Effective Interventions for Bipolar I Disorder in Pregnant Women
The DSM-5 categorizes symptoms of bipolar I disorder into three: manic episode, hypomanic episode, and major depressive episode. While major depressive episodes and hypomanic episodes are not required for the diagnosis of the disorder at least one manic episode during a lifetime is required for a psychiatric mental health nurse practitioners (PMHNPs) to diagnose a patient with bipolar I disorder. However, due to the recurrence of mania and depression among patients with bipolar proposed interventions must address the related symptoms. Hence, clinical practice guidelines necessitate the use of mood stabilizers as first-line treatments for the disorder to mitigate manic symptoms, and they are often accompanied by antidepressants to combat bipolar depression. However, treating pregnant women with bipolar requires PMHNPs to consider the risk that pharmacological or non-pharmacological interventions pose to both the parent and developing fetus. In this regard, the benefits of Lamotrigine and Quetiapine, which are mood stabilizers, and cognitive behavioral therapy (CBT), which is a non-pharmacological adjunct to medication, outweigh the risks that they pose to pregnant patients.
Lamotrigine is a beneficial FDA-approved drug for women with bipolar I during the prenatal period. Overall, this mood stabilizer is effective at preventing the reoccurrence of bipolar I disorder symptoms. In a systematic review comparing the effectiveness of Lamotrigine and Lithium as maintenance treatments for bipolar, Hashimoto et al. (2021) concluded that although Lithium was more effective in preventing recurrences, Lamotrigine was overall safer in that it had a lower rate of adverse events relative to Lithium. Pregnant patients present a unique challenge to PMHNPs, who must consider the potential impact of the pharmacological intervention on the developing fetus. According to Kameg (2021), Lamotrigine has the strongest safety profile for use during pregnancy when compared to other FDA-approved interventions, including Lithium and Carbamazepine, both of which can cause birth defects. This low risk status makes Lamotrigine the safest intervention for pregnant women suffering from bipolar I disorder.
Quetiapine is not only an effective off-label medication for maintenance treatment in bipolar I disorder but also a safe option for pregnant women. PMHNPs often turn to off-label drugs to either supplement approved products or mitigate inherent risks. Quetiapine is especially valuable in this off-label application because of its efficacy. In a randomized, double-blind, controlled trial comparing Quetiapine to Lithium, Patino et al. (2021) found that the former had a greater rate of response and overall symptom reduction than the latter. PMHNPs must weight the benefits of off-label drugs and their risk on their patients, particularly with pregnant women for whom the health of the fetus is a priority. According to Rybakowski et al. (2019), Quetiapine is safe for both the parent and fetus during the first trimester of pregnancy. However, its use during the third trimester may lead to involuntary muscle movements and withdrawal symptoms. While these risks are concerning, PMHNPs must consider the harms that uncontrolled psychiatric disorders might have on the fetus and the high risk of minor and major malformations posed by other off-label medication like Valproate. In this regard, Quetiapine is the lowest-risk off-label medication for pregnant patients with bipolar disorder.
Evidence-based psychotherapies like cognitive behavioral therapy (CBT) can significantly enhance the outcomes of patients with bipolar disorder. Novick and Swartz (2019)observe that psychotherapists strive to help patients identify and alter maladaptive thoughts, beliefs, and behaviors that contribute to and escalate bipolar symptoms through CBT. While this therapeutic approach has a positive effect on symptoms, it is more effective when used alongside pharmacological interventions. Novick and Swartz’s (2019) systematic literature review of randomized controlled trials demonstrate that CBT lowers the rate of discontinuing medication against medical advice, which effectively reduces hospitalizations and affective episodes resulting from noncompliance with treatment. They also observed that patients receiving cognitive therapy alongside regular treatment also have lower depression scores compared to those patients who only rely on medication. Nevertheless, PMHNPs must consider the impact of CBT on pregnant women. According to Cuthrell et al. (2022), CBT is especially beneficial to pregnant women with bipolar disorder who are susceptible to psychological stresses like bad life events and interpersonal problems, which can increase the risk of relapse. Moreover, CBT can assist pregnant women to manage the disorder with minimal pharmacotherapy. These benefits are essential for the patient during the prenatal period because they minimize risk to both the mother and the developing fetus.
Overall, FDA-approved medication and evidence-based off-label treatments and non-pharmacological interventions can enhance the health outcome of pregnant women with bipolar disorder. While there are inherent risks in using FDA-approved or off-label pharmacological interventions, Lamotrigine and Quetiapine offer more benefits at lower risks. Besides, PMHNPs must also consider the adverse pregnancy outcomes likely to occur from untreated or undertreated bipolar I disorder. Incorporating CBT in the course of treatment ensures that patients adhere to the course of medication the PMHNP recommends, while also empowering the mother to overcome internal and environmental psychological stressors that may precipitate relapse.
References
Cuthrell, K. M., Singh, M., Villamar, M., & Shabbir, U. (2022). Antipsychotic medications and cognitive therapy in pregnant women with bipolar disorder. Asian Journal of Biochemistry, Genetics and Molecular Biology, 12(4), 42-59. https://doi.org/10.9734/ajbgmb/2022/v12i4270
Hashimoto, Y., Kotake, K., Watanabe, N., Fujiwara, T., & Sakamoto, S. (2021). Lamotrigine in the maintenance treatment of bipolar disorder. Cochrane Database of Systematic Reviews, 9(9). https://doi.org/10.1002/14651858.CD013575.pub2
Kameg, B. N. (2021). Bipolar disorder: Treatment strategies for women of childbearing age. Perspectives in Psychiatric Care, 57(3), 1244-1249. https://doi.org/10.1111/ppc.12680
Novick, D. M., & Swartz, H. A. (2019). Evidence-based psychotherapies for bipolar disorder. Focus, 17(3), 238-248. https://doi.org/10.1176/appi.focus.20190004
Patino, L., Klein, C. C., Strawn, J. R., Blom, T. J., Tallman, M. J., Adler, C. M., Welge, J. A., DelBello, M. P. (2021). A randomized, double-blind, controlled trial of lithium versus quetiapine for the treatment of acute mania in youth with early course bipolar disorder. Journal of Child and Adolescent Psychopharmacology, 31(7), 485-493. https://doi.org/10.1089/cap.2021.0039
Rybakowski, J., Cubala, W. J., Galecki, P., Rymaszewska, J., Samochowiec, J., Szulc, A., & Dudek, D. (2019). Recommendations of the Polish Psychiatric Association regarding the treatment of affective disorders in women of childbearing age. Part II: Bipolar disorder. Psythiatria Polska, 53(2), 263-276. https://doi.org/10.12740/pp/103555
ReplyReply to Comment
PRESCRIBING FOR OLDER ADULTS AND PREGNANT WOMEN
After assessing and diagnosing a patient, PMHNPs must take into consideration special characteristics of the patient before determining an appropriate course of treatment. For pharmacological treatments that are not FDA-approved for a particular use or population, off-label use may be considered when the potential benefits could outweigh the risks.
In this Discussion, you will investigate a specific disorder and determine potential appropriate treatments for when it occurs in an older adult or pregnant woman.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
·
American Psychiatric Association. (2016).
The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia Links to an external site.
. https://doi.org/10.1176/appi.books.9780890426807
· Agency for Healthcare Research and Quality. (2019).
Maternal and fetal effects of mental health treatments in pregnant and breastfeeding women: A systematic review of pharmacological interventions Links to an external site.
. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/protocol-pharm-pregnant-women_0
· Hardy, L. T., & Reichenbacker, O. L. (2019).
A practical guide to the use of psychotropic medications during pregnancy and lactation Links to an external site.
.
Archives of Psychiatric Nursing,
33(3), 254–266. https://doi.org/10.1016/j.apnu.2019.04.001
· National Library of Medicine. (2006–2020).
Drugs and lactation database Links to an external site.
(LactMed). https://www.ncbi.nlm.nih.gov/books/NBK501922/
·
· The LactMed® database is a peer-reviewed, evidence-based resource on drugs that may be used by breastfeeding mothers. It includes possible effects on nursing infants and offers drug alternatives where possible.
· Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015).
Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
·
· Chapter 27, “Psychiatry and Reproductive Medicine”
· Chapter 33, “Geriatric Psychiatry”
· Stewart, J. G., & DeNisco, S. M. (2019).
Role development for the nurse practitioner (2nd ed.)
. Jones & Bartlett Learning.
·
· Chapter 3, “Vulnerable Populations”
· Chapter 4, “Mental Health and Primary Care: A Critical Intersection”
· Chapter 5, “Cultural Sensitivity and Global Health”
Required Media
· American Psychiatric Association. (2020).
Geriatric telepsychiatry Links to an external site.
[Video].
https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/geriatric-telepsychiatry
TO PREPARE:
· Choose one of the two following specific populations: either pregnant women or older adults. Then, select a specific disorder from the
DSM-5-TR to use.
· Use the Walden Library to research evidence-based treatments for your selected disorder in your selected population (either older adults or pregnant women). You will need to recommend one FDA-approved drug, one non-FDA-approved “off-label” drug, and one nonpharmacological intervention for treating the disorder in that population.
· Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your chosen disorder in older adults or pregnant women.
· Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?
· Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.
· Support your reasoning with at least three current, credible scholarly resources, one each on the FDA-approved drug, the off-label, and a nonpharmacological intervention for the disorder.
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