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Major depression is highly prevalent among childbearing women and is present in twice the rate of depression among men in the same age group. Unfortunately, major depression is the leading cause of disability among women of childbearing age. (Kalfoglou 2016). Not only does perinatal depression result in being a significant cause of disability during pregnancy, but it also adversely impacts intra-uterine growth and development. Unfortunately, there are limited evidence-based treatment guidelines or algorithms for treating mental conditions during pregnancy due to the complicated risk-benefit analysis for both mother and unborn child. (Van Ravesteyn et al., 2017).
There are several psychotropic treatment modalities for depression during pregnancy. Selective serotonin reuptake inhibitors are relatively safe during pregnancy. Sertraline is considered a first-line treatment for depression during pregnancy, but not without risk to the fetus. Current research studies pose an increased risk of atrial/ventricular defects and craniosynostosis associated with the use of Sertraline during the first trimester of pregnancy. (Bérard et al., 2015). There are limited off-label treatment options for perinatal depression. Gabapentin is extensively used as an off-label treatment modality for many conditions. It is likely to become increasingly prescribed for off-label use during pregnancy. There is very little information about the safety of Gabapentin during pregnancy. Current studies found that Gabapentin use during pregnancy was associated with a higher rate of preterm births and low birth weight. (Patorno et al. 2020).
Due to all the complex risk-benefit analyses for psychotropics medications during pregnancy, non-pharmacological interventions should be explored before prescribing psychotropic medications during pregnancy. There are several viable non-pharmacological treatment modalities for perinatal depression. Cognitive-behavioral therapy, psycho-educational and interpersonal therapy (IPT) are good non-pharmacological options (Evans et al. 2020).
I was unable to find clinical practice guidelines for treating perinatal depression. However, I was able to find the clinical practice guidelines for postpartum depression. The mood disorder questionnaire or Edinburgh, postnatal depression scale can be utilized to screen for depression. There are many challenges associated with prescribing psychotropic medications during pregnancy. When selecting a psychotropic medication, the provider must consider the health of the mother and unborn child. The provider needs to understand the withdrawal of these medications during pregnancy and the possibility of symptom relapse during pregnancy. The provider should consider that all medications could enter the fetus through the placenta. It is essential to consult the FDA risk category before prescribing the medication. (Lotito & Cook 2015). It is also essential to determine the severity of the depressive symptoms, mild depression symptoms should be treated with psychotherapy only.
Bérard, A., Zhao, J.-P., & Sheehy, O. (2015). Sertraline uses during pregnancy and the risk of major malformations. American Journal of Obstetrics and Gynecology, 212(6). https://doi.org/10.1016/j.ajog.2015.01.034
Evans, K., Spiby, H. & Morrell, J.C. (2020) Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women. A systematic review and narrative synthesis of women’s views on the acceptability of and satisfaction with interventions. Arch Women’s Ment Health 23, 11–28 https://doi.org/10.1007/s00737-018-0936-9
Kalfoglou A. L.(2016) Ethical and Clinical Dilemmas in Using Psychotropic Medications During Pregnancy. AMA J Ethics. 2016;18(6):614-623. DOI: 10.1001/journalofethics.2016.18.6.stas1-1606.
Lotito, M., & Cook, E. (2015). A review of suicide risk assessment instruments and approaches. Mental Health Clinician, 5(5), 216–223. https://doi.org/10.9740/mhc.2015.09.216
Patorno, E., Hernandez-Diaz, S., Huybrechts, K. F., Desai, R. J., Cohen, J. M., Mogun, H., & Bateman, B. T. (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. PLoS medicine, 17(9), e1003322. https://doi.org/10.1371/journal.pmed.1003322
van Ravesteyn LM, Lambregtse – van den Berg MP, Hoogendijk WJG, Kamperman AM (2017) Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis. PLoS ONE 12(3): e0173397. https://doi.org/10.1371/journal.pone.0173397