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Psychopharmalogical Approaches to Treat Psychopathology - Anxiety 

Middle-Aged White Male With Anxiety
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Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.
The Assignment: 
Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: use atleast 5 references not more that 5 years old in APA format.

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Generalized Anxiety Disorder

 

Generalized anxiety is a disorder characterized by excessive worry enough to interrupt normal activities of living. People with GAD may present with worrying symptoms like chest tightness and breathlessness requiring urgent medical attention. However, due to a lack of any medical illnesses, they often end up in psychiatric care. Some commonly utilized medications for GAD include but are not limited to selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs). They play a significant role in alleviating symptoms. However, they also have numerous side effects, interactions, and adverse reactions. It is the health professional's role to conduct a thorough physical examination and history enough to offer individualized treatment care. Some factors that might guide the treatment of the patient in the case study are a positive history of hypertension, overweight, and alcohol drinking. It is also important to consider the client's harsh working environment and his attempt to care for his aging parents.

Decision One

The listed options for decision one include Zoloft 50 Mg PO daily, Imipramine 25 mg Po BID, and Buspirone 10 Mg PO BID. My choice for the patient is Zoloft 50 Mg PO daily.

Reasons for the choice- Serotonin is responsible for mood and anxiety changes in the brain. Increased levels of serotonin (5-HT) are the major reason for increased anxiety and other symptoms in patients with GAD (Kaur & Sigh, 2017). Zoloft is a Selective serotonin reuptake inhibitor. It binds to the serotonin transporter to inhibit neuronal re-uptake of serotonin and increased dopamine neurotransmission (Kaur & Sigh, 2017). The mechanism would help alleviate the anxiety symptoms for the patient. Moreover, evidence shows that patients may start experiencing changes soon after taking the drug and the effect is maintained for a long time to prevent symptom relapse.

Reasons for not choosing other options- Imipramine is a tricyclic antidepressant (TCA). It works by blocking the norepinephrine and serotonin re-uptake pumps (Fayez & Gupta, 2020). As a tertiary amine, it works better in blocking the serotonin reuptake pump which helps alleviate anxiety in GAD. However, tricyclics are associated with weight gain. The patient is already overweight and Imipramine not the best choice for his anxiety.

Buspirone is an anxiolytic FDA approved for the management of anxiety. It works due to its high affinity for 5HT1a receptors resulting in its partial agonist on anxiety (Kaur & Sigh, 2017). Due to this mechanism of action, it is better as a short-term approach for anxiety (Stahl, 2020). GAD is a chronic solution that requires a long-term measure for best outcomes.

The goal of treatment- To have a long-term management approach for the patient towards total symptom remission.

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Decision 2

 The listed options in decision two include increasing the Zoloft 50 Mg to 75 Mg, 100 Mg, or no change at the time. My choice is to have no change in the dosage at this time.

Reasons for the choice- According to Stahl. (2020) the full therapeutic impact of Zoloft may take up to 2-4 weeks. The patient reports no chest tightness, breathlessness, and anxiety after 4 weeks of medication. He has reduced anxiety about work over the past four-five days and scores 18 (initial score: 26) on the Hamilton Anxiety Rating Scale. The outcomes are consistent with the intended goal of care.

 Reasons for not choosing other options: Psychiatric principles dictate that the health professional prescribes the least effective dose of antipsychotic medication and only continues with a drug if there is a discernable benefit to the patient (Stroup & Gray, 2018). Zoloft 50 Mg a day is the least amount for patients with anxiety. The patient shows a significant improvement from the initial symptoms. Moreover, he does not report any side effects with the 50 Mg dosage, and increasing the dosage to 75 or 100 Mg would only predispose him to adverse side effects. It is best practice to maintain the current dose and follow-up in the subsequent visit.

The goal of Treatment- The goal of treatment is to have a complete response on the Hamilton Anxiety Rating Scale through complete symptom remission.  

Decision Point 3

The options for decision three include increasing Zoloft’s dosage to 75 mg, augmenting with BuSpar (Buspirone), or switching to an SNRI like Effexor. My decision is to increase the dosage to 75 Mg Po/day.

Reasons for the choice- The patient is now on the eighth week on Zoloft 25 Mg. Although there was a significant improvement with the medication in the first four weeks, there is no further symptom alleviation. Stahl. (2020) states that the health professional must consider increasing the dosage if there is no improvement within 8 weeks of management. The recommended dose increase is 25 Mg at a 1-week interval but not to exceed the maximum 200 mg (Procyshyn et al., 2019). However, since there was an improvement with the least possible dose at four weeks with no reported side effects, the best approach at this point is to increase the dosage to 75 Mg through an individualized risk-benefit assessment.

Reasons for not choosing other options- Augmenting is a possible option when there is a partial response or treatment resistance. Psychiatric principles guide switching to an SNRI when there is evidence that the SSRI is ineffective for a patient (Ansara, 2020). However, the patient is only at the least therapeutic dose with Zoloft and had already reported a significant change within the first four weeks. As such, there is no evidence that there is treatment resistance with the medication. The reasonable course of action and per psychiatric principles is to increase the dosage to 75 Mg/day and follow-up in the next to determine efficacy and the possibility of side effects.

The goal of treatment- The goal is to have a progressive trajectory of the patient's symptoms with minimal or no side effects while maintaining the least possible dose required for better outcomes.

Ethical Considerations

Ethical considerations are a critical component of psychiatric evaluation and treatment. The greatest ethical concerns include worsening of symptoms, drop-out, client’s safety issues, and maintaining a good patient-provider relationship (Altis et al., 2015). A major consideration for the patient in the case is prescribing an antipsychotic with a discernable benefit. Choosing Zoloft is based on the patients’ clinical situation through a thorough psychiatric evaluation. Moreover, there is the element of improving the patient's symptoms while maintaining the least effective dose in a risk-benefit assessment (Stroup & Gray, 2018). It is an aim to minimize the side effects and the possibility of non-compliance. Such ethical considerations have a tremendous impact on the treatment plan of the patient.

Communication is the guiding element of psychiatric care. Effective psychiatric care dictates that the health professional listens to the patient's concerns, maintains respect, and involves them in the plan of care. The return of the patient after 8 weeks provides an opportunity for listening to the patient's concerns due to the partial response of the treatment plan. Through effective communication, there is a chance of making changes to the initial plan for continued treatment efficacy. It is also an opportunity to reassure and provide the patient with confidence about the care plan.

Conclusion

There is a significant impact on the quality of life with generalized anxiety disorder. However, effective patient-provider interactions through ethical considerations are an opportunity for better patient outcomes and increased patient satisfaction. The initial recommendation based on the patient's clinical presentation is to start Zoloft 50 Mg. It has a high safety profile and provides a better alternative to long-term anxiety management compared to the available options. The second recommendation is to maintain Zoloft at the initial dose due to the reported improvement at four weeks. More time will help assess the drug's efficacy in the recommended 6-weeks period and reduce the potential risk for adverse side effects of a higher dose. The last recommendation is to increase Zoloft dosage to 75 Mg after 8 weeks of therapy. The time frame is enough to provide a clear understanding of Zoloft's response for the patient and increasing the dosage would help in continued symptom alleviation. Future interactions with the patient are an opportunity for complete symptom remission towards an improved quality of life.

 

 

References

Altis, K. L., Elwood, L. S., & Olatunji, B. O. (2014). Ethical issues and ethical therapy associated with anxiety disorders. Ethical Issues in Behavioral Neuroscience, 265-278. DOI: 10.1007/7854_2014_340

Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician, 10(6), 326-334. https://doi.org/10.9740/mhc.2020.11.326

Fayez, R., & Gupta, V. (2020). Imipramine. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK557656/

Kaur, S., & Singh, R. (2017). Role of different neurotransmitters in anxiety: a systemic review. International Journal of Pharmaceutical Sciences and Research, 8(2), 411.

Procyshyn, R. M., Bezchlibnyk-Butler, K. Z., & Jeffries, J. J. (Eds.). (2019). Clinical handbook of psychotropic drugs. Hogrefe Verlag.

Stahl, S. M. (2020). Stahl online. https://stahlonline.cambridge.org/prescribers_drug.jsf?page=9781108926010c20.html.therapeutics&name=BUSPIRONE&title=Therapeutics#IDXl-tgt-0314

Stroup, T. S., & Gray, N. (2018). Management of common adverse effects of antipsychotic medications. World Psychiatry, 17(3), 341-356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6127750/

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