NURS 6630N Psychopharmacologic Approaches To Treatment Of Psychology
Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and a feeling of impending doom. He does have some mild hypertension (which is treated with a low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. The remainder of the physical exam was WNL.
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at. NURS 6630N Psychopharmacologic Approaches To Treatment Of Psychology.
In your office, he confesses to the occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for his aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26. The client has never been on any type of psychotropic medication. NURS 6630N Psychopharmacologic Approaches To Treatment Of Psychology.
MENTAL STATUS EXAM
The client is alert and oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. The client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. The effect is somewhat blunted but does brighten several times throughout the clinical interview. Affect broad. The client denies visual or auditory hallucinations, and no overt delusional or paranoid thought processes are readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation. NURS 6630N Psychopharmacologic Approaches To Treatment Of Psychology.
The PMHNP administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.
Diagnosis: Generalized anxiety disorder
§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0
Decision Point One
Select what the PMHNP should do:
- Begin Zoloft 50 mg po daily
- Begin Imipramine 25 mg po BID
- Begin Buspirone 10 mg po BID
ORDER NURS 6630N Psychopharmacologic Approaches To Treatment Of Psychology Assignment
Managing Generalized Anxiety Disorders
Generalized anxiety disorder (GAD) refers to a mental disease characterized by persistent and excessive worry. Affected patients anticipate disaster and get overly concerned about work, family, health, and money among others. It is estimated that GAD affects at least 6.8 million US adults annually (Bandelow, Michaelis & Wedekind, 2017). The disease is linked to biological factors life experiences and family backgrounds. The purpose of this paper is to review a 46-year-old white male diagnosed with a generalized anxiety disorder. The patient has anxiety attaches and reports feeling the need to “run” or “escape”. He uses ETOH to manage worries and takes 3 to 4 beers per night. He fears losing his job and has a HAM-A score of 26 (Laureate Education, 2016b). The paper will use a decision tree to recommend pharmacological interventions that resolve the patient’s problems. Additionally, the paper will describe the ethical considerations impacting treatment and communication with the patient.
Decision Point One
Begin Zoloft 50mg PO daily
Reason for Selection
Zoloft is a selective serotonin reuptake inhibitor and thus considered first-line therapy for GAD. The drug works by inhibiting the reuptake of 5-HT in the central nervous system which increases the extra-synaptic diffusion (Chen et al., 2019). The drug has no affinity for adrenergic, serotonergic, histaminergic, dopaminergic and cholinergic receptors which minimizes anticholinergic, sedative and cardiovascular effects. The drug is absorbed slowly from the GI and its peak serum levels occur after 6-8 hours. The drug has a half-life of 26-32 hours among adults which makes it suitable for once-daily administration. Compared to a placebo, Zoloft significantly reduces anxiety symptoms (Chen et al., 2019). Additionally, the patient is starting psychotropic medication and thus should begin with less active medication that reduces the symptoms effectively.
Imipramine 25 mg PO daily is avoided because although it reduces anxiety among GAD patients, it has some properties that diminish or counteract its anxiolytic effects (Carl et al., 2020). Additionally, research shows that Zoloft is marginally better than imipramine and significantly better than a placebo (Baldwin et al., 2017). The drug is absorbed rapidly with peak concentrations of 2-4 hours and has a high affinity for α1 adrenergic, cholinergic and histaminergic receptors and thus causes common side effects like weight gain, constipation, and dry mouth. Compared to Zoloft, Imipramine has a higher risk for QTc prolongation and the patient is reported to be hypertensive. Lastly, the drug falls under TCAs which are viable options for patients who do not respond to multiple trials of SSRIs and SNRIs (Carl et al., 2020). Although Buspirone has a decreased side-effect profile when compared to other anxiolytic treatments, it is avoided because is a second-line agent (Baldwin et al., 2017). It is offered after a patient fails to respond to or cannot handle the side effects of SSRIs.
Zoloft significantly reduces the frequency of panic attacks, diminishes anticipatory anxiety and improves phobic symptoms (Baldwin et al., 2017). The patients should report reduced symptoms after four weeks. His HAM-A scale should reduce to 13 and he should report diminished chest tightness, shortness of breath and feeling of impending doom. He should also tolerate the medication with minimal side effects.
Difference between Expected and Actual Results
The expectations of the clinician were met. After four weeks, the patient reported that he no longer experienced shortness of breath or tightness in the chest and his worriers about his job had reduced for 4 to 5 days (Laureate Education, 2016b). The HAM-A score also reduced from 26 to 18 which was a partial response since a 50% reduction of symptoms was expected.
Decision Point Two
Increase the dose to 75mg orally daily
Reason for Selection
The patient had a minimal therapeutic response with no side effects. Nevertheless, the response was below the set threshold of 50% reduction of symptoms. To increase the response it is essential to up-titrate the dosage to 75mg orally daily. Generally, antidepressants should be increased on a “start low and go slow’ procedure (Stroup & Gray, 2018). The slow-up titration helps one to reach an effective dosage and reduce the appearance and severity of side effects. Increasing the dosage to 100mg is avoided because it translates into a loading strategy which can induce side effects resulting in adherence issues and increased discontinuation. Maintenance of the current dosage is counterproductive because it will still offer similar results. Additionally, Zoloft dosage can be increased gradually to a maximum dose of 200mg until an effective dosage is achieved or tolerance issues arise (Carl et al., 2020).
Significant improvement of the symptoms should be reported. The patient should exceed the 50% symptom improvement set for the initial dosage. The expectations are set because a modest increment of medication may improve the treatment effect (Stroup & Gray, 2018).
Difference between Expected and Actual Results
After four more weeks on the drug, the patient report aligned with the clinician’s expectations. His symptoms reduced further as indicated by scoring 10 on the HAM-A scale (Laureate Education, 2016b). The symptoms reduced by 61% which was a remarkable achievement.
Decision Point Three
Maintain the current dose
Reason for Selection
A positive therapeutic response has been achieved. The patient has attained a greater than 50% reduction in symptoms without experiencing any side effects. The dosage can be termed as the lowest effective dose that limits side effects. It is therefore essential to maintain the dosage for four more weeks and then evaluate the full effect of the drug. An increase in dosage to 100mg may reduce the symptoms however the risk of side effects increases. Generally, a higher dosage increases adverse effects more than beneficial effects which eventually result in an unfavorable benefit-harm balance (Stroup & Gray, 2018). Lastly, augmentation with Buspirone is avoided because it is recommended when a patient fails to respond to SSRIs or cannot tolerate their side effects. Specifically, augmentation is preferred when one intends to reduce the sexual side effects of SSRIs (Chen et al., 2019). The patient has not reported experiencing any sexual dysfunction. It is also essential to avoid polypharmacy to reduce the risk of adverse drug effects and drug-drug interactions.
The clinician expects that the patient will progress to remission. He should report to the clinic with no complaints of chest tightness or shortness of breath. Additionally, the nervousness surrounding his job should dissipate. He should score 5 on the HAM-A scale.
Differences between Expected and Actual Results
After four weeks, the patient reported to the clinic as expected. His HAM-A score had reduced to the set target and his symptoms fully resolved. His affect was broad and his self-reported mood was great. He appreciated the clinician for helping him regain a normal life.
The first ethical obligation is an accurate diagnosis of generalized anxiety disorder. Gad patients complain of chronic medical conditions like chest pain and hypertension which complicates the accuracy of diagnosis and delays treatment. An accurate diagnosis is achieved through a thorough evaluation of the patient (Syse, Førde & Pedersen, 2016). Secondly, the clinician is supposed to make ethical decisions that produce positive outcomes for the patient. There is a need to avoid causing harm and maximize the success of the selected interventions. The selected interventions should be supported by evidence-based research on their applicability to the specific disorder. Education is an important component when prescribing medication. It ensures that the patient understands all the available medication. The patient also comfortably offers complete consent and assent for any medication offered since they understand the risks and benefits (Syse, Førde & Pedersen, 2016). Once a medication is agreed on, it should then be started at a low dose to assess repose and tolerability. After a positive response, the medication should be titrated gradually to ensure that an effective dose is achieved while limiting the side effects.
For the patient, an accurate diagnosis was made after assessing the symptoms and employing the HAM-A scale. The first-line treatment of Zoloft was then prescribed since the patient was starting on psychotropic medications. Additionally, the drug is supported by evidence on its efficacy and has characteristics that limit side effects. The medication was then initiated at a lower dosage and then increased gradually until an effective dosage was established. The dosage was then maintained to achieve a benefit-harm balance. All the decisions were made after the patient consented and assented to the medication.
Generalized anxiety disorders cause persistent and excessive worry. The disease symptoms have to be adequately managed to ensure that the patient leads a stable and productive life. Secondly, any pharmacological agent selected should be backed up by a rationality that it is the best possible solution. Additionally, the decisions made should be made following ethical considerations. The decision should maximize success and minimize harm. Lastly, the entire process of initiating a drug, monitoring its effects, and achieving remission should be supported by evidence-based practices.
Baldwin, D. S., Hou, R., Gordon, R., Huneke, N. T., & Garner, M. (2017). Pharmacotherapy in generalized anxiety disorder: novel experimental medicine models and emerging drug targets. CNS drugs, 31(4), 307-317.
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.
Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., … & Powers, M. B. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1-21.
Chen, T. R., Huang, H. C., Hsu, J. H., Ouyang, W. C., & Lin, K. C. (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis. Journal of psychiatric research, 118, 73-83.
Laureate Education. (2016b). Case study: A middle-aged Caucasian man with anxiety [Interactive media file]. Baltimore, MD: Author.
Stroup, T. S., & Gray, N. (2018). Management of common adverse effects of antipsychotic medications. World Psychiatry, 17(3), 341-356.
Syse, I., Førde, R., & Pedersen, R. (2016). Clinical ethics committees–also for mental health care? The Norwegian experience. Clinical Ethics, 11(2-3), 81-86.
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