WK9 RESPONESES TO DISCUSSIONS
- Rebekah Vigileos
Week#9 Discussion
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Introduction
Treating mental health conditions for women with mental or behavioral health disorders during pregnancy is often necessary to maintain the woman’s health and decrease the risk of harm to the mother and child (FDA, 2018). Without treatment, the woman who is unable to safely care for herself or a new child faces an increased risk of pre and postnatal complications. Treatment options of particular concern are psychotropic medications, which may differentially affect fetal neurodevelopment compared to other agents (Creeley et al., 2018). Risk assessments and careful monitoring of depressed pregnant patients should always be done. The Columbia Suicide Severity Rating Scale Scale (C-SSRS), PHQ-9, and GAD-7 are a few useful tools to gauge the severity of depression and anxiety symptoms (Creeley et al., 2018). Safety should always be the priority. There are times when the risk and benefits of beginning or continuing psychopharmacological treatment during pregnancy must be considered. (Creeley et al., 2018)
Psychopharmacology for Depression During Pregnancy
The potential to impact fetal neurodevelopment is always a risk, however, the befits of mental stability, preventing relapse, or exacerbation of mental health symptoms in the pregnant population cannot be understated (FDA, 2018). Because mental illness in the mother is not a benign event, it may itself pose an increased risk for harm to mother and baby. The discontinuation or avoidance of medication use during pregnancy is not always an option for a pregnant woman. This makes prenatal exposure to psychotropic drugs a major public health concern (FDA, 2018). Decisions regarding medication, dose, and duration should be made carefully (Creeley et al., 2018). Considerations include balancing the severity of symptoms, chronicity, and co-morbidity of the mental illness, disorder, or condition against the potential risk for adverse outcomes due to neonatal exposure (FDA, 2018).
If a pregnant woman uses SSRIs such as Prozac, during the third trimester, there is an increased risk the baby may be born with neonatal abstinence syndrome (NAS) (Creeley et al., 2018). Symptoms of this condition may include irritability, excessive crying, jitteriness, increased muscle tone, difficulty breathing, trouble sleeping, tremors, and trouble feeding. Despite these risks, the medical literature has well documented the use of SSRIs are used during pregnancy (Creeley et al., 2018).
The benefits of antidepressant treatment for pregnant women with depression may outweigh the possible risk to the fetus in certain circumstances when depression is severe (FDA, 2018). This may include symptoms such as suicidal ideation or behavior, psychotic symptoms, complete loss of appetite, or if there is a family history of re-occurring mental disorders. Individuals lacking family or social support, or if moderate depression persists despite psychotherapeutic treatment, and antidepressant use should be pregnant women who meet any of these criteria (Creeley et al., 2018). Before obtaining informed consent from the patient and family, providers should always include the pros and cons of treatment as well as provide alternative treatment options (FDA, 2018).
Currently, most guidelines recommend the use of the SSRIs fluoxetine and citalopram, or the tricyclic antidepressant, nortriptyline for the treatment of depression during pregnancy (Creeley et al., 2018). Providers should ensure that the patient and her family are aware of any potential risks and know to immediately report any related symptoms (Creeley et al., 2018). Providers treating pregnant women with antidepressants should also need to coordinate their treatment with the responsible obstetrician to reduce the risk of adverse outcomes (Creeley et al., 2018).
Nonpharmacological Interventions
Nonpharmacological interventions include cognitive behavioral therapy, mindfulness, yoga, psychological and psychosocial assessment, supportive, and educational-based interventions (Evans et al., 2020). All may be intentional interventions to prevent an escalation of symptoms and improve a woman’s quality of life. Pregnant women who participate in psychological or mind-body interventions reported an overall satisfaction and described interventions as enjoyable, valuable, and beneficial. Group interventions may also be beneficial and allow women to discuss their thoughts and experiences (Evans et al., 2020). Other benefits range from learning practical breathing techniques to developing an ability to reflect on their thoughts and emotions. Exercises such as the body scan which fosters awareness of different areas of the body can help improve sleep (Evans et al., 2020). Individuals participating in group therapy teaching mindfulness and CBT interventions reported a greater understanding of the causes of stress and anxiety in their lives and greater self-awareness of their thought patterns (Evans et al., 2020). This helped them respond in a more positive way to situations and feelings before negative thought patterns could escalate (Evans et al., 2020).
A Lack of Clear Clinical Guidelines
Although there are no specific clinical practice guidelines for the treatment of depression in pregnant women, the panel for APA recommendations found that various types of interventions are available for the treatment of depression in the general adult population (APA, 2019). Comparative effectiveness studies indicated similar effects across different models of psychotherapy (APA, 2019). Types of psychotherapeutic interventions to consider include behavioral therapy, cognitive and cognitive-behavioral therapy, interpersonal psychotherapy, psychodynamic therapy, and supportive therapy (APA, 2019). When considering combined treatment, the panel recommends cognitive-behavioral therapy or interpersonal psychotherapy plus a second-generation antidepressant (APA, 2019).
Conclusion
Healthcare professionals and their patients must weigh the small potential risk of major adverse reactions such as persistent pulmonary hypertension of the newborn (PPHN) that may be associated with SSRI use in pregnancy against the substantial risks associated with under-treatment or no treatment of depression during pregnancy (FDA, 2018). Untreated depression during pregnancy is associated with poor birth outcomes, including low birth weight, preterm delivery, lower Apgar Scores, lack of prenatal care, failure to recognize or report signs of labor, and an increased risk of fetal abuse, neonaticide, or maternal suicide. (FDA, 2018).
References
American Psychological Association. (2019). Clinical practice guideline for the treatment of
depression across three age cohorts. American Psychological Association. Retrieved
July 22, 2022, from https://www.apa.org/depression-guideline
Evans, K., Spiby, H., & Morrell, J. C. (2020). Non-pharmacological interventions
to reduce the symptoms of mild to moderate anxiety in pregnant women. A
systematic review and narrative synthesis of women’s views on the
acceptability of and satisfaction with interventions. Archives of women’s
mental health, 23(1), 11–28. https://doi.org/10.1007/s00737-018-0936-9
FDA. (2018). SSRI antidepressant use during pregnancy and reports of a rare hea… U.S. Food
and Drug Administration. Retrieved July 22, 2022, from
https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-s
elective-serotonin-reuptake-inhibitor-ssri-antidepressant-use-during
Creeley, C. E., & Denton, L. K. (2019). Use of Prescribed Psychotropics during
Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood
Outcomes. Brain sciences, 9(9), 235.
https://doi.org/10.3390/brainsci9090235
- Edoghogho Edosonmwan
wk 9
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Prescribing Anti-Anxiety Medications for Pregnant Women
When prescribing medications for women, it is important that the provider assess for current pregnancy or plans for the patient to become pregnant because pregnancy is a contraindication for some medications. For patients with anxiety disorder, Buspar is an FDA approved medication for pregnant women. Buspar has been shown to be effective for management of Generalized Anxiety Disorder. This FDA approved medication is considered a category B risk drug for pregnancy and studies have shown undetectable levels of Buspirone levels in breast milk 13 days post-partum since taking 45 mg daily (Drugs and Lactation Database, 2021). Propanolol is a beta-blocker used as an off-label medication for anxiety disorder; propranolol is a category C medication and there is no well controlled studies in pregnant women (Creely & Denton, 2019). Aromatherapy is a non-pharmacological method for pregnant women to ease their anxiety. Studies show aromatherapy with roses, lavender, bergamot, oranges, and lemon essential oils have been helpful to relieve anxiety symptoms, and poses no risk in pregnancy (Barati et al, 2016).
Risks and Benefits
Risk assessment is important for decision making in healthcare because it enables the provider to assess the risks, and to provide the safest treatment possible based on known risks; risk assessment methods includes assessing for allergies, assessing previous class of medications tried, completing medication reconciliation, and assessing patient safety. The risk of prescribing Buspar to a pregnant woman are the possible side effects of increased drowsiness, outbursts of anger, and musculoskeletal pain and weakness. Benefits of Buspar is that it has a low potential for abuse and low in toxicity; therefore it is safe for mother and child (Wilson & Tripp, 2022). Some risks of prescribing propranolol to a pregnant woman is that it can decrease blood pressure, and patients on beta-blockers increases risk of developing preeclampsia and eclampsia by 1.9% (Duan et al, 2018). The benefits of prescribing propranolol to a pregnant woman is that is has low potential for abuse, and it has been proven to be effective in reducing physical symptoms of anxiety such as tachycardia, palpitation, and excessive sweating (Srinivasan, 2019).
Clinical Practice Guidelines for Anxiety Disorder in Pregnant Women
The first-line of treatment for GAD in pregnant is cognitive-behavioral therapy (CBT). Studies show that SSRI’s are the most common used for pregnant patients with GAD; according to research, 70% to 86% of SSRI’s and SNRI’s cross the placenta to the infant especially when taken in the first-trimester (Misri et al, 2015). It is important for the provider to consider these side effects before prescribing. This justifies my recommendation of prescribing Buspar because of its low toxicity levels and it does not affect the infant. The provider should also consider the mothers choice to breastfeed as SSRI’s can be present in breast-milk (Misri et al, 2015).
References
Barati F, Nasiri A, Akbari N, Sharifzadeh G. The Effect of Aromatherapy on Anxiety in Patients.
Nephrourol Mon. 2016 Jul 31;8(5):e38347. doi: 10.5812/numonthly.38347. PMID: 27878109; PMCID: PMC5111093.
Creeley CE, Denton LK. Use of Prescribed Psychotropics during Pregnancy: A Systematic Review
of Pregnancy, Neonatal, and Childhood Outcomes. Brain Sci. 2019 Sep 14;9(9):235. doi: 10.3390/brainsci9090235. PMID: 31540060; PMCID: PMC6770670.
Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): National Library of Medicine
(US); 2006-. Buspirone. [Updated 2021 Mar 17]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501449/
Duan L, Ng A, Chen W, Spencer HT, Lee MS. Beta-blocker subtypes and risk of low birth weight
in newborns. J Clin Hypertens (Greenwich). 2018 Nov;20(11):1603-1609. doi: 10.1111/jch.13397. Epub 2018 Sep 28. PMID: 30267456; PMCID: PMC8030941.
Misri S, Abizadeh J, Sanders S, Swift E. Perinatal Generalized Anxiety Disorder: Assessment and
Treatment. J Womens Health (Larchmt). 2015 Sep;24(9):762-70. doi: 10.1089/jwh.2014.5150. Epub 2015 Jun 30. PMID: 26125602; PMCID: PMC4589308.
Srinivasan AV. Propranolol: A 50-Year Historical Perspective. Ann Indian Acad Neurol. 2019
Jan-Mar;22(1):21-26. doi: 10.4103/aian.AIAN_201_18. PMID: 30692755; PMCID: PMC6327687.
Wilson TK, Tripp J. Buspirone. [Updated 2022 Mar 16]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531477/
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