Assessing and Treating Vulnerable Populations for Depressive Disorders

Depression in Pregnant Women

The mental health of pregnant women today is a public health concern. Pregnant women are a vulnerable population concerning various illnesses and health risks. Depression among pregnant women is a health concern because of safety risks and poor patient outcomes associated with it.

It is diagnosed clinically and treated by pharmacological and nonpharmacological methods. The purpose of this paper is to explain the causes, diagnosis, treatment, and special considerations of depression and depressive disorders among pregnant women.

Assessing and Treating Vulnerable Populations for Depressive Disorders

What Causes of Depression?

The exact cause of depression is unclear from the documented items of scientific literature. Depression, however, has known risk factors that predispose, precipitate, and maintain this condition in susceptible individuals. Various theoretical models and hypotheses have been put forward to explain how depression arises among susceptible individuals, including pregnant women.

Biological theories attempt to explain how genetics and some biophysiological deficiencies leading to an imbalance in neurotransmitters in the brain contribute to depression. In a study by Khanghah et al. (2020), various factors contribute to depression among pregnant women.

High maternal stress, the mother’s young age, low educational level, poor socioeconomic conditions, tobacco smoking, and family history of depression put the pregnant mother at a greater risk of depression during pregnancy. Premenstrual syndrome, a mood illness that occurs around menstruation, is also a risk factor for depression during pregnancy.

Stressful events during pregnancy, history of miscarriage, lack of family support, lack of husband’s support, fear of the unknown outcomes of delivery, and unwanted pregnancies are also documented recipes for depression in the antennal period.

What are the symptoms of depression during pregnancy

Depression, generally, is characterized by sadness, emptiness in mood irritability, altered concertation, appetite, and sleep alterations. When depression occurs during pregnancy, it is called antenatal or prenatal depression. Depressed pregnant women show symptoms such as loss of appetite, and loss of interest in pleasurable activities, also known as anhedonia.

They can also have increased appetite, increased or decreased sleep, fatigue, and sometimes increased appetite. Sometimes, these women can become increasingly irritable or anxious, thus impairing their ability to make proper decisions. According to a publication by Claes in 2018 in the book, Progress in Molecular Biology and Translational Science, this emotionality signifies the limitation of these women in their ability to tolerate stress.

Sometimes these women find it difficult to admit these symptoms, leading to late diagnosis. In severe situations, suicidal thinking can set in. In the worst case scenarios, antenatal depression can lead to these women dying by suicide

How is depression diagnosed among pregnant women?

The fifth edition of the diagnostic and statistical manual of mental disorders, also referred to as DMS-5 by psychiatric professionals, is used to diagnose depression in any person. DSM-5 set nine symptom criteria for a depression diagnosis.

A pregnant woman suspected of having depression must show at least five symptoms of the nine to be diagnosed with major depression. The nine symptoms include depressed mood, inappropriate guilt or worthlessness feelings, decreased interest or pleasure in most activities daily, impairment in concentration or thinking, repeated thoughts of death, feelings of anxiety or restlessness leading to inappropriate physical movements, sleep pattern changes, significant changes in weight & appetite, and fatigue. Fatigue, weight changes, appetite changes, and mood changes are common even in normal pregnancies, and thus care must be taken before the conclusion of the diagnosis of depression.

Why are pregnant women a vulnerable population?

About one in every five pregnant women gets some level of depression. Up to 20% of pregnant women get major depression when pregnant. This means that in every 100 pregnancies; 20 mothers would be diagnosed with major depression, according to a study by Khanghah et al. in 2020.

According to the study by Fasanella et al. in 2019, less than 15% of pregnant and postpartum mothers who get depression during pregnancy do not get treatment. Depression among pregnant women has consequences ranging from behavioral changes to subtle complications for both the mother and the unborn fetus.

According to the study by Jahan et al. in 2021, antenatal depression can cause serious repercussions such as miscarriage, preterm birth & low birth weight, hypertension in pregnancy, and depression in the postdelivery period, also called postpartum depression. Developmental problems and delays are common in babies born to mothers who had untreated prenatal depression.

Poor infant-mother bonding, problems with breastfeeding, death of the mother, or death of the infant are potentially high-risk complications in the period after birth, according to a study by Fasanella et al. in 2019. Ideally, mothers should be screened and treated for depression before conception.

In most cases, these women conceive and develop depressive symptoms late into pregnancy when medication treatment options are limited. This can lead to escalation symptoms of depression. Therefore, medication treatment for pregnant women must consider these factors that influence the treatment choice and outcomes of treatment.

What are the medication treatment options for pregnant women?

Antidepressants are the main type of medication used in the treatment. A subclass of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) has been found to have no teratogenic effects on the fetus. Various guidelines have contradictory information on dose recommendations.

The table below summarizes the most commonly used antidepressants in pregnancy for major depressive disorder in terms of their risks, benefits, side effects, and approval by the food and drug administration (FDA).

Medication Risks and side effects Benefits FDA approval
Zoloft (sertraline) Should not be withdrawn abruptly; Risk of increase in suicidal ideations Safest in pregnancy; Also safe in lactating mothers FDA-approved, category B
Prozac (Fluoxetine) Persistent pulmonary hypertension of the newborn contraindicated in breastfeeding mothers. Also indicated in bipolar disorder and resistant depression FDA-approved, category C
Celexa (Citalopram) Unsafe in the third trimester; Risk of Persistent pulmonary hypertension of the newborn; Increased suicidality; safety in lactation is unknown Relatively safe in pregnancy, better tolerance in breastfed infants low-level evidence (Uguz, 2018) FDA-approved, category C
Wellbutrin (Bupropion) Unsafe in pregnancy, not to be sued in bipolar depression, risk of hypertension Safe in breastfeeding mothers FDA-approved, category B (Anderson et al., 2020)

Medication Considerations

  1. Patients who had been on prior treatment for depression and showed improvement in symptoms can continue to be prescribed the same medication, but this rests on the doctor’s decision.
  2. Other psychiatric illnesses such as bipolar disorder, binge ting disorder, and seizure disorders must also be taken into account because the medication used in their management may interact with the above medications to cause fatal side effects
  3. The gestational age of the patient is important before initiating medication treatment because some medications, such as Celexa, are unsafe late in the pregnancy.
  4. In some cases, treatment may continue into the period after delivery and may need a change of medication because some medications are contraindicated in breastfeeding. For example, fluoxetine. Choosing an alternative medication earlier in pregnancy is advisable
  5. Most importantly, patients must be evaluated for risk of suicide ideations before choosing medication because most medications worsen this suicidality.

What is important to monitor?

The risk of suicidality must be monitored after the initiation of antidepressant therapy (Anderson et al., 2020). Blood pressure and blood sugar measurements should also be monitored because most SSRIs can cause hypoglycemia and sometimes hypertensive disorders in combination with other medications.

Fetal well-being must also be monitored because the safety of some medications does not mean an absolute absence of teratogenic effects. Liver function tests must be monitored because most SSRIs are metabolized by the liver.

What are other special considerations in depression management?

Patient-centered and culturally-sensitive care should take into account patient-specific factors for the best patient outcomes. These considerations should align with the best nursing and healthcare practices that foster patient safety and care quality.

The table below summarizes the ethical, legal, and cultural considerations that should be taken into account in the treatment of depression among pregnant women.

Legal consideration Ethical considerations Cultural considerations
Suicidal risk, fetal demise, and admission of pregnancy patients with high social risks are some of the legal considerations in depression management. Decisions must weigh the potential benefits and risks. Confinement to inpatient units and the use of psychiatric holds may become controversial in some cases. The risk of abortion with untreated depression has potential ethical implications with varied religious and faith-based opinions relating to fetal demise. Medical malpractice issues may ensue. Religious views and traditional practices regarding depression will impact treatment uptake and adherence.

 Conclusion

Depression among pregnant women is a serious health concern with maternal and fetal outcomes. Its presentation is similar to depression among other populations. However, this population is vulnerable owing to the potential subtle complications of untreated depression, such as fetal death and abortion.

Most common pregnancy symptoms mimic depressive symptoms, thus late depression diagnosis in some cases. Medication treatment usually includes SSRIs which have potential suicidality increment but are relatively safer for the mother and the fetus. Legal, ethical, and cultural considerations ensure patient-centered and culturally sensitive care.

References

  • Anderson, K. N., Lind, J. N., Simeone, R. M., Bobo, W. V., Mitchell, A. A., Riehle-Colarusso, T., Polen, K. N., & Reefhuis, J. (2020). Maternal use of specific antidepressant medications during early pregnancy and the risk of selected birth defects. JAMA Psychiatry (Chicago, Ill.), 77(12), 1246–1255. https://doi.org/10.1001/jamapsychiatry.2020.2453
  • Claes, S. (2018). Neuroepigenetics of prenatal psychological stress. Progress in Molecular Biology and Translational Science, 158, 83–104. https://doi.org/10.1016/bs.pmbts.2018.04.007
  • Fasanella, D. R., Benner, S. L., Tejada, F. R., & Jackson-Ayotunde, P. (2019). Adverse drug reactions and adverse drug events are associated with the use of psychotropic, antiepileptic, antihypertensive, and antidiabetic drugs in pregnancy. In S. D. Ray (Ed.), Side Effects of Drugs Annual (Vol. 41, pp. 505–517). Elsevier. https://doi.org/10.1016/bs.seda.2019.08.012
  • Jahan, N., Went, T. R., Sultan, W., Sapkota, A., Khurshid, H., Qureshi, I. A., & Alfonso, M. (2021). Untreated depression during pregnancy and its effect on pregnancy outcomes: A systematic review. Cureus, 13(8), e17251. https://doi.org/10.7759/cureus.17251
  • Khanghah, A. G., Khalesi, Z. B., & Hassanzadeh, R., Afagh. (2020). The importance of depression during pregnancy. JBRA Assisted Reproduction, 24(4), 405–410. https://doi.org/10.5935/1518-0557.20200010
  • Uguz, F. (2018). Better tolerance of citalopram in a breastfed infant who could not tolerate sertraline and paroxetine. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 13(1), 89–90. https://doi.org/10.1089/bfm.2017.0168

Appendix: Sample Prescriptions

Pregnancy Hospital 111 Kings Street

(254) 123 4567

Patient’s name: Jane DoeSex: Female DoB: September 20, 1997Age: 25 years Address: 003 Minor Street
Medication Name Celexa 20 mg tabs
Dosage and frequency 20 mg, PO, q6hr, for 1 week Dispense 28  tabs
Signature: Take one tab every six hours with or without food Call 911 or the emergency room in case of increased suicidal thinking
Prescriber’s signature:      …                  …      …. Date:       ….      …..      …..
Pregnancy Hospital111 Kings Street

(254) 123 4567

Patient’s name: Jane DoeSex: Female DoB: September 20, 1997Age: 25 years Address: 003 Minor Street
Medication Name Zoloft 50mg tabs
Dosage and frequency 50 mg, PO, q6hr, for 1 week Dispense 28 tabs of Zoloft
Signature: Take one tab every six hours daily with or without food Call 911 or the emergency room in case of increased suicidal thinking
Prescriber’s signature:                                                  . Date:                                ….
Pregnancy Hospital111 Kings Street

(254) 123 4567

Patient’s name: Jane DoeSex: Female DoB: September 20, 1997Age: 25 years Address: 003 Minor Street
Rx Wellbutrin-SR (100 tabs)
100 mg TABS, PO, Q12r, for 7 days Dispense 14 tabs of Wellbutrin-SR
Take one tab every day in the morning and evening; Take it with or without food Call 911 or the emergency room in case of increased suicidal thinking
Doctor’s signature:                                                    … Date:                                      …

Assessing and Treating Vulnerable Populations for Depressive Disorders Instructions

For this assignment, you will develop a patient medication guide for treatment of depressive disorders in a vulnerable population (your choice for one vulnerable patient population to choose from: children, adolescents, older adults, dementia patients, pregnant women or one not listed of your choice!). Be sure to use language appropriate for your audience (patient, caregiver, parent, etc.).

You will include non-copyright images and/or information tables to make your patient medication guide interesting and appealing. Limit your patient medication guide to 5 pages. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 3 scholarly supporting resources outside of your course provided resources.

In your patient guide, include discussion on the following:

Depressive disorder causes and symptoms
How depression is diagnosed for the vulnerable population of your choice, why is this population considered vulnerable
Medication treatment options including risk vs benefits; side effects; FDA approvals for the vulnerable population of your choice
Medication considerations of medication examples prescribed (see last bullet item)
What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring
Special Considerations (you must be specific, not general and address at least one for EACH category; you must demonstrate critical thinking beyond basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health
Where to follow up in your local community for further information
Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.