Assignment Task:
Respond to two of your colleagues who selected different disorders. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature. Need Assignment Help?
Peer 1: Gina Ruggerio
Treating Depression in Pregnancy
When treating depression in pregnancy, the clinician balances managing maternal mental health while minimizing potential fetal risks. Evidence-based recommendations and clinical guidelines support a combination of pharmacological and nonpharmacological interventions, depending on the severity of the symptoms.
FDA-Approved Pharmacologic Intervention
Sertraline, or Zoloft, is a selective serotonin reuptake inhibitor (SSRI) that is used as a first-line pharmacologic treatment for moderate to severe depression during pregnancy (Yonkers et al., 2020). While there are potential risks, including neonatal adaptation syndrome and a small increased risk of persistent pulmonary hypertension of the newborn (PPHN) when used in the third trimester, it is FDA-approved for major depressive disorder and has a favorable safety profile in pregnant populations (Yonkers et al., 2020). Untreated depression during pregnancy can lead to suicide, poor prenatal care, and adverse birth outcomes, which outweighs the potential harms (Yonkers et al., 2020).
Off-Label and Adjuncts: Mirtazapine & Omegas
Mirtazapine (Remeron), though not FDA-approved specifically for use in pregnancy, is an effective off-label option, especially in cases where patients have poor appetite and insomnia (Berard et al., 2017). It is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is has not been shown to increase the risk of major congenital anomalies, though it is associated with sedation and weight gain. However, it can be an appropriate choice for patients that cannot tolerate SSRIs or who need an alternative due to side effects such as sexual dysfunction or insomnia (Berard et al., 2017).
Of additional note, omega-3 fatty acids have been shown to have mild antidepressant effects and are not only safe to take during pregnancy, they contribute positively to fetal brain development (Freeman et al., 2022). Although not considered a solo treatment option for depression, it can be a helpful adjunct to other pharmacological therapy.
Interpersonal Psychotherapy (IPT)
Interpersonal Psychotherapy (IPT) is an evidence-based, first-line treatment for mild to moderate depression in pregnancy (Sockol, 2018). IPT focuses on role transitions and interpersonal conflict, both of which are relevant for pregnant women. IPT has shown to be highly effective in reducing depressive symptoms in perinatal populations and may be offered individually or in group settings (Sockol, 2018).
Clinical Guidelines
Clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) support SSRIs like sertraline as first-line pharmacologic treatment during pregnancy, especially when symptoms are moderate to severe (ACOG Practice Bulletin No. 235, 2023). They also endorse psychotherapy as the first-line intervention for mild to moderate depression. In clinical practice, I would use the Edinburgh Postnatal Depression Scale (EPDS) or PHQ-9 to assess symptom severity (ACOG Practice Bulletin No. 235, 2023).
Summary
An integrated treatment plan for depression in pregnancy could include an SSRI such as sertraline, or an off-label medication like mirtazapine if poor appetite and insomnia are part of the patient's symptom profile. However, psychotherapy is the first-line treatment for mild to moderate depression, and interpersonal psychotherapy has been proven effective in treating symptoms of depression in perinatal women. By implementing an evidence-based approach supported by current guidelines and literature, we can responsibly treat maternal depression while minimizing fetal risk.
References:
Berard, A., et al. (2017). Antidepressant use during pregnancy and the risk of major congenital malformations: An updated analysis of the Quebec Pregnancy Cohort. BMJ Open, 7(1), e013372.
Freeman, M. P., et al. (2022). Omega-3 fatty acids for perinatal depression: A systematic review and meta-analysis. Journal of Clinical Psychiatry, 83(1), 21r14119.
Sockol, L. E. (2018). A systematic review of the efficacy of cognitive-behavioral therapy and interpersonal psychotherapy for pregnant women: Treatment of antenatal depression. Journal of Affective Disorders, 232, 85-100.
Yonkers, K. A., et al. (2020). The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstetrics & Gynecology, 135(3), 703-713.
ACOG Practice Bulletin No. 235. (2023). Screening for Perinatal Depression. American College of Obstetricians and Gynecologists.
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Peer 2: Maurice Mccormick
Generalized Anxiety Disorder (GAD) in Pregnant Women
When treating a pregnant woman with GAD, it is important to find a balance between effective symptom relief and safety for both the mother and fetus. Sertraline is considered a good first-line treatment option and is an FDA approved drug commonly used to treat anxiety and depression. It is often considered one of the safest antidepressants during pregnancy, especially when compared to others like paroxetine, which carry higher risks (Muzik et al., 2021). Buspar is another off-label option that is sometimes used. It is an anxiety medication that does not have the same sedating or addictive properties as benzodiazepines and has shown a relatively safe in treating pregnant women with anxiety (Andrade, 2020). Cognitive Behavioral Therapy (CBT) is a good nonpharmacological option. It has proven to have good results for treatment of GAD, works just as well as medication in some cases, and has no risks to the unborn fetus (Arch et. al., 2019). For many pregnant patients, especially those with mild or moderate symptoms, CBT is often the first step for treating pregnant patients, especially if their symptoms are mild to moderate.
Risk Assessment
It is important to weigh the risks and benefits before starting any treatment regime. This involves considering how severe a patient's anxiety is, how far along they are in pregnancy, and how much anxiety is affecting their daily life. We also look at whether pharmacological treatment might affect fetal development or cause complications during or after delivery. Sertraline has a good safety record, but it is not completely risk-free. There is a small chance it could lead to neonatal adaptation syndrome and possibly a slight increase in the risk of persistent pulmonary hypertension of the newborn (Muzik et al., 2021). Yet, the benefits of reducing the mother's anxiety symptoms often outweigh these risks. Buspirone, while used off-label, has not shown any known harmful effects and is not associated with withdrawal symptoms in newborns, however, since it is not well studied in pregnant populations, it is used more cautiously (Andrade, 2020). CBT does not come with any of these medical risks, which makes it a really good option when available.
Clinical Guidelines
There are clinical practice guidelines to help inform treatment, and the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA)recommend sertraline as a first-line treatment for moderate to severe anxiety and depression during pregnancy. They also highlight the importance of CBT alone or paired with medication, depending on how severe the symptoms are. These guidelines support using medications like sertraline when the benefits clearly outweigh the risks. Buspirone is not specifically endorsed in most guidelines due to limited data, but it is still used when SSRIs cannot be tolerated or are not effective (APA & ACOG, 2016). When no guidelines specifically address a medication, clinicians have to rely on current research, case studies, and risk assessments to personalize care for each patient on a case-by-case basis.
References:
American Psychiatric Association & American College of Obstetricians and Gynecologists. (2016). The American Psychiatric Association Practice Guideline on Psychiatric Evaluation of Adults. Arlington, VA: American Psychiatric Association Publishing.
Andrade, C. (2020). Use of buspirone during pregnancy and lactation. The Journal of Clinical Psychiatry, 81(2), 20f13294.
Arch, J. J., Dimidjian, S., Chessick, C. A., & Kendall, P. C. (2019). CBT for perinatal anxiety: A meta-analysis. Journal of Anxiety Disorders, 68, 102148.
Muzik, M., DiPietro, J. A., & Rosenblum, K. L. (2021). Sertraline for perinatal depression and anxiety: A review. Archives of Women's Mental Health, 24(2), 173-183.