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Pregnant Women and Bipolar Depression
In this discussion post, I will explain pregnancy in women diagnosed with bipolar disorder (BD), classified as high-risk due to various clinical and pharmacotherapeutic factors. When giving psychiatric drugs to a pregnant woman, it is very important to carefully weigh the possible effects of psychotropic drug exposure on the unborn fetus against the chance of a bipolar disorder relapse. If bipolar disorder is not treated, it can have detrimental effects on the health of both the mother and the unborn child in the case of a relapse. Access to comprehensive and up-to-date information regarding the safety of preventive medications for bipolar disorder is essential for making informed choices (Singh & Deep, 2022).
It is crucial for healthcare providers to have discussions with patients about psychiatric drugs, including their advantages and disadvantages, both before and during pregnancy, as well as postpartum; however, we will concentrate on pharmacological interventions during pregnancy in general. Even if the patient decides not to pursue pharmacotherapy, this choice is still considered a therapeutic option. Most mental health conditions, including postpartum depression, anxiety, bipolar disorder, and schizophrenia, require therapeutic drug management during pregnancy (Creeley & Denton, 2019).
The discontinuation of antipsychotic medication in patients is well documented to increase the likelihood of return of dipolar episodes. This is a significant problem, leading to a higher risk of inadequate peripartum care, suboptimal mother and fetal nutrition, difficulties throughout pregnancy, and postpartum depression. Furthermore, there is a hypothesis suggesting that the dysregulation of the hypothalamic-pituitary-adrenal system, which is linked to untreated depression, may have detrimental impacts on the fetus's health and the child's development (Creeley & Denton, 2019). Another significant concern is that no two expectant mothers with bipolar 1 depression are identical. For example, one patient has a documented record of multiple suicide attempts, while the other has been stable. The patient with a history of suicidal attempts would undoubtedly benefit from psychotropic medication at this juncture.
There is no documented approved FDA first-line drug therapy for pregnant women who are bipolar. However, atypical antipsychotics are used off-label, according to Betcher et al. (2019). Lurasidone is deemed a preferable option for antipsychotic treatment during pregnancy due to its categorization as a Category B medication in the previous pregnant drug classification system. This classification indicates that animal tests did not indicate birth defects. Regrettably, there is a lack of empirical data regarding the safety or potential hazards of lurasidone in human subjects during pregnancy or lactation (Betcher et al., 2019). Several clinical investigations indicate that lurasidone is tolerable, demonstrating a favorable combination of effectiveness and safety. These antipsychotics are regarded as metabolically favorable. It does not affect weight gain, lipids, or glucose levels. Additionally, it is the only atypical antipsychotic proven not to induce Qtc prolongation and one of the few atypicals that do not have a Qtc warning (Stahl's, 2021).
One thing to keep in mind with pregnant and non-pregnant patients is the metabolic issues that arise from the use of antipsychotics. The physiologic changes that occur during pregnancy, like increased metabolism and a subsequent drop in antipsychotic serum levels, are both physiological effects of pregnancy. The amount of medicine in the body decreases during pregnancy because the uridine diphosphate glucuronosyltransferase (UGT) isoenzymes and the cytochrome P450 isoenzymes CYP3A4, CYP2D6, and CYP2C9 become more active. Gaining or losing weight, increasing or decreasing plasma volume, and altering renal clearance affect medication concentrations (Betcher et al., 2019).
The non-pharmacological treatment options for bipolar disorder (BD) in pregnant women include family-focused treatment (FFT), interpersonal and social rhythm therapy, and cognitive behavioral therapy (CBT). These intense psychotherapies have substantial evidence supporting their effectiveness in treating bipolar illness (Chiang & Miklowitz, 2023). The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study and other psychotherapy studies highlight the significance of psychoeducation as a crucial element in treating bipolar depression. Group treatment that focuses on four clinical issues provides strong evidence for the effectiveness of psychoeducation. These issues include increasing awareness of the condition, promoting adherence to treatment, detecting prodromal symptoms and recurrence early, and encouraging a consistent lifestyle. After 5 years, individuals who underwent structured group psychoeducation experienced a reduction of 75% in the duration of their depressive episodes compared to those who participated in an unstructured support group (Chiang & Miklowitz, 2023).
The presence of bipolar disorder in pregnant and lactating women poses significant hazards to both the mother and the child, necessitating the need for comprehensive management (Graham et al., 2018). Several guidelines emphasize the importance of carefully weighing the danger of bipolar relapse against the potential harms of psychotropic drugs to the newborn when making decisions about psychotropic therapy for women with bipolar disorder throughout this period. Still, the study showed that there was not a lot of agreement among the guidelines about how dangerous these drugs might be. This made clinical recommendations and prescribing methods less effective (Graham et al., 2018).
Lastly, the risks and outcomes linked with untreated maternal disorder are as follows if a bipolar-depressive pregnant patient chooses not to use medications: Factors such as low birth weight, small size at birth, preterm birth, and an increased risk of cesarean birth can contribute to various health complications. These complications include small head circumference, hypoglycemia, and an increased risk for long-term neurocognitive, behavioral, and social deficits. Additionally, there is a high postpartum risk for first-onset and recurrent bipolar episodes, hospitalization due to substance use, poor prenatal care, and maternal suicide (Creeley & Denton, 2019). Some antipsychotic medications have harmful effects on pregnant women. For example, Clomipramine can lead to malformations in the fetal cardiovascular system; Valproates can cause birth defects; Carbamazepine can result in spina bifida; and Lithium can be teratogenic and increase the risk of miscarriage (Gruszczyńska-Sińczak et al., 2023).
