NRNP 6675 Prescribing for Older Adults and Pregnant Women Walden University
Week 9 Main Post
Managing bipolar disorder, a highly complex mental health condition, becomes particularly challenging when it involves pregnant women. The delicate balance between the potential risks associated with discontinuing medication during pregnancy and the potential risks tied to continuing certain medications creates a unique clinical conundrum. Notably, many mood stabilizers commonly used to treat bipolar disorder carry an elevated risk of congenital defects when taken during pregnancy (Epstein et al., 2014). However, among the treatment options, Olanzapine, also known as Zyprexa, stands out as an atypical antipsychotic medication frequently employed for bipolar disorder management. Encouragingly, Zyprexa has not been linked to an increased risk of miscarriage or congenital birth defects (Olanzapine (Zyprexa®), n.d.). Research studies have even suggested that pregnant patients taking Zyprexa face no greater risk of adverse effects than the general population (Galbally et al., 2014).
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It’s important to note that the FDA categorizes Zyprexa as a level C pregnancy medication, implying that while it may be a valuable treatment option, some uncertainties remain regarding potential risks. This classification is part of the FDA’s framework for providing guidelines on medication prescription during pregnancy (Armstrong, 2008). Although abruptly discontinuing medication is generally not recommended, some patients opt for therapy as an alternative to medication during pregnancy. Cognitive Behavioral Therapy (CBT) has shown promise in helping patients manage depressive symptoms and mania during pregnancy without the need for medication (Epstein et al., 2014). Additionally, for bipolar disorder, some off-label use of safer antidepressant medications is possible during pregnancy. Zoloft, one such medication, stands out as a potentially safer option. Most Selective Serotonin Reuptake Inhibitors (SSRIs) are considered safe choices during pregnancy, with Zoloft being among the safest options for pregnant patients (What Is the Safest Antidepressant to Take When Pregnant?, 2021). This multifaceted approach to managing bipolar disorder in pregnant women reflects the complex decision-making process in the field of mental health.
Resources
Armstrong, C. (2008). ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation. American Family Physician, 78(6), 772–778. https://www.aafp.org/pubs/afp/issues/2008/0915/p772.html
Epstein, R., Moore, K., & Bobo, W. (2014). Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges. Drug, Healthcare and Patient Safety, 7, 7. https://doi.org/10.2147/dhps.s50556
Galbally, M., Snellen, M., & Power, J. (2014). Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects. Therapeutic Advances in Drug Safety, 5(2), 100–109. https://doi.org/10.1177/2042098614522682
Olanzapine (Zyprexa®). (n.d.). MotherToBaby. https://mothertobaby.org/fact-sheets/olanzapine/
What Is the Safest Antidepressant to Take When Pregnant? (2021, November 30). Psych Central. https://psychcentral.com/depression/safest-antidepressant-in-pregnancy#zoloft-vs-lexapro
Pregnancy is often viewed as a period of joy and emotional well-being for women. However, the experience of pregnancy and parenthood can also heighten a woman’s vulnerability to psychological disorders, such as anxiety and depression. Recent research indicates that depression is a common issue among many pregnant women. Unfortunately, this condition is frequently misdiagnosed, with symptoms often being attributed to fluctuations in the mother’s mood or physiology during pregnancy. Moreover, concerns about potential side effects of medication often lead to the underdiagnosis and neglect of this ailment.
Depression, with its associated side effects like changes in sleep patterns, appetite, and energy levels, can be challenging to distinguish during pregnancy from the typical experiences of expectant mothers. While up to 75% of pregnant women exhibit symptoms of some form of mood disorder, the percentage of women meeting the diagnostic criteria for major depression has been estimated to range from 12.6% at 31 weeks gestation to 16% at 34 to 35 weeks of pregnancy (Shimada et al., 2021).
However, there is reason for optimism. Depression during pregnancy can now be addressed through medical or psychological means, often a combination of both. Healthcare professionals, including pharmacists and doctors, commonly recommend Sertraline as a treatment for depression in pregnant women. Sertraline is an FDA-approved medication used to manage depressive and anxiety disorders, with a particular focus on pregnant women. This medication has the potential to enhance mood, sleep patterns, appetite, and energy levels, helping pregnant women regain interest in their daily activities (Shimada et al., 2021). Additionally, it can alleviate feelings of fear, anxiety, and negativity, and reduce the occurrence of panic events. It may also reduce the need to engage in repetitive behaviors that disrupt daily life.
Reference
Shimada, B. M. O., Santos, M. D. S. O. M. D., Cabral, M. A., Silva, V. O., & Vagetti, G. C. (2021 ). Treatments amongst Expectant Females in the Field of Songs Treatment: An Organized Evaluation. Revista Brasileira de Ginecologia e Obstetrícia, 43, 403-413.
Addressing Anxiety in the Elderly Population
Anxiety disorders are a prevalent concern among the elderly, with generalized anxiety disorder (GAD) being the most common among them (Park, 2022, pp. 2649). The treatment options for GAD in this demographic are multifaceted and require careful consideration due to the increased vulnerability of older adults to adverse effects, intolerability, and potential drug-drug interactions (Crocco et al., 2017, pp. 2).
One FDA-approved medication for anxiety in older adults is Escitalopram (Lexapro), an example of a selective serotonin reuptake inhibitor (SSRI). SSRIs are often the primary choice for treating GAD in older adults due to their safety profile and better tolerability within this population (Crocco et al., 2017, pp. 3). Lexapro has been shown to effectively reduce symptoms of GAD in older adults. However, there is a potential risk of “abnormal cardiac conductivity” associated with Lexapro, which necessitates a maximum dosage of 20 mg per day for the elderly to mitigate this risk (pp. 3). It is crucial to closely monitor elderly individuals with cardiac conditions while on this medication, including routine lab work and examinations.
An off-label medication used to address anxiety in older adults is Pregabalin, also known as Lyrica, an anticonvulsant. Pregabalin has demonstrated its efficacy in treating GAD in elderly patients in various research studies (Garakani et al., pp. 3). Notably, it is well-tolerated by the elderly, which is a significant advantage. However, potential adverse effects such as sedation, dizziness, and weight gain should be considered. Additionally, Pregabalin is classified as a Schedule V drug, indicating a higher potential for misuse and abuse. Occasional drug screenings may be necessary to ensure responsible use by the elderly. When discontinuing this medication, it is crucial to taper it off to prevent withdrawal symptoms, such as tremors, tics, or seizures, in older adults.
Nonpharmacological interventions for anxiety in elderly adults include techniques like “The Butterfly Hug.” This intervention involves crossing both hands on the chest and clapping them, imitating the flapping wings of a butterfly, while practicing deep breathing (Girianto, 2021, pp. 297). This approach, known as “direct bilateral stimulation,” induces a calming effect and reduces anxiety. Psychotherapy sessions can teach this technique to elderly patients.
Several risk assessment tools aid in identifying elderly adults in need of anxiety treatment. The Generalized Anxiety Disorder scale-7 (GAD-7) is one such tool, which is a simple 7-item scale based on the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for identifying likely GAD cases (Sapra et al., 2020, pp. 2). The score reflects the severity of a patient’s symptoms, classifying them as minimal, mild, moderate, or severe (pp. 3). This tool helps the APRN determine the necessity of GAD treatment.
Guidelines for managing generalized anxiety disorder recommend a comprehensive assessment by the provider to diagnose GAD. Afterward, the provider must decide between psychotherapy, pharmacotherapies, or a combination of both for the patient (Gautam et al., 2017). Therefore, a combination of Lexapro and Pregabalin appears to be a suitable treatment option for elderly GAD patients, along with psychotherapy to foster healthy coping mechanisms.
Treating the elderly, a unique patient population, is a complex process. Factors such as comorbid conditions like renal failure or cardiac issues need to be considered before initiating pharmacotherapy. Additionally, the cognitive decline often seen in the elderly, due to age or other comorbid conditions such as dementia, may affect the effectiveness of psychotherapy due to reduced understanding. Careful evaluation and tailored treatment plans are essential when addressing anxiety in this vulnerable population.
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