This is 4 different postings from 4 colleagues. I need 1 reply to each posting; each reply must be a good paragraph or so, with their own references each. I do not need a title page.
1.) Posting by Virginia E:
Week 9 Discussion: Prescribing for Older Adults with Major Depressive Disorder
Major depressive disorder (MDD) has been identified as a prevalent mental health concern among the elderly population. It frequently remains unrecognized or unaddressed due to its nonspecific manifestations or misinterpretation with symptoms of other conditions such as malignant neoplasms, significant neurocognitive problems, or diabetes mellitus (Sekhon, Patel, & Sapra, 2023). The purpose of this discussion is to examine FDA-approved, off-label, and nonpharmacological therapies for the treatment of Major Depressive Disorder (MDD) in older adults, together with risk assessment for treatment options.
FDA-Approved Drug, Off-Label Drug, and Nonpharmacological Intervention for Treating Older Adults with Major Depressive Disorder.
Medication Approved by the FDA: Sertraline is an FDA-approved pharmaceutical for the management of severe depression in elderly patients. Sertraline is a selective serotonin reuptake inhibitor (SSRI) that possesses antidepressant and anxiolytic effects. Sertraline (50-200 mg/day) is advantageous in treating major depressive disorder in elderly patients (≥60 years of age) because, it demonstrates superior efficacy, tolerability, safety and mild risk of medication interactions in treating MDD (Singh & Saadabadi, 2023).One off-label drug for treating MDD: The selected off-label medication is fluoxetine, which is effective in treating elderly individuals with dementia and depressive symptoms (Ampuero, et al., 2024).
Nonpharmacological Intervention: A nonpharmacological method for addressing major depressive disorder (MDD) in elderly people is cognitive-behavioral therapy (CBT). The advantages of CBT encompass its effectiveness, longevity, and acceptance for elderly individuals with MDD. Cognitive Behavioral Therapy may also improve coping mechanisms, self-efficacy, and overall quality of life for elderly individuals with Major Depressive Disorder. The potential risks associated with CBT are insignificant but may encompass anxiety, frustration, or reluctance throughout the therapeutic process (Purebi, Schnitzspahn, & Zsak, 2023).
The Risk Assessment that I would use to inform My Treatment Decision Making
Many antidepressants have been beneficial in older people with major depressive disorders without psychotic symptoms. When choosing an antidepressant, it is recommended to evaluate the optimal side effect profile and the minimal risk of drug-drug interactions. Sertraline exhibits fewer anticholinergic effects compared to earlier antidepressants, making it well tolerated by those with cardiovascular conditions. Nausea, xerostomia, insomnia, drowsiness, agitation, diarrhea, hyperhidrosis, and, less frequently, sexual dysfunction are prevalent side effects of SSRIs (Gabriel, et al., 2020). Monitoring sodium levels one-month post-initiation of SSRI treatment is essential, particularly if the patient is concurrently on other medications that may induce hyponatremia, such as diuretics (Croatto, Vancampfort, & Miola, 2022).
Fluoxetine is not associated with the withdrawal syndrome observed with other SSRIs. Fluoxetine should not be disregarded in the senior population, and in certain instances, it may be the preferred medication. Due to its extended half-life and persistent adverse effects, fluoxetine is typically contraindicated for use in the elderly. Paroxetine is generally not recommended for the elderly due to its significant anticholinergic effects, which are comparable to those of the tricyclics desipramine and nortriptyline (Gabriel, et al., 2020). Older patients with MDD receiving the SSRI fluoxetine may have diminished drug efficacy in comparison to the nonelderly people.
Clinical Practice Guidelines for Major Depressive Disorder
The elderly are potentially more susceptible to depression due to biological or psychosocial reasons. Older persons experience significant losses with advancing age, including the death of a spouse or friend, loss of employment, diminished social status, and declines in physical and mental abilities (Ruberto, Jha, & Murrough, 2020). Older adults may exhibit greater sensitivity to pharmacological treatments due to age-related physiological changes. Geriatric patients may necessitate more prudent adjustments in dosage and exhibit heightened vulnerability to drug-related adverse effects (Croatto, Vancampfort, & Miola, 2022). Medications are often administered to the elderly for multiple reasons, and drug interactions pose a significant problem.
Tricyclic antidepressants are no longer considered first-line therapies for the elderly due to the danger of adverse effects, including postural hypotension, which can result in falls and fractures, irregular cardiac conduction, and anticholinergic effects. Typical side effects include delirium, urinary issues, dry mouth, retention, and constipation (Gabriel, et al., 2020)A tricyclic antidepressant may worsen certain medical conditions prevalent in the elderly, such as dementia, Parkinson’s disease, and cardiovascular issues (Gabriel, et al., 2020). When tricyclics are employed as a second-line therapy, nortriptyline and desipramine are the optimal choices due to their reduced anticholinergic effects.
When choosing an antidepressant for an elderly patient, the initial dosage should be half of what a younger adult would receive. Side effects of antidepressants in the elderly are likely attributable to age-related alterations in hepatic metabolism, coexisting medical conditions, and drug-drug interactions. To achieve an average therapeutic level, the objective should be to incrementally increase the dosage at intervals of 1 to 2 weeks (Croatto, Vancampfort, & Miola, 2022). Moreover, it is now recognized that, although the typical therapeutic dose is frequently lower than that recommended for younger adults due to the effects of aging on hepatic metabolism, significant individual variabilities exist. Certain individuals will require a therapeutic dose that exceeds the average.
Assuming that no significant improvement is observed after 2 to 4 weeks at a standard therapeutic dosage. The dosage must be escalated until clinical improvement occurs, serious adverse effects manifest, or the maximum recommended dosage is attained (Gabriel, et al., 2020). Consequently, it is essential to schedule regular follow-up consultations to monitor therapeutic response, assess side effects, and modify dosage as necessary. It is essential to monitor for any indications of deteriorating depression, agitation, anxiety, and the risk of suicide, particularly during the initial stages of treatment.
2.) Posting by Kanietrice Whitfield:
Prescribing for Pregnant Women with Bipolar Disorder
Bipolar disorder (BD) is a severe mood disease that manifests as an episodic course with months or years of remission. The lifetime prevalence of bipolar disorder (BD) is 1% worldwide in representative community samples, and rates approach 4%–5% when bipolar spectrum disorder and other subthreshold illnesses are taken into account. Furthermore, the course of BD is marked by numerous, repeated episodes, with the median age of start being in the early twenties. There are a number of clinical and pharmacotherapeutic factors that make pregnant women with bipolar disorder (BD) at high risk. Pharmacological treatment during pregnancy necessitates a careful balance between the risk of BD relapse and exposure to psychotropic drugs.
FDA-Approved Drug/Off-Label Drug/Nonpharmacological Intervention for Treating Bipolar Disorder in Pregnancy
Lamotrigine is approved by the FDA for treating bipolar depression and for the maintenance treatment of bipolar disorder. It is increasingly recognized as a first-line option for managing bipolar disorder during pregnancy, especially for individuals who experience a higher rate of depressive episodes. Research indicates that lamotrigine effectively helps prevent symptom relapse during both pregnancy and the postpartum period (Hasser et al., 2024). There is a guideline recommending that valproate use during pregnancy keep the dose below 1000 mg/day, particularly in combination and/or during the first trimester (Gomes et al., 2022). While antipsychotics can be effective for treating bipolar disorder in pregnant women, their safety is a significant concern. Therefore, it’s important to consider alternative therapeutic approaches, such as Cognitive Behavioral Therapy (CBT). CBT is an evidence-based practice that can effectively address bipolar disorder without the negative side effects associated with antipsychotic medications. It is crucial to investigate the use, risks, and benefits of antipsychotic medications during both the prenatal and postnatal periods. Furthermore, there is an ongoing debate about whether to continue or discontinue these medications during pregnancy. At the same time, the role of CBT in treating pregnant women with bipolar disorder should be highlighted (Singh & Deep, 2022).
Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?
Treating pregnant women with bipolar disorder is a challenging clinical task. Patients and physicians face tough decisions, as no strategy eliminates risks or potential malpractice claims. The debate centers around whether to continue or discontinue antipsychotic medications during pregnancy. Discontinuation may increase the risk of relapse, while continuation can lead to adverse outcomes for both the mother and fetus. Although some antipsychotics effectively manage bipolar symptoms, their potential side effects have prompted defensive practices by some medical professionals, raising ethical concerns. Ultimately, the risks of using these medications during pregnancy cannot be ignored.
According to Singh & Deep (2022), prenatal exposure to valproic acid or its formulations, particularly during the first trimester, is linked to a significantly high incidence of multiple congenital malformations (9%–11%) and a substantially increased risk of neural tube defects. It is crucial to discuss contraception with all women undergoing valproate therapy to prevent unplanned pregnancies. Women with bipolar disorder (BD) should ideally be switched to a safer prophylactic agent before conception. Additionally, folate supplementation should begin prior to conception. While valproate can be highly effective in stabilizing mood and preventing manic and depressive episodes in individuals with bipolar disorder, it may be especially beneficial for women with severe bipolar disorder who have not responded to other medications. In such cases, valproate can provide significant mood stabilization and help prevent dangerous episodes.
Lamotrigine is generally considered safer than other mood stabilizers, such as lithium and valproate, during pregnancy, though it is not entirely without risks. It is particularly effective in treating the depressive episodes of bipolar disorder and in preventing mood cycling. While it may be less effective for managing acute mania, it aids in mood stabilization, which is crucial for effectively managing bipolar disorder during pregnancy (Singh & Deep, 2022). Studies have indicated that lamotrigine carries a relatively low risk of causing major birth defects. The most notable risk associated with its use during pregnancy is a higher chance of oral clefts (such as cleft lip and/or palate) in the baby, especially if the medication is taken during the first trimester. While this risk appears to be low, it is elevated compared to the general population, estimated to be about 1 in 1,000 to 3,000 births. This risk remains significantly lower than that associated with the use of valproate (Singh & Deep, 2022).
Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.
When evaluating the safety of pharmacotherapeutic agents used to treat bipolar disorder (BD), it is essential to consider several critical factors. These include (a) the potential for teratogenic effects, meaning that certain medications may cause developmental abnormalities in a fetus if taken during pregnancy; (b) the risk of poor neonatal adaptation, which refers to difficulties that newborns may experience in adjusting to life outside the womb due to exposure to these medications; and (c) the possibility of long-term neurobehavioral sequelae, indicating that the impacts of these drugs could lead to persistent behavioral and cognitive issues in children who are exposed to them in utero. Carefully considering these aspects is crucial for ensuring the safety and well-being of both the mother and the child (Singh & Deep, 2022).
If a patient has an extremely mild illness and has been stable without medication for many years, you may cautiously consider withholding mood stabilizers during the first trimester. Alternatively, you could use low-dose lithium or other low-dose medications, such as atypical antipsychotics, during this time. For patients with moderate to severe illness, it is generally recommended to continue the mood stabilizers that are effective, along with any other necessary psychiatric medications, to maintain stability throughout the pregnancy. Ultimately, treatment choices should be made on a case-by-case basis. The best practice is to use the safest regimen that maintains maternal mood stability while ensuring fetal safety (Batt et al., 2022).
3.) Post by Melissa Souza
Geriatric Population with Late-Life Depression
The prevalence of depression in people older than 60 increases from approximately 5 %. The prevalence increases to almost 50 % for people over 85 years old. The DSM-5 TR has the criteria listed for major depression and bipolar depression, but the elderly may not present specifically to the criteria (Devita et. al., 2022). Late-life depression consists of a somatic presentation, such as more physical complaints than the typical sad or depressed mood (Devita et al., 2022). Depression later in life may present with poor sleep, hopelessness, poor appetite, and passive suicidal thoughts. It’s difficult to diagnose when the elderly person has typically more co-morbidities than the younger individual. Depression could be related to medical problems, environmental and social factors, or the loss of loved ones. Regardless, it is essential to ask the patient about depressive symptoms. There is no DSM-5 TR diagnosis for Late-Life depression, but studies are ongoing to perhaps compile clinical guidelines in the future. The provider must utilize several resources to diagnose Late-life depression, such as family and friends’ perception and geriatric depression scales. The provider must also consider medication side effects and environmental circumstances. Simply informing the individual of resources to pay rent and utility bills may help decrease depressive symptoms.
SSRIs and SNRIs are FDA-approved medications for depression due to fewer adverse effects (Devita et al., 2022). Since cognition can be a comorbidity with depression or a part of the depressive symptoms, this class of medication can improve cognition. The risk of SSRIs and SNRIs in the elderly is hyponatremia, and the provider should check a sodium level periodically because of this side effect. It’s also essential to order routine labs due to the possibility of gastrointestinal bleeding. There are several other side effects; therefore, it is wise to prescribe the lowest effective dose in the geriatric population. It’s also wise to have an EKG baseline since this class of medication can cause EKG changes, such as a prolonged Q-T wave (Scheffler et al., 2023). It is recommended to avoid fluoxetine because of its long half-life and avoid Paxil due to anticholinergic effects (Wiese, 2011).
Lithium is an off-label drug as an antidepressant adjunct. Studies are concluding that Lithium increases the effect of SSRIs, including decreasing the risk of suicide. Studies have also concluded that Lithium may not work as well if the individual had depression that was resistant to several other antidepressants. It may not be the best choice if the patient has kidney disease since it can increase damage to the kidney (Ercis et. al., 2023). Studies have shown that Lithium as an adjunct to an SSRI has better efficacy than an SSRI alone in treating depression (Ercis et al., 2023). Lithium is recommended once-a-day dosing for the elderly. Studies advise a lithium level of less than 0.6 mEq/L in the elderly (Ercis et al., 2023). Before starting lithium, the provider should get a baseline EKG, thyroid, kidney function test, and calcium levels (Ercis et al., 2023).
The Beers criteria should also be reviewed when considering certain medications for the elderly (American Geriatrics Society, 2023).
Nonpharmacological intervention
Supportive therapy has been shown to decrease depression in the elderly, focuses on positive thinking, and highlights success in the past (Devita et al., 2022). Interpersonal therapy can also help the individual get through grief and changes in roles. (Davita, et. al., 2022). Regardless of the recommendations, the geriatric population may not have access to therapy. Realistically, today, the elderly must decide whether to pay for medications, food, and rent. Therapy is not the first on the list, and the thought process may not be present depending on the culture. Encouraging the patient to get involved in senior citizen groups or groups that include activities that intrigue them may at least help with socialization, which could also lead to community resource access due to word of mouth.
4.) Post 4 by Sharon Muchina
Evidence-Based Treatment for Depression in Pregnant Women
Introduction: Depression during pregnancy and the postpartum period, collectively referred to as Major Depressive Disorder (MDD) with Peripartum Onset, is a significant mental health concern, affecting an estimated 7-15% of women worldwide (Radoš et al., 2024). The DSM 5 TR describes MDD with Peripartum Onset as depression that occurs during pregnancy or up to four weeks after giving birth. It features a low mood or loss of interest in daily activities lasting at least two weeks. At least four other additional symptoms must be present, like appetite changes, sleep problems, tiredness, feelings of worthlessness, trouble focusing, or thoughts of suicide (American Psychiatric Association, 2022).
Risks and Benefits of FDA-Approved Drug: Sertraline (Zoloft)The FDA-approved drug recommended for treating Major Depressive Disorder (MDD) with Peripartum onset is Sertraline. Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI) that improves mood by increasing serotonin in the brain. Sertraline has a well-established safety profile in pregnancy and for postpartum depression, with studies indicating a low risk of significant congenital anomalies and minimal excretion into breast milk. The benefits include improved maternal mood, reduced risk of relapse, and better mother-infant bonding (Desaunay et al., 2023). While safe, Sertraline may slightly increase the risk of neonatal adaptation syndrome, characterized by symptoms such as irritability and feeding difficulties, leading to preterm low birth weight, which usually resolves within a few days (Desaunay et al., 2023).
Off-Label Drug: Bupropion (Wellbutrin)While not FDA-approved specifically for perinatal depression, bupropion is sometimes used off-label in pregnant women who have not responded well to SSRIs or have a history of positive response to this medication. Benefits include its effectiveness in treating depression, smoking cessation, and low prevalence of congenital malformations, mean birthweight, or mean gestational age of exposed babies. Risks may include a slightly increased risk of cardiac malformations in the fetus, although the evidence is limited and conflicting (Gallitell et al., 2024).
Nonpharmacological Intervention: Cognitive Behavioral Therapy (CBT)CBT is a highly effective nonpharmacological treatment for perinatal depression. It helps women recognize and change negative thoughts and behaviors linked to depression. There is no risk of exposing the baby to medications. It also leads to better coping skills and long-lasting results. The main downside is that severe depression might not improve enough with CBT alone and may need extra help (Zeng et al., 2025).
Complementary therapies, including exercise, yoga, bright light therapy, and acupuncture, provide additional advantages for individuals experiencing mild to moderate depression, which can be utilized as supplementary options or as an alternative to traditional treatments (Wichor et al., 2022).
Risk Assessment for Treatment Decisions The risk assessment process involves looking at the severity of depressive symptoms and the patient’s medical and psychiatric history. It also considers risks to both mother and baby. Untreated severe depression can lead to suicidal thoughts and poor prenatal care. It may affect the bond between mother and child more than the side effects of medication. It is crucial to talk with patients about how untreated depression might impact fetal and infant health and compare the safety of treatment options (Gallitell et al., 2024).
Clinical Practice GuidelinesAccording to the American College of Obstetricians and Gynecologists (ACOG) guidelines, screening all pregnant women for depression is a critical component of prenatal care. For mild to moderate depression, healthcare providers typically begin with nonpharmacological interventions, such as therapy, as the first-line approach. The severity of the patient’s condition is then reassessed before considering antidepressant therapy. Before initiating pharmacological interventions, it is essential to carefully evaluate the risks and benefits to both the mother and the fetus. These recommendations align with ACOG’s clinical practice guidelines for managing depression during pregnancy and the postpartum period (Nitzan et al., 2024).
Conclusion Treating MDD with Peripartum onset requires a careful balance of risks and benefits to ensure the safety of both the mother and infant. Sertraline is an effective and safe FDA-approved option, while bupropion may be used off-label in specific cases. CBT remains a highly recommended nonpharmacological intervention. Complementary therapies such as exercise, yoga, bright light therapy, and acupuncture offer additional benefits for mild to moderate depression. Adherence to clinical guidelines and individualized risk assessments is essential for optimal treatment outcomes.
