Diagnosis and Management of Perinatal Depression

Perinatal depression is a mood disorder that may occur during pregnancy or within a year after childbirth. It can be disabling for the birthing parent and cause attachment and developmental problems for the infant. A host of risk factors, including genetics, reproductive history, and life experiences, are associated with perinatal depression. With validated screening tools, health care providers can assess individuals, initiate treatment, and/or refer as appropriate. Successful treatment, which may include modalities such as cognitive behavioral therapy and/or pharmacologic therapies, helps individuals maintain a sense of control, develop self-confidence, take control of their thinking, and learn coping skills. Integrative therapies and lifestyle changes have some success but may not be adequate for many individuals. Patients may benefit from providers learning and initiating cognitive behavioral therapy techniques while awaiting therapy.     

双心境稳定剂联合喹硫平治疗双相情感障碍躁狂发作的效果

目的评价双心境稳定剂(丙戊酸钠缓释片和碳酸锂片)联合喹硫平片(思瑞康)治疗双相情感障碍躁狂发作的临床疗效与安全性。方法将100例双相情感障碍躁狂发作患者按随机数字表法分为研究组(n=50)和对照组(n=50)。研究组应用碳酸锂、丙戊酸钠缓释片以及喹硫平片治疗6周;对照组应用丙戊酸钠缓释片联合碳酸锂片治疗6周。治疗前及治疗后第1、2、4、6周分别采用Bech-Rafaelsen躁狂量表(BRMS)、不良反应量表(TESS)进行评分。结果研究组各时点有效率均高于对照组,其中治疗2、4周2组有效率比较差异有统计学意义(P<0.05);研究组治疗后各时点BRMS分值与对照组比较均明显降低(P<0.05)。研究组心动过速发生率显著高于对照组(P=0.04),其余不良反应发生率2组比较差异无统计学意义(P>0.05)。结论双心境稳定剂联合喹硫平治疗双相情感障碍躁狂发作疗效好,安全性高。     

Goal Appraisals and Vulnerability to Bipolar Disorder: A Personal Projects Analysis

Although studied extensively in depressed populations, the implications of goal appraisals for bipolar disorder are not well understood. Four hundred sixty-four college students completed questionnaires measuring personal goal appraisals (a modified version of B. R. Little's, 1989, Personal Projects Analysis), history of bipolar disorder symptoms, and current symptoms of hypomania and depression. Participants endorsing hypomania symptoms or current positive affect tended to construe goals in a positive manner, as likely to be attained, enjoyable, controllable, and not difficult or stressful. A history of clinically significant hypomania symptoms, however, correlated with negative, pessimistic goal appraisals. This relationship could be explained in a mediational model by higher current depression among those with previous hypomania/mania. Discussion highlights the potential of studying bipolar disorder from a goal theoretical perspective.     

Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMADs) are a public health issue that has a profound negative effect on women, families, and communities. It is estimated that 15% to 21% of pregnant and postpartum women experience PMAD, which includes depression, anxiety, obsessive-compulsive disorder, posttraumatic stress disorder, and postpartum psychosis. The purpose of this article is to provide an overview of perinatal mood and anxiety disorders in an effort to improve recognition, screening, diagnosis, treatment, and referral by nurse practitioners and midwives.     

Implementing a Safety Bundle to Improve Screening and Care for Perinatal Mood and Anxiety Disorders

ObjectiveTo improve screening and care of individuals with perinatal mood and anxiety disorders (PMAD) through the implementation of a perinatal mental health safety bundle.DesignRapid-cycle quality improvement model using four plan–do–study–act cycles over the course of 90 days. Individuals between 28 and 32 weeks gestation and at their 6-week postpartum follow-up visit were screened and offered stage-based care for PMAD.Setting/Local ProblemAt baseline, only 15% of clients of a suburban, private-practice women’s health clinic were receiving PMAD screening with a validated tool, and the site lacked standardized PMAD care practices among health care providers.ParticipantsHealth care providers (n = 2), staff (n = 4), and eligible patients (n = 78) at a private-practice women’s health clinic.Intervention/MeasurementsA screening, brief intervention, referral, and treatment/follow-up (SBIRT) model was used to screen eligible patients, provide treatment options, and appropriately refer for follow-up to mental health services. Team engagement occurred via weekly meetings. Measurements included pre–post maternal and team engagement survey results, biweekly chart review, and run chart analysis.ResultsEffective PMAD screening and right care were achieved for 85% of eligible individuals; this included receiving screening, referral to treatment, a scheduled mental health appointment, and clinic follow-up to ensure mental health care uptake.ConclusionUse of the SBIRT model to implement a safety bundle may contribute to improved mental health outcomes for individuals receiving perinatal care in a private-practice outpatient health care setting. Education and engagement among clinicians, staff, and patients are key to successful implementation of a safety bundle.     

精神分裂症与双相情感障碍患者认知功能的比较

[目的]精神分裂症和双相情感障碍都存在某些认知功能障碍,由于临床症状的重叠,这两类患者的鉴别较困难。本研究对两类疾病的认知功能障碍进行比较,探讨认知功能对临床鉴别诊断的价值。[方法]对30例阳性症状为主的精神分裂症患者、22例阴性症状为主的精神分裂症患者、27例双相情感障碍(躁狂状态)患者和28例正常对照者行相关认知心理试验(COGLAB)。[结果]COGLAB区别阴性精神分裂症和双相情感障碍的正确率达到了73．5％,其中分类测验、持续操作测验和倒行掩蔽测验判别作用最大。[结论]本研究的结果提示．阴性精神分裂症和双相障碍患者的认知作业反应的特征不同,威斯康星卡片分类、持续操作测验、倒行掩蔽测验对于临床上鉴别某些精神分裂症和双相情感障碍有一定参考意义。     

Management of Obsessive Compulsive Symptoms in a Patient Diagnosed With Bipolar 1 Disorder and a History of Migraines

Bipolar disorder and obsessive compulsive disorders (OCDs) may exist together. If the patient also experiences migraines, medication management may be complicated. Lithium and aripiprazole are prescribed as combination therapy to manage both bipolar disorder and OCD. Lamotrigine can be added for depressive symptoms and migraine prophylaxis; however, lamotrigine may exacerbate OCD symptoms. For proper medication management, advanced practice nurses will be asked to be a collaborating partner in the care of patients with both medical and psychiatric disorders.     

Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

TOPIC:  The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings.
PURPOSE:  In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder.
SOURCES:  This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality.
CONCLUSIONS:  Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.     

Triptan Exposure During Pregnancy and the Risk of Major Congenital Malformations and Adverse Pregnancy Outcomes: Results From The Norwegian Mother and Child Cohort Study

(Headache 2010;50:563‐575) Objective.— To evaluate the safety of triptan therapy during pregnancy. Background.— Information on the safety of triptan therapy during pregnancy is scarce and only available for sumatriptan, naratriptan, and rizatriptan. No associations with congenital malformations have been detected so far, but one study found a significant association between sumatriptan exposure during pregnancy and prematurity. Methods.— The study population consisted of 69,929 pregnant women and their newborn children for whom data on drug exposure and pregnancy outcome were available. Information on triptan therapy and potential socio‐demographic and medical confounding factors was obtained from the Norwegian Mother and Child Cohort Study. Information on congenital malformations and other adverse pregnancy outcomes was obtained from the Norwegian Medical Birth Registry. The datasets were linked via the women's personal identification number. Pearson's χ² tests and logistic regression analyses were used to identify associations between triptan therapy and pregnancy outcome. Results.— No significant associations between triptan therapy during the first trimester and major congenital malformations (unadjusted OR: 1.0; 95% CI 0.8‐1.3, adjusted OR: 1.0; 95% CI 0.7‐1.2) or other adverse pregnancy outcomes were found. Triptan therapy during the second and/or third trimesters was significantly associated with atonic uterus (unadjusted OR: 1.5; 95% CI 1.1‐1.9, adjusted OR: 1.4; 95% CI 1.1‐1.8), and blood loss >500 mL during labor (unadjusted OR: 1.3; 95% CI 1.1‐1.5, adjusted OR: 1.3; 95% CI 1.1‐1.5). Conclusions.— Triptan therapy during pregnancy was not associated with an overall increased risk of congenital malformations. It cannot, however, be excluded that a difference in the risk between triptan use and individual or rare congenital malformations may exist. A slight increase in the risk of atonic uterus and hemorrhage was associated with triptan use during the second and/or third trimesters. Although the present findings are reassuring, confirmation in independent studies is warranted.     

双相障碍患者照顾者身心发展概念框架的构建

目的 总结归纳双相障碍患者照顾者身心健康影响因素,构建身心发展概念框架,明确照顾者心理转归机制。方法 基于社会生态系统理论、资源守恒模型及社会认知理论确定框架各大维度,以心理弹性模型与双相障碍或其他重性精神疾病相关领域文献为支撑,提取核心影响因素,构建身心发展概念框架。结果 研究确定了以社会环境层、人与环境互动层、个体表现层及个体内在层的4大框架维度,涵盖因素包括文化价值、经济因素、雇佣关系、照顾负担;社会疏远/隔离、社会支持、社会冲突;精神或心理障碍、物质滥用、躯体状态、家庭暴力;个人心理特质、心理弹性。结论 基于4大框架维度的核心因素之间相互影响、相互嵌套,对照顾者身心发展起到了评估与预示作用。该概念框架可为后续的实证研究提供理论基础,但尚需量性研究加以检验。     

Biopsychosocial Model of Hypersexuality in Adolescent Girls With Bipolar Disorder: Strategies for Intervention

TOPIC: Engagement in high‐risk behaviors, impaired judgment, and hypersexuality present unique health challenges to adolescent girls with bipolar disorder (BD). Behavioral management of sexuality does not routinely fall under the purview of psychiatric care, but requires preventive measures. PURPOSE: This paper presents a biopsychosocial model of hypersexuality in girls with BD, describes factors that lead to high‐risk sexual behaviors, and provides a framework for cognitive–behavioral intervention. SOURCES USED: The study used a review of empirically based clinical and research literature. CONCLUSIONS: Sexual health education, improved treatment adherence, symptom monitoring, interpersonal skills training, parental involvement, and clinician education can improve hypersexual behavior in girls with BD.     

Milieu Management of a Child with Bipolar Illness

During inpatient psychiatric treatment, children with bipolar disorder may present particular management issues. They may experience intense periods of affect regulation that can spiral into frenetic, aggressive behaviors that are difficult to interrupt with de-escalation techniques. This case study presents such a child and the behavior patterns that resulted in seclusion and PRN medication. Also presented is the plan that staff derived which eventually helped this young boy regulate his behavior.     

Comorbidity of Migraine and Mood Episodes in a Nationally Representative Population‐Based Sample

Objective.— To examine the lifetime comorbidity of migraine with different combinations of mood episodes: (1) manic episodes alone; (2) depressive episodes alone; (3) manic and depressive episodes; (4) controls with no lifetime history of mood episodes, as well as sociodemographic and clinical correlates of migraine for each migraine–mood episode combination. Background.— Migraine has been found to be comorbid with bipolar disorder and major depressive disorder in clinical and population‐based samples. However, variability in findings across studies suggests that examining mood episodes separately may be fruitful in determining which of these mood episodes are specifically associated with migraine. Methods.— Using a cross‐sectional, population‐based sample from the Canadian Community Health Survey 1.2 (n = 36,984), sociodemographic and clinical correlates of migraine were examined in each combination of mood episodes as well as controls. Logistic regression analyses controlling for age, sex, and education level compared the lifetime prevalence of migraine (1) between controls and each combination of mood episodes, and then (2) among the different combinations of mood episodes. Results.— Migraine comorbidity in all combinations of mood episodes was associated with lower socioeconomic status, earlier onset of affective illness, more anxiety, suicidality and use of mental health resources. Compared with controls, the adjusted odds ratio of having migraine was 2.0 (95% confidence interval [CI] 1.4‐2.8) for manic episodes alone, 1.9 (95% CI 1.6‐2.1) for depressive episodes alone, and 3.0 (95% CI 2.3‐3.9) for subjects with both manic and depressive episodes. Compared with those with manic episodes alone and depressive episodes alone, the odds of having migraine were significantly increased in subjects with both manic and depressive episodes (odds ratio 1.5 vs manic episodes alone; 1.8 vs depressive episodes alone). In addition, migraine comorbidity was associated with different correlates depending on the specific combination of mood episodes; in subjects with both manic and depressive episodes, migraine comorbidity was associated with an earlier onset of mental illness, while in subjects with either manic or depressive episodes alone, migraine comorbidity was associated with increased suicidality and anxiety. Conclusions.— Migraine comorbidity appears to delineate a subset of individuals with earlier onset of affective illness and more psychiatric complications, suggesting that migraine assessment in mood disorder patients may be useful as an indicator of potential clinical severity. Differences in the prevalence of migraine as well as sociodemographic and clinical correlates associated with specific combinations of mood episodes underscore the importance of examining this comorbidity by specific type of mood episode.     

The Organization of the Self-Concept in Bipolar Disorders: An Empirical Study and Replication

Two studies are described that used a self-concept card sort task to investigate the structure of the self-concept in individuals with bipolar disorders. Both studies showed in the euthymic state, that such individuals had a modularized self-concept in which key aspects of the self tend to be organized as completely positive or completely negative. The inclusion of a chronic illness control group of individuals with diabetes in the 2nd study demonstrated that these effects were not simply a change in the self-concept that was consequent on the experience of a long-term chronic disorder.     

Nursing Care of Childbearing Families After Previous Perinatal Loss

Nurses who care for childbearing families facilitate the family’s adaptation to the arrival of a newborn through assessment of physical, emotional, and psychological needs. After experiencing a perinatal loss, such as miscarriage, stillbirth, or neonatal death, a woman’s perception of pregnancy and of her sense of control in becoming a mother can include fear and anxiety, and she may have significantly different needs than a pregnant woman who has not experienced perinatal loss. In this article, we provide evidence-based information and recommendations for maternal–child nurses caring for childbearing families who are preparing to welcome a new baby (sometimes called a “rainbow baby”) after a previous perinatal loss.