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Please respond to discussion post Week 9: Special Considerations Related to Vul

Please respond to discussion post
Week 9: Special Considerations Related to Vulnerable Populations.
The use of psychotropic medications during the perinatal period is often met with fear and discomfort on the part of both clinicians and patients. There is a great deal of misinformation about the risks of medication use during pregnancy and lactation. The risk of untreated or undertreated mental illness during this time is an important consideration when making treatment recommendations. Uncertainty about extent of ill effects of psychotropics on the fetus has led to discontinuation or under treatment of pregnant women with bipolar disorder.
The special population I chose for this discussion is pregnant women and the disorder I will talk about is bipolar disorder in pregnancy.
. Bipolar disorder is defined by a minimum of one hypomanic episode and one major depressive episode (American Psychiatric Association, 2013). It is a specific mental illness that typically occurs during early reproductive years, and it places women at high risk (Gentile, 2012). Untreated Bipolar disorder during pregnancy leads to deleterious effect on mother and baby. Women with bipolar disorder has a greater risk of relapse during pregnancy and post-partum period (Munk-Olsen & Viktorin, 2018).
One FDA-approved drug for the treatment of bipolar disorder.
The FDA-approved drug for the treatment of bipolar disorder in pregnant women is Lithium. Lithium is a mood stabilizer used to treat bipolar. According to Tondo et al., 2019 Lithium continues to be the standard and most extensively evaluated treatment for bipolar disorder, especially for long-term prophylaxis. Lithium received approval by the US Food and Drug Administration (FDA) in 1970 for the treatment of bipolar disorder (Tondo et al., 2019). Till today Lithium treatment remains the “gold standard” of treatment for preventing recurrences in bipolar disorder, both types I and II (Tondo et al., 2019).
The Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder recommended that “if the use of a mood stabilizer is essential in first trimester, lithium is the safest”, but recommends constant monitoring (CPGs, 2014). They also recommend the use of lithium in the second and third trimester. A 5-year follow-up of 60 children exposed to lithium in the second and third trimester found no increase in developmental anomalies (Schou & Amdisen as cited in CPGs,2014).
Risk assessments for the use of Lithium in pregnancy.
Every pregnancy is associated with risk either with or without medications, but the risk increases with medication intake most especially during the first trimester. The risk assessment that informed my decision about lithium is that the benefit of continuing the patient treatment outweighs the risk of discontinuing the medication. Discontinuation of treatment has led to relapse with increased suicide attempts. The risk of using lithium includes increased chance of miscarriage though based on the data available, lithium has not been known to increase the chance of miscarriage. Every pregnancy has a 3-5% chance of birth defect, some study suggests that an increased risk of Epstein’s anomaly with the use of lithium in pregnancy especially during the first trimester (Poels, et al.,2018). The benefit of lithium use in pregnancy lowers the risk of relapse (Poels, et al., 2018). A recent meta-analysis showed significantly higher postpartum relapse rates in women whose lithium was discontinued in pregnancy as compared to those using lithium. The use of lithium prophylaxis during pregnancy in women with bipolar disorder is important not only to maintain mood stability but also for postpartum relapse (Poels, et al., 2018).
Off-Label drug for the treatment of bipolar disorder.
The off-label drug used in the treatment of bipolar disorder in pregnancy is Neurontin. Neurontin is not generally recommended in pregnancy because of lack of sufficient information about its safety for the fetus (Purse,2021). Since there is no evidence of harmful effect of this medication to the fetus, it should be taken when the benefit outweighs the risk. A 2007 review study in the Annals of General Psychiatry, Neurontin can be used as a supplementary therapy for the treatment of anxiety in pregnant women with bipolar disorder (Purse, 2021).
Risk assessments for the use of Gabapentin in pregnancy.
Neurotin use in pregnancy in a recent study suggests the presence of a major risk of fetal cardiac malformation, other malformations include eclampsia, Small Gestational age, and preterm birth (Patorno, 2020).
Clinical Practice Guideline exists for the treatment of bipolar disorder in pregnancy.
The clinical practice guideline in the use Lithium for treatment of bipolar disorder in pregnancy recommends starting with the lowest therapeutic dose. Although lithium is associated with a known risk of cardiac malformations in the first trimester, I still recommend it because the background rate is so low that even the increased risk means the overall rate is low (FDA.gov, n.d.). The guideline recommends Level one: Lithium monotherapy ONLY under initial treatment.
Nonpharmacological Intervention for treating bipolar disorder in pregnancy.
The nonpharmacological intervention I will recommend in the treatment of pregnant women with bipolar disorder is Cognitive Behavioral Therapy (CBT). CBT is a cognitive-behavioral approach and techniques of addressing dysfunctional attitudes and cognitive schemata and cognitive schemata in bipolar disorder (Naik, S. K. 2015). CBT in the treatment of bipolar disorder includes behavioral strategies such as activity scheduling as well as cognitive restructuring aimed at changing negative automatic thoughts and addressing maladaptive schemas (Naik, S. K. 2015). A review of 45 trials conducted up to September 2005 on clinical and economic effectiveness of interventions for prevention of relapse with bipolar disorder, the authors reported evidence showing that CBT in combination with medications is more effective for prevention of relapse (Naik, S. K. 2015).
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
Gentile S. (2012). Lithium in pregnancy the need to treat, the duty to ensure safety. Expert opinion on drug safety. 11(3), 425-437. Retrieved from https://doi.org/10.1517/14740338.2012.670419.
Patorno, E. (2020). Gabapentin in pregnancy and the risk of adverse neonatal and maternal outcomes: A population-based cohort study nested in the US Medicaid Analytic eXtract dataset. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462308/#sec020title
Poels, E. M. P., Bijma, H.H., Galbally, M., & Bergink, V. (2018). Lithium during pregnancy and after delivery: a review. International Journal of Bipolar Disorders 6 Article number: 26 (2018). Retrieved from https://journalbipolardisorders.springopen.com/articles/10.1186/s40345-018-0135-7#citeas
Naik, S. K. (2015). Management of bipolar disorders in women by nonpharmacological methods. Retrieved from https://www.ncbi.nlm.nih.gov./pmc/articles/PMC4539871/#_ffn_sectitle
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Bipolar Disorder
Food and Drug Administration, (n.d.). Treatment guidelines for Mood disorders during pregnancy.
Retrieved from http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentaResources/Labeling/ucm093307.htm

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Week 9: Special Considerations Related to Vul
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