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Assessing and treating patients with anxiety disorder 

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.

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Assessing and treating patients with anxiety disorder 

Generalized Anxiety Disorder (GAD) affects 2.7% of the US population, which a higher prevalence recorded in middle-aged females as compared to males. GAD is a condition manifested in persistent and unrealistic worries, and overwhelming fear about life events such as financial situation, health, and social issues (Munir & Takov, 2020). Like most psychiatric conditions, factors attributing to the etiology of GAD are diverse ranging from biological, social, and psychological factors. Some of the symptoms associated with the condition include shortness of breath, restlessness, sweating, headache, fatigue, fear, dizziness, centration difficulties, and worries. The physical symptoms occur because people with anxiety experience muscle tension with a simultaneous response in preparation for the future danger that ignites the avoidant behaviors. The DSM-V criteria for diagnosing GAD include restlessness, muscle weakness, inability to control worries, irritability, and anxiety that have lasted for six months or more. The following report details the decision points made towards the treatment of a patient presenting with GAD.

The client is a 46-year-old Caucasian male who has been referred by his PCP following a visit to the emergency room. The client complained of shortness of breath, chest tightness, and a feeling of impending doom an encounter that felt as if he was having a heart attack. Medical history and assessment of the client reveal mild hypertension, overweight, and alcohol consumption. The patient reports pressure at work because of strict management. Mental examination of the patient indicates that the client confirms feelings of nervousness and his mood is “bleh”. The affect is blunted but with occasional moments of excitement. The patient denies hallucinations both visual and auditory, and no suicidal ideation. The Hamilton Anxiety Rating Scale (HAM-A) gives a score of 26, which confirms the diagnosis of GAD.

Decision Point #1

Begin Zoloft 50 mg daily

I decided to start with Zoloft because it presents more benefits to the patient than risks. Zoloft is a first-line medication approved for the treatment of GAD among other psychiatric conditions. SSRIs are more preferred because of their association with fewer side effects compared to other classes of drugs. In addition, the medication is well-tolerated and effective in the treatment of GAD. A 12-week study by Allgulander et al. (2015) proves the efficacy of Zoloft with patients suffering from GAD, as well as high levels of tolerability. The study also reveals that the medication has anxiolytic benefits both with somatic and psychic symptoms of anxiety (Strawn, Geracioti, Rajdev, & Clemenza, 2018). Moreover, the absorption of the drug is quick when taken with food.

I did not go for Imipramine because compared to Zoloft, it is less effective and has a high tendency for undesirable side effects. For example, the medication is associated with weight gain, delirium, constipation, confusion, blurred vision, dry mouth, cardiac arrhythmia, orthostatic hypotension, and urinary retention (Fayez & Gupta, 2020). Given that the patient is already experiencing some of these symptoms such as chest tightness, giving this medication will likely worsen the situation. Moreover, the medication can also trigger suicidal thoughts making it unsafe for the patient. The other option was Buspirone, which I ruled out because of its potential harm to the patient. Buspirone is associated with several symptoms making it less efficacious and safe for the patient. Some of the adverse effects of the drug include sore throat, chest pain, CNS depression, blurred vision, muscle weakness, akathisia, and diaphoresis. Since the patient already has mild hypertension, the medication may only worsen the condition and the symptoms of anxiety (Wilson and Tripp, 2020).

In making the medication decisions, some of the ethical considerations were the safety of the patient based on patient factors such as mild hypertension. Some medication may worsen hypertension (Wilson and Tripp, 2020). Thus, it was important to weigh the risks and benefits of the medications to ensure maximum safety and efficacy. With the decision I made, I expected significant improvement in the patient’s symptoms and a reduction in the HAM-A score. The patient returned to the clinic after four weeks reporting decreased worry and HAM-A score of 18. The patient also notes that they no longer have shortness of breath or chest pain. This shows a significant improvement congruent with my expectation.

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Decision Point #2

Increase the dose to 75 mg daily

At this point, Zoloft has demonstrated effectiveness with the client. Moreover, the medication is well-tolerated with a good response as the client has not reported any side effects. Thus, it is essential to maintain the current medication, but increase the dosage to enable improvement in relief from the GAD symptoms. The client has noted a decrease in certain symptoms but to some extent, these symptoms are still present. The goal of the treatment is to achieve more than 50% improvement (Wilson and Tripp, 2020). Thus, the treatment is on the right path, but appropriate therapeutic effectiveness has not been achieved, hence the rationale for the dose increase. Moreover, it is safer to start with a small dosage and increase bit by bit while observing the patient’s response. The maximum allowable dosage for Zoloft per day is 200 mg, thus, there is still room to increase dosage for effectiveness as long as the patient responds well.

The second option was less preferable because dose increment is more effective when done in small amounts rather than a large amount at once. This is because the increase in dosage may cause side effects and the higher the dose the more adverse the side effects become (Wilson and Tripp, 2020). The third option of maintaining the dose is a good consideration, but at this point, the desired level of therapeutic effectiveness is yet to be achieved. Thus, a slight increase in dosage is necessary for the patient. HAM-A score is 18, which is still high while some of the symptoms of anxiety are present. Maintaining the dose may make the symptoms reoccur in full instead of continued remission. Ethical decision-making involved talking to the patient about the dosage increase including the risks and benefits (Strawn, Geracioti, Rajdev, & Clemenza, 2018). In addition, patient safety is a priority in every treatment decision. Thus, the choice of treatment is in consideration of the patient’s mild hypertension.

The expected outcome from this decision was a significant improvement in symptoms and a reduction in the HAM-A score. I hoped that the client will resume normal functioning, especially at work without any effects of anxiety. I also anticipated that with reduced anxiety, the client will also limit his alcohol consumption or stop is possible. Having alcohol in the system when taking drugs is not safe as it may cause toxicity thus interfere with the effectiveness of the treatment. The client returned to the clinic after four weeks noting a further reduction in symptoms with a HAM-A score of 10. This showed good progress beyond what I expected would happen.

Decision Point #3

Maintain the Current Dose

I chose this option because the current dose has shown appropriate therapeutic effectiveness given that the symptoms have reduced, as well as the HAM-A score. For the 8 weeks of treatment, the patient has shown tremendous response with the medication and current dosage with no side effects reported. Guidelines recommend the maintenance of dose for 12 weeks to evaluate the effectiveness (Allgulander, et al., 2015). However, over those weeks, the client will be closely monitored to ensure that the drug’s effectiveness is maintained and there are no side effects. In the case there is a need to change medication, the practitioner will discuss with the patient it and evaluate the risks and benefits. The option of increasing the dosage to 100 mg daily is not necessary at this point since the patient’s response to the current dose is satisfactory.

Similarly, augmenting Zoloft with another class of drug is not required at this point since the client is doing well with Zoloft. Combining classes of drugs improves the efficacy of treatment, but is only recommended in a case where a treatment trial with one class of drug has failed in producing the required therapeutic effect. Moreover, such as combination can increase the risk of side effects, which is absent at the moment (Strawn, Geracioti, Rajdev, & Clemenza, 2018). Introducing another medication will also require evaluation of its possible effects on the patient’s hypertensive condition as some drugs may worsen hypertension. Another issue that might arise with the introduction of a new drug is medication interactions, which can harm the patient due to its adverse effects (Jain et al., 2017). Finally, the patient will be advised on limiting alcohol consumption to enhance the effectiveness of the treatment plan. Another issue addressed is the patient’s overweight issue by referring them to appropriate resources to help in the weight reduction process.

With this third decision, I expect that the patient will continue responding well to the medication and achieve normal functioning and ability to work effectively. Ethical issues arise from time to time in the cause of treatment. In this case, maintaining confidentiality is important to promote trust and ensure that the client gains the confidence to share important/sensitive information with the therapist, which helps in understanding the patient. Additionally, privacy and informed consent provisions must also be observed (Jain et al., 2017). Creating an individualized treatment plan for every client is important in promoting treatment effectiveness and reducing the risk of harm. Thus, factors such as the socio-cultural background of the patient, alcohol consumption, health status, are critical when designing a treatment plan. Moreover, patients must be fully engaged in their treatment plan to promote autonomy and promote equality leading to better health outcomes.

Treatment of patients with anxiety requires a person-centered approach that seeks to understand personal factors of the patient that influence care outcomes. The decision made for the treatment plan was to use Zoloft because of its proven efficacy, safety, and long-term tolerance ability. Starting with a small dose then adjusting gradually is recommended as opposed to starting with a large amount of dose. This ensures that the patient is monitored for any side effects, as well as effectiveness, tolerance, and response. Other medication options given have a tendency for side effects that would only worsen the condition of the patient. Patient factors considered when evaluating the risks and benefits of medication include mild hypertension, alcohol consumption, socioeconomic background, and overweight issue. Ethical issues include patient autonomy, confidentiality, privacy, and safety issues in prescribing medication to patients.

 

References

Allgulander, C., Dahl, A., Austin, C., Morris, P., Sogaard, J., Kutcher, S., & Clary, C. (2015). Efficacy of Sertraline in a 12-Week Trial for Generalized Anxiety Disorder. American Journal of Psychiatry, https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.9.1642#:~:text=In%20conclusion%2C%20the%20results%20of,psychic%20and%20somatic%20anxiety%20symptoms.

Fayez R, Gupta V. Imipramine. [Updated 2020 October 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK557656/

Jain, S., Kuppili, P. P., Pattanayak, R. D., & Sagar, R. (2017). Ethics in Psychiatric Research: Issues and Recommendations. Indian journal of psychological medicine, 39(5), 558–565. https://doi.org/10.4103/IJPSYM.IJPSYM_131_17

Strawn, J. R., Geracioti, L., Rajdev, N., & Clemenza, K. (2018). Pharmacotherapy for Generalized Anxiety Disorder in Adults and Pediatric Patients: An Evidence-Based Treatment Review. Expert Opin Pharmacother, 19(10), 1057–1070.

Wilson TK, Tripp J. Buspirone. [Updated 2020 Sep 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531477/

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