Please review the post and create a 3-4 paragraph reply for each post’s below indicating 2 key details that was learnt from the post. please add citation to back up the ideas and be clear with your thought process. TY

POST 1

1. How would your treatment plan (medications, therapy, etc) change for the pregnant female in Module 5 with Depression and Module 7 with Bipolar Mania?Treatment of Depressed Pregnant Patient: Depression is common in pregnancy and often remains untreated, which can lead to poor health outcomes such as poor nutrition, substance abuse, post-partum depression, impaired bonding between mother and infant, and increased rates of suicide (Grigoriadis, 2020). Although many practitioners are reluctant to use pharmacotherapy to treat depression in pregnancy, due to lack of familiarity and fear of harming the fetus, pharmacotherapy may be beneficial when considering all of the risks and benefit to the patient, particularly if the patient suffers from major depressive disorder and has been successfully treated with pharmacotherapy prior to pregnancy (Grigoriadis, 2020). Failure to continue pharmacotherapy for existing depression during pregnancy is associated with depressive relapses (Grigoriadis, 2020). Therefore, if a patient is stable on antidepressants prior to pregnancy, it is often advisable to continue treatment during pregnancy in order to prevent relapse, just as continuation of psychotherapy is recommended if this has been successful in treating the patient’s symptoms in the past (Grigoriadis, 2020). For pregnant women with severe depression, antidepressant medication is recommended as first line treatment, although psychotherapy is a reasonable alternative if the patient is resistant to medication after weighing all of the risks and benefits and is not experiencing suicidal ideation or impaired functioning (Grigoriadis, 2019).SSRIs are the most commonly used drugs to treat depression in pregnancy and do cross the placenta and fetal blood brain barrier, therefore carrying a risk for negative impacts to the fetus (Stewart & Vigod, 2020). Although no randomized clinical trials exist regarding safety of antidepressants during pregnancy, observational studies indicate that the risk of birth defects with SSRI use is low, although there may be some increased risk of preterm birth and postpartum hemorrhage (Stewart & Vigod, 2020). Some potential risks that do exist with use of SSRIs during pregnancy, although rare and small, do include increased risk for septal heart defects when used in early pregnancy, increased risk of pulmonary hypertension in newborns when used in late pregnancy (although this is unproven), increased risk of gestational hypertension and preeclampsia for the mother when used in late pregnancy, and possible complications following birth similar to drug discontinuation syndrome, including respiratory distress, when exposed late in pregnancy (Stahl, 2021). The patient must be informed of all risks, however rare, and these must be balanced against the not insignificant risks of untreated depression in the mother discussed above (Stahl, 2021).Sertraline would be my initial drug of choice for Alison, regardless of her pregnancy or lactation status. Sertraline, also known as Zoloft, is a Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant. Escitalopram, which is another SSRI that may be chosen for treatment of depressive symptoms in the initial depression case study, appears to be associated with a low risk for birth defects or increased risk of complications during pregnancy, except possibly increasing the risk for post-partum hemorrhage as with other SSRIs (Stewart & Vigod, 2020). Although escitalopram can be an appropriate choice for starting an SSRI in pregnancy, sertraline has been the most studied in terms of safety for pregnancy and has been found to be safe during lactation as well (Grigoriadis, 2019). Therefore, provided the patient is not already taking an SSRI, I would start her on Sertraline at the lowest dose, 25 mg/day, particularly during the first trimester (Grigoriadis, 2020). I would also recommend psychotherapy as adjunctive treatment (Grigoriadis, 2020). As with all patients suffering for depression, the patient should be continuously monitored for safety and suicidal ideation, but particularly following the birth of the child, when the risk for post-partum depression increases (Grigoriadis, 2020).Treatment of Bipolar Pregnant Patient: In the initial module 7 case study I recommended treating the bipolar patient’s symptoms of mania (including paranoid delusions, hallucinations, increased activity/agitation, lack of sleep, and pressured speech) with Lithium, 300mg, BID. Pharmacotherapy is also recommended for pregnant patients with manic episodes characterized by symptoms such as those discussed in the week 7 case study (Hendrick, 2020). Generally, pregnant patients should be treated with medications with the lowest risk of teratogenicity (birth defects), and where possible with monotherapy at the lower end of the therapeutic range (Hendrick, 2020). First generation antipsychotics, particularly haloperidol (Haldol) is recommended as first-line treatment for mania in pregnancy, as there is more experience and evidence of safety during pregnancy than with second-generation antipsychotics, and a lower risk for birth defects as compared with lithium (Hendrick, 2020). However, pregnant patients are often unable to tolerate extrapyramidal side effects of Haldol or other first-generation antipsychotics (Hendrick, 2020). Although the safety of second-generation antipsychotics in pregnancy has not been as extensively studied as first-generation antipsychotics, research suggests that they are not associated with and increased risk for major malformations, whereas lithium is (Hendrick, 2020). Therefore, for a pregnant patient, I would not recommend lithium for symptoms of mania, but rather would recommend starting risperidone, 1mg daily, divided in two doses (Stahl, 2021). Risperidone appears to be more effective than quetiapine and better tolerated than olanzapine in treating symptoms of mania (Hendrick, 2020). Risks include increased risk of birth defects when used in early pregnancy (although less than with lithium), particularly congenital cardiovascular defects and withdrawal symptoms in the newborn (Hendrick, 2020).2. How would this change if the female were lactating?Treatment of Lactating Depressed Patient: The recommendation would not change for a lactating patient. Although trace amounts of SSRIs, including sertraline, can be found in breastmilk and in nursing children whose mothers are taking sertraline, it has been shown to be effective in treating postpartum depression, which is a high risk to the mother, particularly if she has had prior depressive episodes (Stahl, 2021). Although breastfeeding women should not be discouraged from using SSRIs because the significant risk of postpartum depression often outweighs the risk to breastfeeding infants, possible risks to the infant include drug toxicity to the infant through breastmilk exposure and undetermined neurodevelopmental effects (Kimmel & Meltzer-Brody, 2020). However, research indicates that these risks are low, particularly when compared against the significant risks to mother and child of untreated post-partum depression (Kimmel & Meltzer-Brody, 2020). There is a slight preference for sertraline or paroxetine when starting lactating women on an antidepressants, as the amount of these medications secreted in breastmilk may be lower than compared with other SSRIs (Kimmel & Meltzer-Brody, 2020). Therefore, I would still recommend starting a lactating patient on 25mg of Sertraline daily for treatment of major depression.Treatment of Lactating Bipolar Patient: Bottle feeding with formula may be recommended for lactating patients being treated with atypical antipsychotics for bipolar disorder (Stahl, 2021). Although there are many benefits to mother and child of breastfeeding, and some studies suggest that levels of risperidone in breast milk and therefore risk of adverse effects are low, the safety of risperidone and other atypical antipsychotics in breastfeeding has not been widely studied (Kimmel & Meltzer-Brody, 2020). If the mother chooses to breastfeed while taking medication, the infant should be carefully monitored for possible symptoms of exposure, including sleep disturbances, irritability, agitation, excessive crying, or poor weight gain, and levels of the medication in breast milk should be periodically tested (Kimmel & Meltzer-Brody, 2020). Serum laboratory tests for drug levels should also be performed in the infant (Kimmel & Meltzer-Brody, 2020). Olanzapine may also be a safer alternative for breastfeeding mothers, as studies have shown low levels in breastmilk and undetectable serum levels in breastfed infants for doses of up to 20mg/day (Kimmel & Meltzer-Brody, 2020). Ultimately, the mother should be informed of the risks and benefits of breastfeeding while on medication and her decision should be respected, with appropriate monitoring of the infant if she does choose to breastfeed (Kimmel & Meltzer-Brody, 2020).3. What patient teaching would you include?Although it is very important to provide accurate information regarding the risks of psychotropic medication use during pregnancy and lactation, it is also important not to discourage pregnant and breastfeeding patients from treating their depression or bipolar disorder with pharmacotherapy for the reasons discussed above (Grigoriadis, 2020, Hendrick, 2020). As discussed, I would provide the patient with teaching not only as regards the risks of medications, and which symptoms to monitor in patient and child, but also the significant risks of untreated mental illness to both mother and child (Grigoriadis, 2020). I would also work with the patient to establish support networks both during pregnancy and following the birth of the child, as providing the patient with proper support and assistance with parenting duties, in order ensure adequate self-care and in particular sleep, is crucial to preventing relapse of symptoms and protecting the safety of patients suffering both from bipolar disorder and unipolar depression as well as their children (Hendrick, 2020).

POST 2

Medication use during pregnancy, especially psychiatric medication use, has always been a delicate subject that warrants further research. During week five of this course, a case study about a young woman with anxiety and depression was discussed. The woman, Mrs. Lane, was suffering from symptoms such as anhedonia, sleep disruption, difficulty concentrating, depressed mood and others. She was treated with a selective serotonin reuptake inhibitor (SSRI), Lexapro, for many years. According to the text, psychiatric medication prescription for the pregnant woman should be considered on a case-by-case basis. SSRI’s can pose numerous risks to the unborn fetus such as premature birth, low birth weight, neonatal withdrawal syndrome (if the SSRI is taken during the third trimester), congenital cardiac formations, and others (Stahl, 2021). However, untreated symptoms of depression and anxiety in the mother can also place both the child and mother at risk for harm. For example, if the mother’s depressive symptoms lead to self-injurious behaviors or suicidality, evidently the result of this would cause direct harm to the mother and baby. Symptoms of depression such as anhedonia can also negatively impact the child if the mother becomes so depressed that she finds herself unable to care for herself, attend her doctors’ appointments, take prenatal vitamins, or prepare for the arrival of the child (Stahl, 2021). If I were coordinating Mrs. Lane’s treatment plan, I would have a discussion with her about therapy and encourage her to practice cognitive behavioral therapy with a therapist to help alleviate some of her symptoms. Mrs. Lane reported that her current prescription for Lexapro no longer seems to be helping, therefore, I would ask her if she would be interested in either increasing the dose or tapering off and switching to a new SSRI such as sertraline. Studies have shown that sertraline, escitalopram, and citalopram have little to no risk of teratogenicity (Stewart & Vigod, 2022). However, it is also important to recognize that Mrs. Lane is suffering from some anxiety, and if taking psychiatric medication while pregnant would increase her anxiety about doing harm to her baby, it may be best to taper her off of the medication. Mrs. Lane is also not suicidal or homicidal, and in less severe cases of depression, it may be beneficial for treatment to only consist of psychotherapy while the client is pregnant.

During week seven of this course, a case study was completed about a woman, Mrs. Contesta, suffering from a manic episode. Her diagnosis was bipolar disorder with psychotic features. Mrs. Contesta was not sleeping, she was hearing voices, and she was paranoid and delusional about her family. If Mrs. Contesta was also pregnant, her medication regimen would have to be changed. As the prescriber, I would not consider the option of de-prescribing Mrs. Contesta’s medicines because her symptoms are erratic and pose a dangerous risk to herself and her unborn child. Her perception of reality is altered, and she is not able to take care of herself or a child in her current state. Studies have shown that placental permeability of antipsychotics varies. For example, research showed that Olanzapine has a 72% placental passage rate, whereas Seroquel only has a 24% passage rate. For this reason, it may be beneficial to prescribe Seroquel instead of other antipsychotics (Hendrick, 2022). Studies have also shown that Lithium exposure is positively correlated with teratogenicity. Valproic acid (Depakote) is also used for mood stabilization in bipolar disorder but is completely contraindicated in pregnancy as research has proven its correlation with neural tube defects amongst other teratogenic risks (Hendrick, 2022). Little research exists regarding the use of benzodiazepines in pregnancy. With this being said, one other treatment option that I might consider for Mrs. Contesta would be electroconvulsive therapy (ECT). Research has shown little to no evidence of neonatal toxicity, altered intrauterine growth, or adverse developmental effects. Research has also showed low risk for teratogenic effects related to anesthetic drug use for ECT (Hendrick, 2022).

If Mrs. Lane were to be breast feeding, her medication regimen may also change. The post-partum period is considered a high-risk period for mothers to have mood episodes, including mothers who suffer from depression, as well as mothers who suffer from bipolar disorder. Mrs. Lane’s first depressive episode was reportedly immediately following the birth of her first child. Because of this, Mrs. Lane is very likely to suffer another depressive episode. Similar to the discussion regarding medication use during pregnancy, medication use during the lactation period should also be considered on a case-by-case basis. In Mrs. Lane’s case, I would likely recommend that she continue on antidepressants because of her increased risk for having another episode, and the stress and sleeplessness that comes with caring for a newborn will likely increase her risk even more for becoming significantly depressed. According to the text, breast feeding is not recommended while taking Lithium. However, breast feeding while taking second-generation antipsychotics, Lamictal, valproic acid, or carbamazepine can be considered if the infant is closely assessed and it may be necessary to obtain infant blood drug levels (Stahl, 2021). If Mrs. Contesta were breast feeding, I would also recommend that she continue to take an atypical antipsychotic, as the post-partum period also places her at risk for having another manic or psychotic episode (Stahl, 2021). I would also recommend that Mrs. Contesta continue with ECT treatment. Research has shown that minimal amounts of anesthetic drugs that are utilized for ECT enter into the breast milk, and that breastfeeding is not a contraindication for ECT (Hendrick, 2021).

Patient education for both patients would include discussion about warning signs that may precede an episode, as it can be critical to identify these and seek help before the condition worsens. I would also educate both Mrs. Lane and Mrs. Contesta about the evidence for folic acid and its benefits in formulating the neural tube of the child (Hendrick, 2021). I would educate Mrs. Lane about the risks and benefits of taking SSRIs while pregnant (as mentioned above) and the more common side effects such as sexual dysfunction, weight gain, gastrointestinal upset and others. I would educate Mrs. Contesta about the potential side effects of antipsychotics such as weight gain, somnolence constipation, prolonged QTC interval, and others (Stahl, 2021). Lastly, it would be especially necessary to point out some of the more common side effects of ECT for Mrs. Contesta as well, such as memory loss, headaches and jaw pain.