Depression during pregnancy is called prenatal depression. According to Jahan and others (2021), prenatal depression in studies has proven to lead to pre-term delivery, poor birth weight, slow fetal development, anemia, and uterine problems. The Edinburgh Postnatal Depression Scale and Patient Health Questionaire are effective screening tools for depression (Niel & Payne, 2020).

The FDA’s approval for medication use to treat depression in pregnancy is often unclear. In many drug books it sees controlled studies have not be done on pregnant women.The FDA has created categories to label medications for their warnings during pregnancy. SSRI’s are usually the first line treatment option for depression during pregnancy. The FDA categorizes most SSRI’s in the C category. The C category informs clinicians that complications are possible, but the benefits may outweigh the risks. Sertraline and citalopram are believed to have the smallest risk. The dose of Zoloft should be on the lower scale and avoid use in the first trimester if possible. Effective non-pharmacologic treatment options for depression are yoga, psychotherapy, and cognitive behavioral therapy.

When it is time to discuss the risks associated with treatment of the perinatal depression, I would used information from the CDC. The CDC runs a Pregnancy Risk Assessment Monitoring System. It is a questionnaire that assesses depression in women during pregnancy and postpartum (Ellington, 2021). The CDC records stats of the incidences of depression among pregnant women and complications. As mentioned above the EDPS is effective for making a decision to treat the depression. Molenaar and others (2018), have created clinical practice guideline and the researchers promote psychotherapy for mild to moderate cases. The authors state that if antidepressants are used, cardiovascular monitoring should take place. Treatment with antidepressants can cause pre-term delivery, low birth weight, congenital heart defects, new-born, pulmonary hypertension, and gestational diabetes (Hlongwane & Phoswa, 2021). However, as mentioned above studies have shown the benefits of medications may outweigh the risks.

References

Hlongwane, R., & Phoswa, W. N. (2021). Effect of antidepressants in pregnancy outcomes: A protocol for systematic review and meta-analysis. Medicine , 100 (50), e27885. https://doi.org/10.1097/MD.0000000000027885

Jahan, N., Went, T. R., Sultan, W., Sapkota, A., Khurshid, H., Qureshi, I. A., & Alfonso, M. (2021). Untreated Depression During Pregnancy and Its Effect on Pregnancy Outcomes: A Systematic Review. Cureus , 13 (8), e17251. https://doi.org/10.7759/cureus.17251 Links to an external site.

Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. The Australian and New Zealand journal of psychiatry , 52 (4), 320–327. https://doi.org/10.1177/0004867418762057

Niel, M. S. V., & Payne, J. L. (2020, May 1). Perinatal depression: A Review . Cleveland Clinic Journal of Medicine. Retrieved January 24, 2023, from https://www.ccjm.org/content/87/5/273

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JL

Jennifer Lisa

Jan 25, 2023 7:06am | Last reply Jan 25, 2023 8:43am

Reply from Jennifer Lisa

Jennifer Lisa — Week 9 Discussion Post (Initial Post)

NRNP 6675 Week 9 Discussion — MDD in pregnancy.docx

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CM

Cindy Mecham (She/Her)

Jan 25, 2023 2:17am | Last reply Jan 28, 2023 9:19pm

Reply from Cindy Mecham

NRNP6675Wk9MechamC.pdf

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CM

Cindy Mecham (She/Her)

Jan 25, 2023 2:15am

Reply from Cindy Mecham

MK

Mbalu Madlene Kebbie

Jan 25, 2023 1:55am | Last reply Jan 27, 2023 11:26am

Reply from Mbalu Madlene Kebbie

Evidence shows that depression, which is a serious mood disorder characterized by persistent feelings of sadness which affects the way a person feels, behaves and thinks is commonly seen among older adults, whereas clinical depression is not a normal part of aging, and when left untreated, can profoundly affect a person’s functioning and overall quality of life (National Institute on Aging, 2021). Older adults could experience different types of depression including Major Depressive Disorder, evidenced by symptoms that last a minimum of two weeks interfering with one’s ability to perform daily tasks, Persistent Depressive Disorder, known as Dysthymia which is a depressed mood lasting more than two years, wherein the person may be still able to perform daily tasks, Substance/Medication-Induced Depressive Disorder which pertains to the use of substances such as alcohol and pain medications, and Depressive Disorder, due to a medical condition which concerns with separate illnesses such as diabetes or heart disease (National Institute on Aging, 2021). Clinical application to treat depression in older adults recommends three psychotherapeutic interventions as well as a second-generation antidepressant- selective-serotonin reuptake inhibitors-SSRIs, selective-norepinephrine reuptake inhibitors-SNRIs, or norepinephrine-dopamine reuptake inhibitors- NDRIs (apa.org, 2019).

FDA Approved Drug for Treating Depression in Older Adults.

An FDA-approved drug for clinical use in the treatment of depression in older adults is Citalopram hydrobromide, which is a SSRI that acts as an antidepressant by potentiating serotonergic activity in the central nervous system, and selectively inhibiting serotonin reuptake in presynaptic neurons (National Library of Medicine, 2021).

Off-Label Drug for Treating Depression in Older Adults.

An off-label drug is one that has been approved by the FDA, with an unapproved use to treat a disease or medical condition, wherein a health care provider makes an appropriate and sound clinical judgement to determine that the off-label drug is medically appropriate for prescription for their patients, given that there may not be an approved drug to treat that specific illness or medical condition, or in other instances wherein the patient may have tried all other approved treatments without seeing benefits or results, or the drug prescribed for the particular illness is either too expensive or inaccessible (U.S. Food & Drug Administration). Trazodone, used for insomnia is an off-label medication used for depression in older adults, which works by aiding to restore the balance of serotonin in the brain, improving mood and energy, and decreasing anxiety and insomnia which are thought to be related to depression (drugs.com, 2022).

Non-pharmacological Intervention for Treating Depression in Older Adults

Among others, a non-pharmacological intervention used to treat older adults with depression is Life-Review Therapy, which involves an adult person referencing their past to attain a sense of peace and empowerment about their lives, allowing a person to put his or her life into perspective, while revealing significant memories about friends and loved ones, thereby aiding the person to deal with challenging or unresolved conflicts that are preventing them from feeling at peace (healthline.com).

Risk Assessment Used to Inform Treatment Decision-Making.

To simplify, risk assessment primarily involves a series of processes and measures put in place to assess, monitor, and mitigate risks, while improving desired outcomes (HealthCare Compliance Pros). In prescribing pharmacological and therapeutic treatments for older adults with depression, it’s prudent that the provider takes into consideration the patient’s medical and psychiatric condition with adequate clinical evidence to make appropriate diagnosis and treatment plan that is patient-centered, aimed at treating/managing the symptoms in ways that the benefits far outweigh potential risks, to improve patient outcomes. In managing risk assessment pertained to prescribing medications and treatments, it’s important that the provider assess a drug or treatment’s benefit-risk balance, implement tools that minimizes risks while preserving benefits, evaluate effectiveness of tools used and re-assessing their benefits-risk balance and making appropriate adjustments to risk minimization tools to further improve the benefit-risk balance, while ultimately providing patient information about their prescribed drug or treatment, with inclusion of package inserts that provide the prescribing information which highlights essential information about the safe and effective use of the drug or treatment (U.S Food & Drug Administration). Other areas of relevance include assessing the patient’s allergy history to prevent adverse and negative treatment outcomes, and fostering interprofessional collaboration that involves providers, pharmacists, nurse practitioners and other clinicians to engage in the implementation and execution of policies and care to improve the patient’s health outcomes (National Library of Medicine, 2022).

Benefits of FDA Approved Medicines

FDA approved medications bear many benefits which includes regulating the safety and effectiveness of drugs sold in the U.S, with ongoing monitoring of the drug for its safety and effectiveness for as long as it’s on the market (Congressional Research Services). In addition, FDA approved medications undergo rigorous clinical trials and scrutiny to validate their efficacy and ensures that the manufacturer meets required specifications including the safety and effectiveness in the drug’s proposed use, appropriateness of the proposed labeling, adequacy of manufacturing methods to assure the drug’s identity, strength, quality, and purity, to optimize treatment outcomes and preserve public/consumer safety (Congressional Research Services).

Risks Of FDA Approved Medicines.

Risks of FDA approved drugs include the likelihood that the drug may not work for its intended use, the possibility of a harmful interaction of the drug with other drugs, food or supplements, and the potential for abuse by consumers, which could cause more harm than good, offsetting its intended purpose and possibly causing patient harm, and the chances that the drug may cause additional problems including addiction which contributes to medical and psychiatric problems (U.S Food & Drug Administration).

Benefits of Off-Label Drugs.

The benefits of off-label drugs include accessibility and cost-effectiveness for consumers, there may be evidence to demonstrate that the drug works for its off-label use, prevents prolonged waiting for treatment interventions in instances when FDA approved drugs are in shortages, or in cases wherein other approved FDA drugs have failed to treat the patient’s condition (Medical News Today).

Risks Associated in Use of Off-Label Drugs.

Potential risks associated in use of off-label drugs include a lack of strong scientific evidence to back up its efficacy in treating a specific illness or condition which potentiates increased risks of adverse effects, in addition to lack of coverage by insurance for off-label drugs, which may pose financial burden to the patient who may already have financial hardship (drugs.com, 2022). In addition, off-label drugs have legal action potential, given that its use often does not reflect “standard of care” treatment, posing legal risks to the provider in the event of unwanted drug/treatment outcomes, lacks sufficient scientific information on the best way to use the drug other than for its intended approval, as well as ethical issues related to its use in patients and for unintended purposes (American Cancer Society).

Clinical Practice Guidelines for Depression In Adults

Clinical practice guidelines are primarily intended to be a central determinant of treatment choice, and mainly pertains to systematic review of evidence about efficacy of treatment in illnesses including depression, data regarding risk of harm gotten from treatments, data regarding patient preferences, values regarding treatments, and data regarding applicability of treatments across populations and settings, serving as essential tool for providers, and guides clinical decision-making for patients to receive the care they need (American Psychological Association). Clinical practice guidelines for older adults with depression specifies a step-by-step action involved in treatment proceedings while monitoring progress to determine effectiveness or modification of plan of care, which is ultimately aimed at improving practice and patient outcomes, hence my recommendation for its utilization in clinical practice, given its evidence-based credibility.

References

American Cancer Society. Off-Label Drug Use: What Is Off-Label Drug Use?

https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/off-label-drug-use.html#:~:text=What%20problems%20can%20be%20caused%20by%20off-label%20drug,does%20not%20regulate%20the%20practice%20of%20medicine.%20 Links to an external site.

American Psychological Association, (2022). Using the APA Clinical Practice Guidelines for The Treatment of Depression in Adults.

https://www.apa.org/depression-guideline/decision-aid-adults.pdf Links to an external site.

American Psychological Association, (2017). Placing Clinical Practice Guidelines in Context. https://www.apa.org/about/offices/directorates/guidelines/context Links to an external site.

apa.org, (2019). Depression Treatments for Older Adults. https://www.apa.org/depression-guideline/older-adults Links to an external site.

Congressional Research Services. How FDA Approves Drugs and Regulates Their Safety and Effectiveness. https://sgp.fas.org/crs/misc/R41983.pdf Links to an external site.

drugs.com, (2022). Trazodone: What is Trazodone? https://www.drugs.com/trazodone.html Links to an external site.

drugs.com, (2022). Off-Label Drug Use: What Is It? https://www.drugs.com/slideshow/off-label-or-off-limits- Links to an external site.

1237#:~:text=What%20Are%20the%20Drawbacks%20to%20Off-Label%20Prescribing%3F%201,cancer%20regimens%20when%20used%20in%20an%20off-label%20manner.

HealthCare Compliance Pros. Risk Assessment HealthCare: Why Does It Matter?

https://www.healthcarecompliancepros.com/risk-assessment-healthcare#:~:text=Risk%20assessment%20in%20healthcare%20is%20a%20complex%20procedure.,safeguarding%20your%20patient%20information%20and%20other%20organizational%20assets Links to an external site. .

healthline.com. Life-Review Therapy: What Is Life-Review Therapy?

https://www.healthline.com/health/life-review-therapy Links to an external site.

National Institute on Aging, (2021). Depression and Older Adults. https://www.nia.nih.gov/health/depression-and-older-adults Links to an external site.

National Library of Medicine, (2022). Risk Management Event Evaluation and Responsibilities. https://www.ncbi.nlm.nih.gov/books/NBK559326/ Links to an external site.

National Library of Medicine, (2021). Citalopram. https://www.ncbi.nlm.nih.gov/books/NBK482222/#:~:text=Mechanism%20of%20Action%20Citalopram%20hydrobromide%20acts%20as%20an,norepinephrine%20%28NE%29%20and%20dopamine%20%28DA%29%20neuronal%20reuptake.%20 Links to an external site.

Medical News Today. What To Know About Off-Label Drug Use.

https://www.medicalnewstoday.com/articles/off-label-drug-use Links to an external site.

U.S Food & Drug Administration. Understanding Unapproved Use of Approved Drugs “Off-Label” https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label Links to an external site.

U.S Food & Drug Administration. FDA’s Role in Managing Medication Risks.

https://www.fda.gov/drugs/risk-evaluation-and-mitigation-strategies-rems/fdas-role-managing-medication-risks Links to an external site.

U.S. Food & Drug Administration. Think It Through: Managing The Benefits and Risks Of Medications. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/think-it-through-managing-benefits-and-risks-medicines

Prescribing For Older Adults and Pregnant Women

Insomnia is a common condition among pregnant women, affecting up to 80% of women in the third trimester. Insomnia is experienced as difficulty falling asleep, staying asleep, and waking too early in the morning. This can be especially troublesome for pregnant women, as it can interfere with the rest needed for a healthy pregnancy. Insomnia can negatively affect a woman’s emotional, physical, and mental health, as well as the fetus. As such, it is important to understand the causes and possible treatments of insomnia in pregnant women. The post will recommend one FDA-approved drug, one off-label, and one nonpharmacological intervention for treating insomnia disorder in pregnant women. It will explain the risk assessment I would use to inform my treatment decision-making, the risk and benefits of the FDA medicine, and the risk and benefits of the off-label drug. It will then explain whether clinical practice guidelines exist for insomnia disorder.

FDA-Approved Drug, Off-Label Drug and Nonpharmacological Intervention for Treating Insomnia

An FDA-approved medicine for treating insomnia disorder in pregnant women is doxepin. Doxepin is a tricyclic antidepressant that is effective in treating insomnia. It is thought to work by increasing the amount of serotonin in the brain, which helps regulate mood and sleep cycles. It is generally considered safe for pregnant women, though there is some evidence that it may increase the risk of preterm delivery. Therefore, it is essential to discuss the risks and benefits of doxepin with the pregnant woman and her care provider before starting the medication (Stahl, 2020). Melatonin is an off-label drug that could be used to treat insomnia disorder in pregnant women. Melatonin is a hormone naturally produced in the body that helps regulate sleep cycles. It is available in supplement form and is considered safe for pregnant women. However, there is not enough evidence to suggest that melatonin effectively treats insomnia in pregnant women. Therefore, it is important to discuss the risks and benefits of melatonin with the pregnant woman and her care provider before starting the medication (Hollifield & Manber, 2018).

A nonpharmacological intervention for treating insomnia disorder in pregnant women is cognitive-behavioral therapy (CBT). CBT is a type of psychotherapy that helps people identify and change their thinking and behavior patterns that are causing distress. It is considered a safe and effective treatment for insomnia in pregnant women and can help them learn how to manage their sleep cycles better (Sivertsen et al., 2020).

Risk Assessments used to Inform my Treatment Decision Making

When making treatment decisions for pregnant women with insomnia disorder, it is important to consider each treatment option’s potential risks and benefits. For the FDA-approved medicine, doxepin, the potential risks include preterm delivery and other adverse effects, while the potential benefits include improved sleep and possibly improved mood. For the off-label medicine, melatonin, the potential risks include unknown effectiveness and possible side effects, while the potential benefits include improved sleep and possibly improved mood (Stahl, 2020). For the nonpharmacological intervention, CBT, the potential risks include the time and effort required to complete the therapy, while the potential benefits include improved sleep, improved mood, and improved coping skills (Sivertsen et al., 2020).

Clinical practice Guidelines

Clinical practice guidelines exist for treating insomnia disorder in pregnant women. The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend that pregnant women with insomnia consider behavioral interventions, such as CBT, as first-line treatments. If these interventions are ineffective, ACOG then recommends using pharmacologic treatments, such as doxepin, as second-line treatments. If these treatments are also ineffective, ACOG recommends the off-label use of melatonin (Sivertsen et al., 2020). Therefore, the recommendations for treating insomnia disorder in pregnant women align with the ACOG guidelines.

A multifaceted approach is recommended to treat insomnia disorder in pregnant women. An FDA-approved drug, such as Doxepin and Zolpidem, should be used with caution due to their potential side effects, including dizziness, confusion, and daytime drowsiness. An off-label drug, such as melatonin, should also be considered an alternative, as it has few known side effects. A nonpharmacological approach, such as mindfulness meditation, may help reduce stress and improve sleep quality. Clinical practice guidelines should also be consulted to determine the safest and most effective treatment for this disorder.

References

Hollifield, M., & Manber, R. (2018). Benzodiazepines for Insomnia: A Review of Effectiveness and Safety. Current Psychiatry Reports, 20(7), 44.

Sivertsen, B., Mork, E., Pallesen, S., Nordhus, I. H., & Bjorvatn, B. (2020). Non-pharmacological Treatment of Insomnia: A Review. Sleep Medicine Reviews, 49, 101098.

Stahl, S. M. (2020). Insomnia: Pharmacological Treatment Options. CNS Spectrums, 25(4), 347–355.

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SC

Saffie Conteh

Jan 24, 2023 3:58pm

Reply from Saffie Conteh

Applied Informatics

Saffie Conteh

NRNP-6675

Dr. Madeleine Reyes

Date 1/24/20203

Applied Informatics

Ideas in Medical Informatics applied in administration and operations to improve data.

The field of healthcare administration informatics is one of the models of applied informatics used in healthcare administration. The relevance of applied informatics in healthcare administration is based on the primary concern of implementing evaluation, acquisition, and implementation of proper day-to-day operations of the healthcare organization (Motiwala et al., 2022). The relevant aspect of implementing applied informatics in healthcare administration is that information technology has made it easier for healthcare managers to use technology systems to support all administrative and clinical functions.

The use of informatics in the management of data for healthcare administration has improved healthcare delivery since all the provider-related issues are essentially addressed. For instance, healthcare providers have difficulty managing provider data regarding which medical experts should operate during which shifts (Pramanik et al., 2020). However, with provider portals, it remains possible to manage to assign changes. The healthcare organization’s daily operations are improved and effectively approved. These administrative decisions are only made better by healthcare-applied informatics in administration. Healthcare administrators can tailor incentive plans to patients through healthcare administrators. Below are how to apply these aspects to healthcare organizations.

Applications of these ideas

In the assisted living organization, applied informatics can be used to achieve proper day-to-day operations of various systems. One area that healthcare administration informatics could apply is to have patient-generated data. Patient-generated data would help manage the patients so the organizations do not have to deal with aspects relating to leaked patient information that can attract legal suits. In conclusion, applied informatics for healthcare administration is a perfect way to deal with challenges regarding day to day operations of the organization.

References

Motiwala, T., Zhang, P., Gregory, M., Fareed, N., Ning, X., Coombes, K., … & Hebert, C. (2022). Review of applied health informatics courses in a multidisciplinary biomedical informatics department. Learning Health Systems , 6 (4). https://www.proquest.com/openview/3306585991d2e670bdb8f7945d951206/1?pq-origsite=gscholar&cbl=4370300 Links to an external site. .

Pramanik, M. I., Lau, R. Y., Azad, M. A. K., Hossain, M. S., Chowdhury, M. K. H., & Karmaker, B. K. (2020). Healthcare informatics and analytics in big data. Expert Systems with Applications , 152 , 113388. https://www.sciencedirect.com/science/article/pii/S0957417420302128 Links to an external site. .

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Oluwaseun Obajolu

Jan 24, 2023 8:17am | Last reply Jan 28, 2023 4:33pm

Reply from Oluwaseun Obajolu

Discussion: Prescribing for Pregnant Women

Postnatal depression and prenatal depression share many characteristics, with depression experienced at other times. Depression is characterized by anxious and pessimistic thoughts directed at the unborn child (Khanghah et al., 2020). Women frequently doubt their abilities to be excellent parents and worry about how others see them. Unfortunately, women often delay receiving therapy for prenatal or postnatal depression much longer than is necessary because they, their families, and occasionally even medical professionals may not recognize the condition (Jahan et al., 2021). This is due to a variety of factors. There is some overlap between typical pregnancy symptoms and depression. Still, women assume incorrectly that their symptoms are a natural aspect of pregnancy or transitioning to having a new baby (Frieder et al., 2018). Unnecessarily, some people worry that others could judge them as unfit parents. Another frequent emotion is shame over not being joyful and ecstatic. Anyone can have perinatal mental health concerns, so if you feel you might be having a problem, don’t hesitate to ask for assistance.

FDA-Approved Drug: Bupropion (Wellbutrin)

The FDA has approved this drug to treat depression, seasonal affective disorder, and substance use disorders linked to smoking. These cover solely adult therapy options. Norepinephrine-dopamine reuptake inhibitors include bupropion. By boosting the levels of dopamine and norepinephrine in the brain by inhibiting their reabsorption following synaptic transmission, the medication improves the patient’s mood, as implied by the name. Bupropion is a class C drug (Jahan et al., 2021). Since there are little to no dangers associated with the medicine on either the patient or the unborn, it is safe for use in treating pregnant women. It is safe to use while expecting or nursing a baby.

Off-Label Drug: Duloxetine (Cymbalta)

This drug is authorized to treat recurrent musculoskeletal pain. However, as a medicine taken off-label, it treats adult depression, including prenatal and postnatal depression. Because multiple studies have demonstrated its usefulness in such processes, it is used unconventionally (Khanghah et al., 2020). It is classified as a Class C medication, which means that even though there are side effects, the benefits exceed the unwanted effects (Jahan et al., 2021). By raising the levels of serotonin and noradrenaline in the brain, the selective serotonin and norepinephrine reuptake inhibitor duloxetine enhances brain function.

Non-pharmacological Intervention: Cognitive-Behavioral Therapy

The most specific psychosocial intervention for treating mental illnesses is this one. It operates on the tenet that our thoughts influence our moods and behaviors. CBT enables patients to recognize and replace negative ideas with positive ones. The patient can consequently have an improved mood (Frieder et al., 2018). It also aids the patient in developing stronger coping mechanisms. In many cases, CBT is said to be more effective than medicine. Combination therapy is strongly advised, nevertheless.

Risk Assessment for Duloxetine and Wellbutrin

Wellbutrin has not been linked to any known adverse effects when used to treat pregnant women. However, it has been linked to sleeplessness, headaches, constipation, mouth dryness, tachycardia, weight gain, and vomiting. However, there is a slight possibility of experiencing negative effects (Kaufman et al., 2022). According to reports, duloxetine might result in nonteratogenic side effects such as cyanosis, sleep apnea, seizures, eating problems, vomiting, hypoglycemia, and hypertonia (Khanghah et al., 2020). However, because it falls under group C, its advantages exceed these negative effects.

Clinical Guidelines

Consensus recommendations for treating depression during pregnancy were recently released by the American Psychiatric Association and the American College of Obstetricians and Gynecologists. The objective was to thoroughly analyse the literature and treatment suggestions from authorities in prenatal psychiatry and obstetrics (Frieder et al., 2018). Given the rising concerns about using antidepressants during pregnancy and the growing, somewhat confused body of literature covering this topic, this significant publication comes at a critical moment.

If a pregnant woman has depression, treatment should be suggested. Psychotherapy is advised as the first line of treatment for mild to moderate depression. Although there is research specifically looking at the effectiveness of psychotherapy for depression during pregnancy, there is much evidence to support its use in the general population (Frieder et al., 2018). Psychotherapy referrals are based on the patient’s willingness, availability of qualified professionals, and financial ability. The final two obstacles must be removed because pregnant individuals are probably more inclined to prefer psychotherapy over drugs. But not every patient, not even those with a comparable ailment, will benefit from a single recommended medication, which includes psychotherapy (Khanghah et al., 2020). To provide alternatives if necessary, a patient who is referred for psychotherapy should continue to have her progress monitored.

Antidepressant use during pregnancy is the main emphasis of the American Psychiatric Association/American College of Obstetricians and Gynecologists guidelines. According to scientists, there is evidence linking the usage of selective serotonin reuptake inhibitors with tiny for gestational age newborns (Khanghah et al., 2020). The absolute difference in birth weight is minor and of uncertain clinical relevance, and it is unclear if this depends on the duration of exposure (Jahan et al., 2021). Although there is evidence linking antidepressant usage during pregnancy to preterm birth (defined as occurring before 37 weeks gestation), the differences between exposed and unexposed groups are minor.

References

Frieder, A., Fersh, M., Hainline, R., & Deligiannidis, K. M. (2019). Pharmacotherapy of postpartum depression: Current approaches and novel drug development. CNS drugs , 33 (3), 265–282. https://doi.org/10.1007/s40263-019-00605-7 Links to an external site.

Jahan, N., Went, T. R., Sultan, W., Sapkota, A., Khurshid, H., Qureshi, I. A., & Alfonso, M. (2021). Untreated depression during pregnancy and its effect on pregnancy outcomes: A Systematic Review. Cureus , 13 (8), e17251. https://doi.org/10.7759/cureus.17251 Links to an external site.

Kaufman, Y., Carlini, S. V., & Deligiannidis, K. M. (2022). Advances in pharmacotherapy for postpartum depression: a structured review of standard-of-care antidepressants and novel neuroactive steroid antidepressants. Therapeutic Advances in Psychopharmacology , 12 , 20451253211065859. https://doi.org/10.1177/20451253211065859 Links to an external site.

Khanghah, A. G., Khalesi, Z. B., & Hassanzadeh, R., Afagh (2020). The importance of depression during pregnancy. JBRA Assisted Reproduction , 24 (4), 405–410. https://doi.org/10.5935/1518-0557.20200010 Links to an external site.

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Sward Kamarah

Jan 23, 2023 8:20pm | Last reply Jan 28, 2023 9:05am

Reply from Sward Kamarah

Wk9DiscussionKamarahS6675.docx Download Wk9DiscussionKamarahS6675.docx

Wk9DiscussionKamarahS6675-1.docx

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Shawn Osborne

Jan 23, 2023 7:29pm | Last reply Jan 28, 2023 9:17pm

Reply from Shawn Osborne

According to Mitchell and Goodman (2018), up to 10 percent of pregnant women will be prescribed an antidepressant while pregnant. There have been some studies that suggest risks including birth defects and health problems with antidepressant use during pregnancy, however, this is controversial and is not supported by strong evidence. The FDA recommends that women do not use antidepressants, but if needed, providers should follow their regular prescribing methods. In the following assignment, I will utilize literature and evidence to make treatment choices ,appropriate for a pregnant woman.

FDA-approved drug, off label drug, and nonpharmacologic intervention

I chose sertraline for my FDA approved drug, which is labeled category C. Use of antidepressants is more likely to cause possible harm in early and late stages of pregnancy, so with this in mind, I felt a drug that was easy to stop and restart as needed would be beneficial. Many others are difficult to wean off, and can cause distressful symptoms. Sertraline is less known to cause such problems, and can often be weaned without difficulty.

Molenaar et al., (2018) Share that treatment guidelines for practice are either neutral, or lack evidence when recommending wether to continue or stop antidepressants during pregnancy. When depression is a new occurrence during pregnancy they found recommendations for CBT or other psychotherapy, and if severe, the preferred antidepressant that most prescribed was Sertraline. The authors discuss the controversy over the safety of SSRI’s during pregnancy, and conversely, the possible harm and negative outcomes that may result from no treatment, such as increased suicide, interrupted or poor bonding, and post-partum depression. They report that some possible but not proven effects from taking an SSRI during pregnancy can result in: heart defects, pulmonary hypertension, premature birth, and low birth weight. They also share that depression without treatment can result in: premature birth, low birth weight, and fetal death. This is important to consider when making treatment decisions, and assessing risk in pregnant patients. The risks are similar in treatment vs. non-treatment. But it appears that with treatment, postpartum outcomes may be preferential. A discussion of risks and benefits with the patient is essential, so that an informed decision can be made. The patient is taking all the risk, and needs to have accurate and comprehensive education to make this decision.

An off-label drug I would use is Buspar, which is FDA pregnancy label B. The NIH (2022) highlights the use of Buspirone as an augmenting agent to help with depression, as well as evidence that Buspirone can be effective as monotherapy for depression. The risks of Buspar in pregnancy is unknown but considered safer than others, as it is a category B drug. Nervousness, agitation, and activation can be experienced with Buspirone as well as headaches and dizziness. The benefits are similar to Sertraline, as the negative effects of non-treatment are avoided.

A non-pharmacologic intervention I would use is psychotherapy. Specifically, cognitive behavioral therapy, or interpersonal therapy, which according to Li et al., (2020), are considered the gold standard for treating depression and anxiety during pregnancy. The authors performed a meta-analysis and found evidence for psychotherapy as beneficial during pregnancy at decreasing depression and increasing quality of life. They found results could be maintained, and had positive effects on cognitive processes and self-monitoring abilities. And notable, is the side effects and complications that can be avoided if therapy is sufficient and medication is not needed.

Conclusion

Choosing medications is a complex task, as there are usually risks and benefits for each. Sharing the information with the patient and discussing the preferences and outcome desires, can aid the decision process. Informed consent, and an informed decision are imperative concepts that must be assured for our patients, as they are personally taking the risk.

References

Li, C., Sun, X., Li, Q., Sun, Q., Wu, B., & Duan, D. (2020). Role of psychotherapy on antenatal depression, anxiety, and maternal quality of life. Medicine , 99 (27), e20947. https://doi.org/10.1097/md.0000000000020947 Links to an external site.

Mitchell, J., & Goodman, J. (2018). Comparative effects of antidepressant medications and untreated major depression on pregnancy outcomes: A systematic review. Archives of Women’s Mental Health , 21 (5), 505–516. https://doi.org/10.1007/s00737-018-0844-z Links to an external site.

Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. Australian & New Zealand Journal of Psychiatry , 52 (4), 320–327. https://doi.org/10.1177/0004867418762057 Links to an external site.

NIH. (2022). Buspirone. National Library of Medicine . Retrieved January 22, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK531477/

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Teresa Kangethe

Jan 23, 2023 5:53pm | Last reply Jan 29, 2023 9:10pm

Reply from Teresa Kangethe

Student Name: Teresa Kangethe

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name: Dr. Reyes

Discussion on Pregnant mothers on psychotropic medications.

There is no extensive testing that has been done on pregnant and lactating mothers. To treat a pregnant woman suffering from the anxiety, gabapentin is one of the FDA approved medications. According to the study gabapentin has no increased risk of major congenital malformations but one study showed increase preterm birth, low birth weight and NICU admission. Monitor gabapentin level due to metabolic changes that occur during pregnancy. An off label anxiety medication is Clonidine and psychotherapy is the nonpharmacological treatment. Other medication mentioned is Pregabalin then buspirone that has no data in human but has had congenital malformations in animals (Fryane, 2021).

The biggest problem is that there is no enough study extensively done with pregnant mothers and babies. In Arizona when a mother become pregnant, they are suppose to call 1-866-961-2388 number to register. This is one way that is used to collect data and do research in most psychotropic medications during pregnancy. The study follows them even after delivering so they can monitor the effects of psychotropic at long run. Pregnant mothers are vulnerable to relapse during the pregnancy. There is a tendency of reducing the dosing especially during the first trimester but this brings more harm to the mother and baby. Patient taking psychotropic are at risk factors of taking street drugs, alcohol, over the counter medications than patient with other medical sickness like hypertension. This may affect the study outcome when other drugs interfere with the prescribed psychotropic doses. During pregnancy body changes including weight gain, metabolism is known to affect dosing,

There is no most recommended psychotropic medication for pregnant women. It is the work of the provider to study the medication they are on and weigh the pro and cons. If the mother relapse or is not mentally stable the harm is as worse as prescribing the psychotropic during pregnancy “one pregnant mother stated, I don’t want to hear my baby is fine in labor and delivery ward, I want to hear that my baby life is normal all his life and my psychotropic medication I took did not harm the baby” (Payne, 2016)

Reference

Frayne, J., Watson, S., Snellen, M., Nguyen, T., & Galbally, M. (2021). The association between mental illness, psychotropic medication use and hypertensive disorders in pregnancy: A multicentre study. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health , 24 , 22–26. https://doi.org/10.1016/j.preghy.2021.02.002

Byatt N, Hicks-Courant K, Davidson A, et al. Depression and anxiety among

high-risk obstetric inpatients. Gen Hosp Psychiatry 2014;36:644-9

Thiels C. Pharmacotherapy of psychiatric disorder in pregnancy and

during breastfeeding: a review. Pharmacopsychiatry 1987;20:133-46.

Chisolm , M. S., & Payne, J. L. (2016). Management of psychotropic drugs during pregnancy Links to an external site. . British Medical Journal , 352 . https://doi.org/10.1136/bmj.h5918

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Laura Assanga Eyong

Jan 22, 2023 4:43pm | Last reply Jan 27, 2023 8:47pm

Reply from Laura Assanga Eyong

Accessing, Diagnosing, and Treating of Depression in Pregnant Women

A DSM-5 definition for depression is a lack of enjoyment or interest in life, low energy, weight gain or loss, mood swings, sleep difficulty, guilt, suicidal thoughts, etc. Numerous medications are teratogens during pregnancy, increasing the risk of congenital disabilities, spontaneous abortions, stillbirths, and maternal mortality. Pregnancy-related treatment and pharmaceutical use are restricted and necessitate knowledge of the pharmacodynamics and effects of the medicine on the expectant mother.

Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your chosen disorder in older adults or pregnant women

The preferred medication for treating personality disorders and mental impairment is typically an antidepressant. Selective Serotonin Reuptake Inhibitors (SSRIs), including Citalopram, are a class of drugs that have received FDA approval (Celexa). It prevents serotonin (5-HT) reuptake by neurons in the synaptic cleft. However, it can also cause drowsiness, vertigo, and sweating (Bérard et al., 2017). Vortioxetine is an off-label medication that has demonstrated its effectiveness. However, it is not yet approved due to its recent regulatory approval into the antidepressant family (Shweiki et al., 2021). Although the medicine is still being studied and has not yet received praise, it has demonstrated strength and had positive results when used to treat depressive episodes in pregnancy.The most effective non-pharmacological treatment for a major depressive illness during pregnancy is psychotherapy (Snapper et al., 2018). It improves function and well-being by helping to eliminate and regulate bothersome symptoms.

Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of FDA-approved medicine? What are the risks and benefits of the off-label drug?

Antidepressants’ teratogenicity and effects on the developing fetus, such as heart abnormalities, primary pulmonary hypertension in newborns, or poor neonatal adaption syndrome, are the main risks associated with using them during pregnancy. After prolonged use, especially in the third trimester, drugs can cause fetal mortality. A non-teratogenicity prescription should guide the medicine selection.

According to Berard et al. (2017), there is a link between Citalopram (an FDA-approved drug) and a higher incidence of poor newborn adaption syndrome. It can result in changes in crucial genes for development during the embryogenic stage, resulting in congenital disabilities. On the other side, vortioxetine increases the chance of injury to the infant and the mother relapsing into depression (Shweiki et al., 2021). However, it offers the advantage of lessening and stopping depressive episodes while having fewer adverse effects. Nevertheless, it is effective in treating pregnancy-related depression.

Explain whether clinical practice guidelines exist for this disorder and if so, use them to justify your recommendations. If you still need to, explain what information you need to consider.

There are clinical practice recommendations for mental retardation and personality problems in pregnancy. These include prescription drugs and counseling. Remission is emphasized as the primary objective of psychotherapy. Medication, however, specifies the drug combinations for treating severe depressive disorder. These include combining tricyclic antidepressants (TCAs) like imipramine, amitriptyline, or nortryptyline with SSRIs like citalopram, escitalopram, fluoxetine, or paroxetine. Therefore, to treat major depressive disorder during pregnancy, I advise utilizing both medication and psychotherapy.

References

(1). Austin, M.-P., Frilingos, M., Lumley, J., Hadzi-Pavlovic, D., Roncolato, W., Acland, S., … Parker, G. (2008). Brief antenatal cognitive behavior therapy group intervention to prevent postnatal depression and anxiety: A randomized controlled trial. Journal of Affective Disorders, 105(1–3), 35–44. https://doi.org/10.1016/j.jad. 2007.04.001 Links to an external site.

(2). Bérard, A., Zhao, J. P., & Sheehy, O. (2017). Antidepressant Use during Pregnancy and the Risk of Major Congenital Malformations in a Cohort of Depressed Pregnant Women: An Updated Analysis of the Quebec Pregnancy Cohort. BMJ Open, 7(1), e013372. https://doi.org/10.1176/appi.ajp.2010.09121743 Links to an external site.

(3). Shweiki, S., & Diav‐Citrin, O. (2021). Pregnancy Outcome after First-Trimester Exposure to Vortioxetine: A case series. Birth Defects Research, 113(6), 511-515.

(4). Snapper, L. A., Hart, K. L., Venkatesh, K. K., Kaimal, A. J., & Perlis, R. H. (2018). A Cohort Study of the Relationship between Individual Psychotherapy and Pregnancy Outcomes. Journal of affective disorders, 239, 253-257.

(5). Sangini S. Sheth, Jenell Coleman, Tirza Cannon, Lorraine Milio, Jean Keller, Jean Anderson & Cynthia Argani (2015) Association between depression and nonadherence to antiretroviral therapy in pregnant women with perinatally acquired HIV, AIDS Care, 27:3, 350-354, DOI: 10.1080/09540121.2014.998610 Links to an external site. 10.1080/09540121.2014.998610 Download 10.1080/09540121.2014.998610 10.1080/09540121.2014.998610