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Jul

NRNP_6675: WEEK 9 Discussion: Prescribing for Older Adults and Pregnant Women

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NRNP_6675: WEEK 9 Discussion: Prescribing for Older Adults and Pregnant Women

Week 9: Special Considerations Related to Vulnerable Populations

The psychiatric mental health nurse practitioner assumes probably no greater responsibility than the responsibility of prescribing medications. While someone can be harmed by psychotherapy, the level and intensity of the harm generally does not come to the same level of harm that can occur from improper prescribing. The PMHNP must understand his/her responsibility both at a state and federal level when it comes to prescribing medications. It is of critical importance to understand the risks and benefits of the medications prescribed and their varying potential effects on special populations such as children/adolescents, pregnant women, or older adults.

This week, you examine the special considerations when prescribing for pregnant women and older adults. Learning Objectives Students will: Recommend psychopharmacological and nonpharmacological interventions for older adults and pregnant women in mental health settings Evaluate the risks and benefits of pharmacological treatment for older adults and pregnant women Justify clinical decision making related to pharmacological treatment of older adults and pregnant women in mental health settings

Discussion: 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.

 

Example 1: Discussion Post Response

Caring for a bipolar I depressive disorder patient during pregnancy can be challenging, especially when pharmacotherapy is required. Generally, the recommendation for managing bipolar disorder during pregnancy includes avoiding medications, particularly during the first trimester, depending on the patient’s risk for recurrence and when medications are required, and prescribing the lowest effective monotherapy doses (Belzeaux et al., 2019). One of the safest FDA-approved medications for treating Bipolar depression during pregnancy is Lamotrigine (Lamictal). Reports consistently show a lower association between Lamotrigine exposure in utero and congenital malformations (Jones & Jones, 2017). However, it is recommended that plasma serum levels of Lamotrigine are regularly checked from pregnancy to postpartum (Ding et al., 2019).

An off-label drug used for bipolar disorder is Gabapentin (Neurontin). However, its use during pregnancy is sparse. Reports show that Gabapentin (Neurontin) use during the first trimester of pregnancy did not have any associations between Gabapentin (Neurontin) exposure and significant malformations (Patorno et al., 2020). Experts, however, recommend that Gabapentin be discontinued or switched to an alternative drug in late pregnancy due to evidence of high cases of Preterm births, Small for gestational age, and neonatal intensive care unit admissions (Patorno et al., 2020). Due to the risks associated with the pharmacological treatment of bipolar in pregnant women, alternative non-pharmacological approaches remain the safest options for such clients.

Cognitive-behavioral therapy (CBT) is a non-pharmacological treatment regimen that can be safely used to effectively treat the associated symptoms of bipolar disorder in pregnant women. Randomized controlled trials of CBT’s efficacy showed similar favorable outcomes as pharmacological treatment regimens (Chiang et al., 2017). The main recommendation for CBT is that sessions should be >90 mins for effective results to be seen (Chiang et al., 2017). In conclusion, women who have the potential of getting pregnant and are being treated with medication must be educated and counseled on the importance of informing their PMHNP when they get pregnant so that a comprehensive review of weighing the risks and benefits of their treatment regimen, including alternatives to medications that meets satisfactory patient outcomes.

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Example 2: Discussion Post Response

The specific population selected for this discussion is pregnant women with schizophrenia.

Treating schizophrenia during pregnancy can be challenging. This population is of great interest to me due to all the positive and negative symptoms schizophrenics experience and the hormonal changes women go through during pregnancy. Their disorder and the period of pregnancy can cause problems for them, their partners, families, and caregivers. Women diagnosed with schizophrenia may become pregnant, and motherhood is common in these women. However, the choice of antipsychotic treatment during pregnancy remains controversial, mainly due to a lack of exposure and outcome data.

Randomized clinical trials are practically impossible due to ethical reasons. Information regarding the safety of antipsychotic use during pregnancy is also limited, creating a strong ethical dilemma. Clinicians prescribing antipsychotic medications to this population must use caution. The use of psychotropics during pregnancy is a complex issue because of the risk of leaving a severe psychiatric illness untreated, the risk of complications to the pregnant patient, and the risk of complications to the unborn baby or the risk of teratogenic/embryo-lethal effects on the developing fetus (Bigiu, Burtea, Ifteni, Moga, & Teodorescu, 2017). Based on my search, the FDA hasn’t recommended any specific antipsychotic medications used for this population. However, they suggest that patients should not stop taking antipsychotic medications if they become pregnant without talking to their healthcare professional because abruptly stopping antipsychotic medications can cause significant complications for treatment.

The FDA noted that Abilify, Clozapine (Clozapine / FazaClo ODT), Fanapt, Geodon, Haldol, Invega / Invega Sustenna, Loxitane, Moban, Navane, Orap, Risperdal / Risperdal Consta, Saphris, Quetiapine (Seroquel / Seroquel XR), Stelazine, Thorazine, olanzapine (Zyprexa), Symbyax (olanzapine and fluoxetine), fluphenazine, perphenazine, perphenazine and amitriptyline, prochlorperazine, and thioridazine causes potential risk for EPS and/or withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy (U. S. Food & Drug Administration (FDA), 2017). Per studies, the reproductive safety data on atypical antipsychotics are limited, but the use of olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), and clozapine (Clozaril) has been associated with increased rates of low birth weight and therapeutic abortion. While the typical antipsychotics have a more extensive reproductive safety profile, no significant teratogenic effect has been documented with chlorpromazine (Thorazine), haloperidol (Haldol), or perphenazine (Trilafon). Doses of typical antipsychotics should be minimized during the peri-partum period to limit the need for additional medications to manage extrapyramidal side effects (Armstrong, 2008).

Off-label medications used to treat this population are Ziprasidone (Geodon); there are no reports of fetal exposure to Ziprasidone or aripiprazole (Yaeger, Smith, Altshuler, 2006). Antidepressants are used to treat symptoms of depression and anxiety. Antidepressants that can be safely used are selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants, primarily if they have worked for the patient. Mood stabilizers help to reduce the likelihood of symptoms recurring (relapse). The most common mood stabilizer is lithium. Other mood stabilizers that may be used are carbamazepine (Tegretol) and lamotrigine (Lamictal) have been safely used (Center of Perinatal Excellence (COPE), 2021). Although treating pregnant schizophrenic women with pharmacological means is essential, preventing relapse is needed.

Non-pharmacological management for this population ensures adequate patient and family support (Galbally, Power, & Snellen, 2014). Psychotherapy has been effective in helping pregnant women with schizophrenia. These therapies are 1) cognitive behavioral therapy (CBT): the cognitive part of this therapy teaches them to think logically and challenge negative thoughts. The behavior part helps them change how they react in situations and can help them get involved in activities they have been avoiding or have stopped doing. 2) Interpersonal psychotherapy (IPT): helps them to find new ways to connect with others and overcome losses, challenges, and conflicts that they may have (Center of Perinatal Excellence (COPE), 2021). The first- and second-generation antipsychotic medications may have side effects; the risk assessment I will use with this population is the “benefits outweighing the risk.” That means I will consider the severe symptoms of schizophrenia and encourage pregnant women with schizophrenia to be compliant with their psychotropic medications.

In addition, when a patient has auditory and visual hallucinations, she may harm her baby in her womb. For instance, in May 2021, I took care of a 27-year-old patient who was 7 months pregnant; the patient had schizophrenia. She was diagnosed with the disorder 6 years ago. The patient had been off her psychotropic medication for over a year when she discovered she was pregnant. She always punched her stomach because she heard two women telling her the baby was an “evil child.” The practice guidelines for pregnant women with schizophrenia focus on the use of and safety of antipsychotics and other psychotropic medications in their treatment. This should include discussing with all patients their pregnancy plans, assisting women in understanding the potential risks they and their infants may face, and assisting with access to adequate contraception if the woman decides not to become pregnant. When a woman chooses to have a baby, assistance should include initiating referrals to appropriate antenatal services and providing linkage to early and ongoing antenatal care, as well as other essential services such as housing support to enable the best possible outcomes for the woman and her baby (Judd, & Newman, 2017).

Furthermore, counseling women with schizophrenia is necessary, and it always has to include her fertility situation, her desire to become a mother or not, planning pregnancy and motherhood (considering the course of her illness, her medication, her psychosocial situation, partnership, social support, etc.). Counseling in case of unwanted pregnancy is of utmost importance as well as addressing issues such as medication and prenatal care during pregnancy. Cooperation with the obstetrician, midwife, pediatrician, and childcare agencies is necessary. After delivery, parenting assessment in mother-baby-units can be beneficial in evaluating the need for additional care. Long-time programs for training parenting skills and “parenting rehabilitation” are urgently needed and should also support the relatives and others who care for the woman and her child (Rössler, 2020).

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