First Student
Prescribing for Pregnant Women (Insomnia)
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Insomnia disorder is a prevalent mental condition that affects many pregnant women. Kalmbach et al. (2022) reveal that 25 – 27% of pregnant women in the first two trimesters experience insomnia. Moreover, the study indicates that 40% of women in the final trimester of pregnancy have admitted insomnia symptoms (Kalmbach et al., 2022). The symptoms of insomnia disorder include the inability to fall asleep, waking up earlier than usual, and daytime fatigue. Health specialists diagnose patients with the condition if symptoms present themselves for three or more consecutive weeks. Pregnant women diagnosed with insomnia disorder risk preterm birth and postpartum depression.
The Food and Drug Administration (FDA) agency enlists certain drugs that insomnia patients can use. Pregnant mothers must be protected from using pharmacological medicines that may adversely affect fetal development. Diazepams are depressants commonly prescribed for pregnant women, especially during the first two trimesters of pregnancy. The drug acts on the hypothalamus and thalamus parts of the central nervous system to sedate patients and reduces anxiety (Bittmann et al., 2019). Despite the everyday use of Diazepams, little is known about the extent of damage they could inflict. Its effectiveness in treating insomnia is determined by dosage. Prescription, therefore, needs to be regulated effectively.
In the US, supplements are not categorized as drugs. Therefore, the FDA does not have the mandate to approve them. Melatonin is a naturally-produced hormone secreted in the pineal gland that promotes sleep by interacting with the hypothalamus and the retina (Savage et al., 2018). Low hormone levels in the human body cause sleeplessness because of irregular sleep-wake cycles. Melatonin supplements help prevent wake-promoting signals (Savage et al., 2018). Up to 10 milligrams of Melatonin are taken two hours before a pregnant woman goes to sleep. Despite not being FDA approved, the American Academy of Family Physicians (AAFP) considers Melatonin an effective drug in dealing with insomnia disorder.
Acupuncture is a traditional Chinese medicine theory used to treat fatigue and insomnia. The procedure has also been termed safe and effective in treating back and pelvic aches daily in pregnant women. According to Foroughinia et al. (2020), acupuncture improves the serum concentration of the sleep-inducing hormone, Melatonin. Foroughinia et al. (2020) further note that pregnant women with insomnia had their Pittsburgh Sleep Quality Index (PSQI) score spike by 6.7 points. The non-pharmacological procedure stimulates neurological points in the body that help in relaxation and better sleep patterns.
Diazepams are rarely used in the third trimester of pregnancy because of the health risk it imposes on a fetus. Like other benzodiazepines, late prenatal drug use has been associated with hypothermia, hyperreflexia, restlessness, incessant crying, and respiratory complications in infants (Bittmann et al., 2019). Excessive melatonin use leads to drowsiness, headaches, and nausea in pregnant women. Healthcare providers must be cognizant of these risks when deciding how to administer pharmacological treatment, especially during the final critical months of gestation.
Clinical specialists are advised to prioritize non-pharmacological therapy when treating insomnia disorder. Medicinal drugs should only be prescribed if the condition persists. Pharmacological treatment is yet to be established as solidly safe for pregnant women (Palagini et al., 2022). FDA-approved drugs like diazepams could impose harm to fetal and post-natal infant development. Furthermore, some benzodiazepines are placed in category X; drugs proved to cause pregnancy complications. Specialists should diagnose insomnia disorder carefully to determine the forms of treatment required. Analyzing the occurring symptoms and the medical history of the pregnant woman helps clinicians pinpoint the condition.
References
Bittmann, S., Villalon. G, Weissenstein. A and Luchter. E. (2019). Benzodiazepine Intoxication in a Neonate by Maternal Use in Pregnancy. J Clin Cases Rep 2(4):106-108. DOI: https://doi.org/10.46619/joccr.2019.2-1050
Foroughinia, S., Hessami, K., Asadi, N., Foroughinia, L., Hadianfard, M., & Hajihosseini, A. (2020). Effect of Acupuncture on Pregnancy-Related Insomnia and Melatonin: A Single-Blinded, Randomized, Placebo-Controlled Trial</p>. Nature and Science of Sleep, Volume 12, 271-278. https://doi.org/10.2147/nss.s247628
Kalmbach, D., Cheng, P., Roth, A., Roth, T., Swanson, L., & O’Brien, L. et al. (2022). DSM-5 insomnia disorder in pregnancy: Associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection. Sleep Advances, 3(1). https://doi.org/10.1093/sleepadvances/zpac006
Palagini, L., Bramante, A., Baglioni, C., Tang, N., Grassi, L., & Altena, E. et al. (2022). Insomnia evaluation and treatment during peripartum: A joint position paper from the European Insomnia Network task force “Sleep and Women,” the Italian Marcè Societ, and international experts task force for perinatal mental health. Archives of Women’s Mental Health, 25(3), 561-575. https://doi.org/10.1007/s00737-022-01226-8
Savage, R., Zafar, N., Yohannan, S., & Miller, J. (2018). Melatonin. Europepmc.org. Retrieved 15 July 2022, from https://europepmc.org/article/nbk/nbk534823.
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Second student
Prescribing for Older Adults
Becoming a psychiatric mental health nurse practitioner (PMHNP) requires one to have a strong knowledge base in the treatment of many different mental health conditions, as well as the treatment of many different age populations. Understanding how to care for special populations, such as the elderly is needed education for PMHNP students. Depression is common in the elderly population and patients may present with atypical features including feeling rejected, having weakness, and increased fatigue (Dai et al., 2022). The Purpose of this discussion post is to discuss one FDA-approved medication and one off-label medication to use for major depressive disorder in the elderly, suggest one nonpharmacological intervention to treat depression in the elderly, explain the risk assessment used to inform treatment decisions, and discuss if there are clinical guidelines for the treatment of depression in the elderly population.
FDA Approved Medication and Off Label Medication
Depression in the elderly is more common in people who have chronic medical conditions and cognitive disorders (Abdoli et al., 2022). Often, depression in the elderly is considered more atypical and does not always meet the criteria for major depressive disorder (Abdoli et al., 2022). Psychopharmacology can be rather tricky in the elderly population as efficacy rates of antidepressants are lower when compared to younger adults (Dai et al., 2022). Research studies indicate that up to forty percent of elderly patients on antidepressants do not show a response to treatment (Dai et al., 2022). One FDA approved medication to help treat depression in the elderly is Zoloft which is a selective serotonin reuptake inhibitor (SSRI) medication (Gutsmiedl et al., 2020). Zoloft is considered a good medication choice as it has few drug interactions, which is important when dealing with the elderly population due to the risk of polypharmacy (Gutsmiedl et al., 2020). This medication is also usually tolerated well with minimal side effects and does not have the anticholinergic issues that tricyclic antidepressants may cause (Gutsmiedl et al., 2020).
One off label medication that can be used to treat major depressive disorder in the elderly population is Abilify. This medication is classified as a second-generation antipsychotic but can be effective for depression when used in conjunction with an antidepressant. The FDA has given approval for use of Abilify for major depressive disorder when given in conjunction with an antidepressant (Gerhard et al., 2020). Use of this in the elderly though should be watched carefully to make sure issues such as rapid weight gain, and other issues do not occur (Gerhard et al., 2020). Use of Abilify needs to be cautioned in elderly people with dementia due to the increased risk of mortality (Gerhard et al., 2020). Studies indicate that using Abilify in conjunction with an antidepressant has been effective in treatment resistant depression in the elderly (Gerhard et al., 2020).
Non-Pharmacological Treatment
One non-pharmacological treatment for major depressive disorder in the elderly population is electroconvulsive therapy (ECT). This type of treatment is often used for treatment resistant depression and has been found to be 80 to 90% effective (Dai et al., 2022). Most people will need treatments twice a week for three weeks (Dai et al., 2022). ECT is safe for the elderly population and has minimal side effects, usually just headaches and short-term memory loss that returns (Dai et al., 2022).
Risk Assessment for Treatment Choice
Starting an elderly patient on any type of medication, including antidepressants, should always be done with careful consideration for risks. One of the assessments that need completed prior to prescribing is the potential risk for adverse reactions. Since older adults are more likely to have other health conditions and be on medications, there is an increased risk of drug interactions when prescribing antidepressant medications (Gutsmiedl et al., 2020). Making sure there is communication between the primary care providers and the mental health providers is important to make sure the patient is receiving safe treatment and to avoid polypharmacy (Gutsmiedl et al., 2020). Understanding there is a risk for altered metabolism and clearance of drugs in the elderly population is also important to think about as antidepressant medications could build up in one’s body and cause overdose risks due to decreased blood flow and decreased creatinine clearance (Gutsmiedl et al., 2020). For elderly patients, antidepressants should be started at a low risk and increases should be made slowly to avoid these risks. Another risk assessment with major depressive disorder is the risk for suicide. Up to 15% of people with major depressive disorder commit suicide, and suicide rates in the elderly population are high, especially with white males (Abdoli et al., 2022)
Clinical Guidelines
The lifetime prevalence of depression in elderly people over the age of sixty-five is 9.6% for men and 20.4% for women (Abdoli et al., 2022). There are clinical treatment guidelines for providers to follow for major depressive disorder in the elderly population. Some guidelines suggest that for mild depression, non-pharmacological treatment is the first line recommendation (Du et al., 2020). For mild to severe depression, the first line treatment that is suggested is the use of selective serotonin reuptake inhibitor (SSRI) medications due to their overall safety and minimal drug interactions (Du et al., 2020). Cognitive Behavioral Therapy either done alone or in a group is recommended for the treatment of major depressive disorder in the elderly combined with SSRI medication use (Du et al., 2020). Life review groups, problem solving therapy can also be a helpful from of treatment for depression in the elderly (Du et al., 2020).
Conclusion
Overall, the treatment of major depressive disorder in the elderly population can be difficult due to many different circumstances. The use of SSRI medications, CBT therapy, and ECT can be effective forms of treatment for depression in the elderly. Knowing the risks of polypharmacy, drug interactions, and suicide risks is important to remember when treating this special population.
References
Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2022). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 132, 1067-1073. https://doi.org/10.1016/j.neubiorey.2021.10.0131
Dai, B., Wu, X., Yan, F., Chen, Y., Xu, Y., Xia, Q., Zhang, X., & Xie, X. (2022). Effects of modified electroconvulsive therapy on serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels in elderly patients with treatment-resistant depression. Frontiers in Endocrinology, 13. https://doi.org/10.3389/fendo.2022.904005
Du, L., Chen, Y., Jin, X., Yuan, W., & Wang, J.S. (2020). Critical appraisal of clinical practice guidelines for depression in children and adolescents: A protocol for systematic review. Medicine, 99(38). https://doi/org/10.1097/MD.00000000022384
Gerhard, T., Stroup, T.S., Correll, C.U., Setoguchi, S., Strom, B.L., Huang, C., Tan., Z., Crystal, S., & Olfson, M. (2020). Mortality risk of antipsychotic augmentation for adult depression. PLoS ONE, 15(9), 1-15. https://doi.org/10.1371/journal.pone.0239206
Gutsmiedl, K., Krause, M., Bighelli, I., Schneider, J., & Leucht, S. (2020). How well do elderly patients with major depressive disorder respond to antidepressants: A systematic review and single-group meta-analysis. BMC Psychiatry, 20. https://doi.org/10.1186/s12888-020-02514-2
