Discussion: Prescribing for Older Adults and Pregnant Women

Depression in Expectant Women. Sample paper

Depression in pregnancy (antenatal depression) or after birth (postnatal depression) is

similar in many ways to depression at other times (Tesfaye & Agenagnew, 2021). Anxious and

negative thoughts, which are common in depression, are often focused on the pregnancy or baby.

Women are often self-critical about their ability to be a good parent, or worry about how others

will judge them. Unfortunately, women, their families, and sometimes even health professionals,

don’t recognise that women have antenatal or postnatal depression and so women wait much

longer than needed before having treatment (Tesfaye & Agenagnew, 2021). There are many

reasons for this. There is some overlap between normal pregnancy symptoms and depression, but

people often wrongly assume that their symptoms are a normal part of pregnancy or adjustment

to having a new baby. Some people worry unnecessarily that professionals may think that they

cannot care for their baby (Tesfaye & Agenagnew, 2021). It is also common to feel guilty about

not feeling happy and excited. Anyone can be affected by mental health issues in the perinatal

period, so you should not be afraid to ask for help if you think that you might be unwell (Tesfaye

& Agenagnew, 2021).

Symptoms of antenatal depression include having some or all of the following for at least

two weeks: low mood, irritability and tearfulness; fatigue and low energy – this is common in

late pregnancy and when you have a baby but can be worse when you have antenatal or postnatal

depression; poor sleep – it is common to have poor sleep-in pregnancy and with a new baby, but

in postnatal depression you may not be able to sleep even when your baby is asleep; poor

appetite – your appetite may be affected by morning sickness or heartburn in pregnancy but

should usually improve as these symptoms resolve; poor concentration; loss of interest and

enjoyment – you may not enjoy things that you usually enjoy and you may not enjoy spending

time with your new baby; loss of interest in sex – this is common in pregnancy and after birth

and is not necessarily due to depression. Sex may be painful after birth or you may be too tired to

have sex; anxious thoughts; negative thoughts; guilty thoughts – you may feel guilty for feeling

depressed and think this is your fault, even though it is not; avoiding people; hopelessness – it

may seem that things will never get better or that life is not worth living; suicidal thoughts and

self-harm; and elf-neglect (Tesfaye & Agenagnew, 2021). The aim of this discussion is to

identify an FDA-approved medication, off-label drug, and nonpharmacological treatment option.

Similarly, the risk assessment and clinical guidelines for depression in women will be discussed.

FDA-Approved Drug: Bupropion (Wellbutrin)

This medication is approved by the FDA for treating substance use disorder associated

with smoking, seasonal affective disorder, and most importantly in this case depression (Creeley

& Denton, 2019). These include treatment options for adults only. Bupropion is categorized

under norepinephrine-dopamine reuptake inhibitor. From the name, the drug works to elevate the

patient’s mood by increasing the concentration of dopamine and norepinephrine in the brain

through inhibition of their reabsorption after synaptic transmission. Bupropion is considered a

class C medication (Creeley & Denton, 2019). It is safe for use in treating pregnant women since

there are little to no risks related to the medication on either the patient or the fetus. It is safe for

use despite being pregnant or breastfeeding (Creeley & Denton, 2019).

Off-Label Drug: Duloxetine (Cymbalta)

This medication is approved for treating chronic musculoskeletal pain (Huybrechts et al.,

2020). However, it is used to treat depression in adults as an off-label medication. It is used

unorthodoxly because of numerous researches that have showcased its effectiveness in such

processes (Huybrechts et al., 2020). It is categorized as a type C medication meaning that even

though there are adverse events associated with the medication its benefits outweigh the side

effects (Huybrechts et al., 2020). Duloxetine is a selective serotonin and norepinephrine reuptake

inhibitor that improves brain functioning by increasing the concentration of serotonin and

noradrenaline in the brain.

Non-pharmacological Intervention: Cognitive-Behavioral Therapy

This is the most common psychosocial intervention used in treating mental health

conditions. It works on the principle that our thoughts affect our mood and this affects our

behaviors. CBT helps patients to identify their destructive thoughts and change them to more

constructive thoughts (Burger et al., 2019). As a result, the patient is able to experience an

elevated mood. It also helps the patient to employ better coping skills. The efficacy of CBT is

stated to be higher than medication in many instances. However, combined therapy is highly

encouraged (Burger et al., 2019).

Risk Assessment for Duloxetine and Wellbutrin

When used in treating pregnant women, Wellbutrin is not stated to have any identified

side effects on the pregnancy, however, it is stated to cause insomnia, headache, constipation,

mouth dryness, tachycardia, increase in weight, and vomiting (Creeley & Denton, 2019).

Nonetheless, there is a low chance of developing side effects. Duloxetine is stated to cause nonteratogenic symptoms like cyanosis, sleep apnea, seizures, feeding issues, vomiting,

hypoglycemia, and hypertonia (Huybrechts et al., 2020). However, it is classified under group C

meaning that its benefits outweigh these side effects.

Recently, the American Psychiatric Association and the American College of

Obstetricians and Gynecologists jointly published consensus guidelines regarding the

management of depression during pregnancy (Ghazanfarpour et al., 2021). The goal was to

provide a comprehensive review of the literature and treatment recommendations by experts in

the fields of perinatal psychiatry and obstetrics. This important publication is timely given the

growing concerns about the use of antidepressants during pregnancy and the increasing and

sometimes confusing body of literature that addresses this issue. The guidelines were published

simultaneously in obstetric and psychiatric journals to increase the dissemination of this

information to medical professionals (Ghazanfarpour et al., 2021). The resulting publication is

essential reading, as it presents specific recommendations for a variety of clinical scenarios.

However, like all guidelines, they cannot address every possibility and should not be used

blindly in the absence of specific experience with this population or a full clinical examination of

the individual patient. In addition, all guidelines suffer from the fact that the evidence base from

which they are derived is constantly changing and can become outdated quickly (Ghazanfarpour

et al., 2021).

Once depression is diagnosed in a pregnant woman, treatment should be prescribed. For

mild to moderate depression, psychotherapy is recommended as a first-line treatment. Although

there is a relative dearth of studies focusing on the efficacy of psychotherapy for depression

during pregnancy, a great deal of data supports its use in the nonpregnant population. Many

forms of psychotherapy are available, and specific recommendations can be made based on the

patient’s clinical presentation (Ghazanfarpour et al., 2021). Considerations for recommending

psychotherapy include the patient’s willingness, access to skilled practitioners, and financial

accessibility. Pregnant patients are likely to prefer psychotherapy over medications, leaving the

last two barriers to be overcome. However, not all patients, not even those with similar disease

characteristics—will respond to a single prescribed treatment, including psychotherapy.

Therefore, a patient who is referred for psychotherapy should continue to have her progress

monitored so that alternatives can be prescribed if necessary (Ghazanfarpour et al., 2021).

Most of the American Psychiatric Association/American College of Obstetricians and

Gynecologists guidelines focus on the use of antidepressants during pregnancy (Zhao et al.,

2021). The authors conclude that there are data supporting an association between selective

serotonin reuptake inhibitor use and small for gestational age infants. Not enough data are

available to conclude whether this is dependent on length of exposure, and the absolute

difference in birth weight is small and of unclear clinical significance. Convincing data indicate

that preterm delivery (defined as ≤37 weeks’ gestational age) is associated with antidepressant

use during pregnancy, but again, the actual differences between exposed and unexposed groups

are small (Zhao et al., 2021). The guidelines report that antidepressants in aggregate are not

associated with major congenital malformations, although paroxetine has been labeled by the US

Food and Drug Administration as causative of septal heart defects in exposed infants. Poorer

neonatal outcomes such as respiratory and feeding difficulties, jitteriness, and irritability are

associated with third trimester use of antidepressants, although these symptoms tend to be

transient (Zhao et al., 2021).

The guidelines provide three flow charts for clinicians evaluating women with

depression: 1) women who present for preconceptual counseling; 2) pregnant women with

depression, not on antidepressants; and 3) pregnant women with depression on antidepressants

(Zhao et al., 2021). If a woman has a history of moderate to severe recurrent depression or is

experiencing a moderate to severe depressive episode, the guidelines recommend initiation or

continuation of an antidepressant. The guidelines only recommend discontinuing antidepressants

in clinical scenarios in which women are minimally symptomatic for 6 months or longer and

have no history of significant symptomatic relapse off medication. These treatment

recommendations are based on the consensus of experts in the field due to a limited evidence

base (Zhao et al., 2021).

However, they are exactly what should be recommended and therefore are likely to

mirror the experience of many experts. The importance of these guidelines is that at no point is it

suggested to counsel a woman to stop antidepressants without considering her psychiatric history

and current symptoms (Zhao et al., 2021). This is why there is a recommendation that the

clinician that is best suited to make these recommendations is a psychiatrist. As a practical

exercise, the clinician should decide what recommendation he or she would make to the patient

in the absence of a potential or current pregnancy. This can clarify the clinician’s thinking about

the patient. Once this decision is made, adding the information about the pregnancy serves to add

complexity rather than being the sole focus of the consultation (Zhao et al., 2021).


Pregnant women are a sensitive population and treatment plans that involve them must

always consider the effect of the intervention on both the mother and the unborn baby. Studies

have showcased that about 25% of pregnant suffer from mood disorders and anxiety. The

treatment of the patient that presents with these conditions is based on evidence that assesses the

impact of the drug on the pregnancy. For this reason, medications are labeled with a letter that

indicates the potential of causing the patient or fetus harm. They are labeled A, B, C, D, and X

with A to C having no significant evidence of causing harm to the mother or fetus but D is stated

to be dangerous and X is indicated not to be given to pregnant women. When treating pregnant

women with psychiatric conditions with medication, it is important to consider the FDA

classification of the medication used to understand the risk that the patient is exposed to. In the

case of depression, Bupropion is indicated to be effective due to a low risk of causing congenita