Week 9 Main Post
One of the most challenging conditions to treat in mental health is bipolar disorder. This complex disorder become even harder to treat in pregnant women. While there are risks to stopping the medication during pregnancy, there are also risks in continuing certain medications. Many of the mood stabilizers used to treat bipolar are known to have an increased risk of congenital defects if taken during pregnancy (Epstein et al., 2014). Zyprexa, Olanzapine, is an atypical antipsychotic medication that is frequently used to treat bipolar disorder. This medication has not been associated with an increased risk of miscarriage or congenital birth defects (Olanzapine (Zyprexa®), n.d.). Studies suggest that patients taking Zyprexa during pregnancy are at no larger risk of adverse effects than the normal population (Galbally et al., 2014).
This medication is ranked by the FDA as a level C pregnancy medication. This means risks cannot be ruled out. This ranking system is how the FDA presents guidelines on prescribing medications during pregnancy (Armstrong, 2008). Although it is not recommended to abruptly stop medications, many patients choose to use therapy instead of medication during pregnancy. CBT can help patients keep the depressive symptoms and mania at bay during pregnancy without having to use medication (Epstein et al., 2014). There are antidepressant medications that are deemed safer for use during pregnancy that could be used off label for bipolar disorder. One of those medications is Zoloft. Most SSRIs are considered safe options during pregnancy. Zoloft is considered one of the safest options for pregnant patients (What Is the Safest Antidepressant to Take When Pregnant?, 2021).
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
Maternity is frequently seen as a duration of pleasure and psychological wellness for females. On the other hand, pregnancy and being a parent increase a female’s sensitivity to psychological disorders such as anxiety as well as anxiousness. According to a recent research, depression is a common problem in a lot of pregnant females. This problem is frequently misdiagnosed because they are attributed to variants in the mother’s mindset or physiology while pregnant. Furthermore, this ailment is frequently undiagnosed and neglected because of concerns concerning drug’s possible negative effects. Clinical depression adverse effects, consisting of modifications in sleep time, hunger, and energy degrees, are commonly hard to figure out during pregnancy from those connected with common expectant experiences. While as much as 75% of pregnant women experience signs of some depressive state of mind problems, the proportion of females satisfying the analysis requirements for major anxiety has actually been estimated to be between 12.6% at 31 weeks gestation and also 16% at 34 to 35 weeks of pregnancy(Shimada et al., 2021). There is a factor for hope. Clinical depression can now be dealt with medically or emotionally. Both are usually used. Pharmacists and also doctors usually recommend Sertraline to treat clinical depression in expecting females. Sertraline is an FDA-approved drug used to deal with depressive conditions as well as anxiety conditions, mainly suggested to pregnant females. This medication might enhance the state of mind, sleeping, hungers, and power level as well as help them uncover an interest in their everyday activities(Shimada et al., 2021). It has the possible to reduce concern, stress and anxiety, unfavorable feelings, and also the occurrence of panic occasions. It may likewise lessen the need to conduct repetitive tasks that disrupt daily life.
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.
The Elderly Adult and Anxiety
Anxiety disorders occur frequently in the elderly population. The disorder with the highest prevalence rate among the elderly is known as generalized anxiety disorder or GAD (Park, 2022, pp. 2649). There are however some treatment options that could be implemented for GAD, which could include FDA-approved medications, off-label medications, and nonpharmacological interventions. As an APRN is important that we consider each treatment option carefully due to the older adult having an increased risk of adverse effects, intolerability, and drug-drug interactions according to Crocco et al. (2017, pp. 2).
One FDA-approved drug for treating anxiety in older adults is Escitalopram (Lexapro), which is considered a selective serotonin reuptake inhibitor (SSRI). SSRIs are known to be the first-line treatment for older adults with GAD. The reason for this is because SSRIs of safety profile and the fact that it has more tolerability within the elderly population. (Crocco et al., 2017, pp. 3). One benefit of using Lexapro is that it has been shown to assist with symptom reduction in older adults suffering from GAD. One risk indicated by Crocco et al. (2017) is the potential for “abnormal cardiac conductivity”, which recommends a maximum Lexapro dosage of 20 mg per day in the elderly population to reduce the possibility of this occurring (pp. 3). Therefore, elderly adults with cardiac conditions should be closely monitored while on this medication, including routine labs and examinations.
An off-label drug that is used to treat older adults with anxiety disorders is Pregabalin or Lyrica, which is considered an anticonvulsant. Often times it has proven to effectively treat anxiety in elderly patients. Garakani et al. report that research studies have proven that the anticonvulsant medication most successful in treating GAD is Pregabalin. It is also mentioned that it is a very tolerable medication among the elderly population, which is a benefit of using this medication. There are several risk factors identified, including adverse side effects such as sedative effects, dizziness, and weight gain. (pp. 3). Another important consideration is that Pregabalin is a Schedule V, which means it has a high contingency for misuse and abuse. After initiating treatment with this occasional drug screening may be necessary to ensure it is being used by the elderly individual. Once deciding to discontinue this medication the APRN should remember Pregabalin must be tapered off to prevent withdrawal symptoms such as tremors, tics, or seizures in the elderly adult.
Nonpharmacological treatment intervention for elderly adults with anxiety is known as “The Butterfly Hug”. The Butterfly hug is done by “crossing both hands on the chest and then clapping both hands like the flapping wings of a butterfly” (Girianto, 2021, pp. 297), while simultaneously deep breathing. This intervention is known as “direct bilateral stimulation” (pp. 297), which produces a calming effect and reduces anxiety. This could be taught to the elderly patient in psychotherapy sessions.
There are multiple risk assessment tools used to assist with recognizing elderly adults who may require treatment for anxiety. The Generalized Anxiety Disorder scale-7 also known as GAD-7 is an “easy-to-use 7-item scale, based on Diagnostic and Statistical Manual of Mental Disorders-IV criteria, for identifying likely cases of GAD” (Sapra et al., 2020, pp. 2). Based on the score it will indicate the severity of the patient’s symptoms, classifying them as minimal, mild, moderate, or severe (pp. 3). This will assist the APRN with validating the necessity of treatment for GAD.
According to Gautam et al. (2017), there are clinical practice guidelines that exist for generalized anxiety disorder. First, the diagnosis of GAD must be given by the provider after a thorough comprehensive assessment is completed. Then the provider must decide between psychotherapy, pharmacotherapies, or a combination of them both for the patient. Therefore, I think that treating the patient with Lexapro and Pregabalin is the correct treatment option for an elderly patient with GAD. Initiating treatment with psychotherapy to assist with introducing healthy coping mechanisms for the patient when anxious is another great recommendation.
Overall treating a special population such as the elderly is a complex process. Many things need to be taken into consideration for an elderly patient with GAD, such as other comorbid conditions like renal failure or cardiac conditions before initiating pharmacotherapy. Also, the cognition of an elderly patient is sometimes declined due to age or other comorbid conditions such as dementia, therefore one must consider if psychotherapy would even be effective due to their lack of understanding.