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WEEK 9 PEER RESPONSES

PEER RESPONSES WEEK 9

brittney cabral 



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            The population I chose was pregnant women, and the disorder I chose was major depressive disorder with peripartum onset. In the Diagnostic and Statistical Manual, there is not a specific disorder for pregnant women that have depression, but rather they are diagnosed with major depressive disorder and then the “with peripartum onset” specifier is added. The diagnosis requires the same major depressive criteria, such as depressed mood, diminished interest in activities, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness, inability to concentrate, and thoughts of death (American Psychiatric Association, 2013).

            There is only one Food and Drug Administration (FDA) approved drug for major depressive disorder with peripartum onset- brexanolone (Zulresso). This drug has a rapid onset of action and must be administered by healthcare personnel via IV infusion (Powell, J., 2020). Risks with this medication include excessive sedation and sudden loss of consciousness, and therefore the medication has a special program called REMS, also known as Risk Evaluation and Mitigation Strategy (Powell, J., 2020). The benefits of the medication include rapid onset of improvement of depressive symptoms.

            All other drugs used for major depressive disorder with peripartum onset are considered to be off-label drugs. The most common medications utilized are the SSRIs (Frieder, A., et. al, 2019). More specifically, sertraline is one of the safest drugs to use in this drug class, with studies showing no congenital abnormalities. Benefits associated with sertraline use include decreased depressive symptoms, however improvement of symptoms is slower than with brexanolone. On the other hand, there are still risks associated with the use of sertraline, such as not responding to treatment, SIADH, and sexual dysfunction. Additionally, common side effects of this medication include insomnia, gastrointestinal upset, fatigue, and loss of appetite (Frieder, A., et. al, 2019)

            The nonpharmacological treatment I would use for this disorder is cognitive behavioral therapy (CBT). CBT has been shown to be as effective as pharmacological treatment of major depressive disorder and can help lessen depressive symptoms with peripartum onset (Buck, K., et. al, 2019). CBT can be utilized alone or as an adjunct to pharmacotherapy.

            Although there are clinical practice guidelines for the treatment of major depressive disorder, there are not any specific guidelines for depression with peripartum onset.  The risk assessment I would consider for this patient population includes whether the medication can be dispersed through breast milk and whether it can cause genetic malformation. There are limited studies in this patient population due to ethical reasons, however it is important to consider the evidence that is available, and much of the evidence shows that CBT should be first-line treatment, with pharmacological management utilized only if CBT does not relieve symptoms. If the patient was already diagnosed prior to pregnancy, then medication should be continued.

 

 

 

 

 

 

 

American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Buck, K., Zekri, S., Nguyen, L, Ogar, J., & Smith, J.P. (2019). American Family Physician, 100(4), 244-245.

 

Frieder, A., Fersch, M., & Deligiannidis, K. (2019). Pharmacotherapy of Postpartum Depression: Current Approaches and Novel Drug Development. CNS Drugs, 33(3), 265-282. http://doi.org/10.007/s40263-019-00605-7

 

Powell, J. (2020). Brexanolone (Zulresso): Finally, an FDA-approved Treatment for Postpartum Depression. Pharmacotherapy.


Oscar Calvino 


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Mild Neurocognitive Disorder DSM-5 331.83 (G31.84) in the older adult population

 

Alzheimer’s is the most common cause of dementia. Alzheimer’s disease differs from Dementia

because it is a specific condition or disease. Dementia describes a group of symptoms that include

decline in memory, reasoning, or other thinking skills. Numerous types of dementia exist, and many

conditions cause it. Alzheimer’s disease is the most common cause of dementia, accounting for 60-80%

of dementia cases in the U.S Aricept (donepezil) is a drug that has been approved by the FDA has been

divided into categories that refer to the degree of the disease: mild-to-moderate or moderate-to-severe.

For mild-to-moderate disease, cholinesterase inhibitors such as donepezil (Aricept; also approved for  

moderate-to-severe disease)

 

The off-label medication that I chose is Seroquel, which is a 2nd generation antipsychotic

Medication. Seroquel is used to treat schizophrenia, depression, and bipolar disorder.  It helps with

brain function and alterations in perception, mood, or consciousness. Practitioners may prescribe and

pharmacists may dispense an FDA-approved drug for an indication not approved by the FDA as long as

it’s review and is an acceptable practice within the bounds of reasonable standards of health care to do

so as long as the unapproved use does not constitute experimentation. Furey, and Wilkins (2016).

 

One nonpharmacological intervention is Reality reorientation is included in the holistic

interventions approach along with reminiscence therapy, validation therapy, and cognitive stimulation

therapy Rabins, et al, (2014). It is a program used to improve cognitive and psychomotor functions in

persons who are confused or disoriented.

 

The risk assessment I would use to inform treatment decision making would start with a

Mini Mental Examination (MMSE) and the Bristol Activities of Daily Living Scale (BADLS) would continue

By assessing Genetic To assess genetic risk in an individual or family, it is critical to obtain an accurate

Family history with as much information as possible about the diagnosis of dementia and age of onset in

reportedly affected family members Patterson, et al (2008). Vascular: studies have indicated that the

relation between blood pressure and successive development of dementia is somewhat complicated.

Although several studies have shown that elevated systolic blood pressure is associated with an

increased risk of both Alzheimer’s disease and all-cause dementia, curiously some studies have shown

that a systolic blood pressure below 140 mm Hg is also associated with an increased risk.

Notwithstanding these and other apparently contradictory findings, the results of the Systolic

Hypertension in Europe (SYST-EUR) study showed a reduced risk of dementia among participants

receiving antihypertensive treatment Patterson, et al (2008). Lifestyles: It seems possible that lifestyle

increased risk of both Alzheimer’s disease and all-cause dementia, curiously some studies have shown

that a systolic blood pressure below 140 mm Hg is also associated with an increased risk.

Notwithstanding these and other apparently contradictory findings, the results of the Systolic

Hypertension in Europe (SYST-EUR) study showed a reduced risk of dementia among participants

receiving antihypertensive treatment Patterson, et al (2008). Lifestyles: It seems possible that lifestyle

interventions (regular exercise, both physical and mental, moderate alcohol intake, and avoidance of

tobacco and head injuries) may also reduce the risk of dementia Patterson, et al (2008). Medications:

There is a good indication to avoid the use of estrogen, alone or in combination with progesterone, for

the sole purpose of reducing the risk of dementia Patterson, et al (2008). Some side effects: can include

headaches, dizziness, and constipation, but these are usually only temporary Patterson, et al (2008)

 

References

American Psychiatric Association (APA) 2013., Diagnostic and statistical manual of mental disorders 5th

ed. DSM-5. American Psychiatric Publishing Washington, DC / London, England

 

Patterson, et al (2008). Diagnosis and treatment of dementia: 1. Risk assessment and primary

prevention of Alzheimer’s disease. CMAJ 2008;178:316-21.



www.cmaj.ca/cgi/content/full/178/5/548/DC1

 

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Chapter 27, “Psychiatry and Reproductive Medicine”

Chapter 33, “Geriatric Psychiatry”

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