Discussion: Assessing and Treating Patients with Anxiety Disorders – Solved

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Assessing and Treating Patients with Anxiety Disorders

Introduction to the Case

The case involves a single 46-year old male referred by a primary care physician. Professionally, the patient is a welder with a fabrication factory. Initially, he was at the emergency room following a suspected heart attack. Subjective data indicated that the patient felt a tight chest, short breath, a feeling of imminent doom, and the necessity to escape. The patient believes that both the chest and short breath’s tightness are anxiety attacks, yet he has not been on any psychotropic medication. The anxiety and fears may cause physical symptoms like shakiness and rapid heart rate. Generalized anxiety disorder (GAD) is an effective form of an anxiety disorder (Locke et al., 2015). He also confesses to using ETOH to remedy work anxiety. He also consumes about 3-4 beers/night. He claims that he cares for his aging parents, yet his workplace management is unbearable, and he fears losing his job.

From the physical exam, the patient has mild hypertension, of which he is under a regimen of a low sodium diet. Besides, the patient is overweight and had tonsils while he was 8yrs. The results from other physical assessments were all treated as within normal limits. Following the assessment using Hamilton Anxiety Rating Scale (HAM-A), the results score yield 26, indicating moderate to severe anxiety (Hamilton, 1959). An examination of mental status reveals he is conscious and aware of the environment, event and time. His dressing is appropriate, has a clear, coherent, and goal-directed speech. However, he reports boredom and nervousness. His reaction is relatively blunted and broad, with stints of bright effect during the interview. The client claims he is free of visual or auditory delusions, irrational or psychotic thinking, and suicidal ideation. His judgment and insight are grossly intact.

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Decision Point One

I selected Zoloft 50mg orally daily. Zoloft is classified as a selective reuptake inhibitor (SSRI), recommended as a first-line treatment for anxiety disorders. The drug acts by increasing the amount of serotonin in the brain, thus, facilitating mood regulation (Locher et al., 2017). Besides, Zoloft hinders serotonin reuptake in the brain and therefore increases its level to help regulates an individual’s mood, improving the anxiety symptoms. In a sense, since anxiety depleted serotonin in the brain and Zoloft replaces and prevents reuptake, then it is the most appropriate choice for GAD and the patient in this case (Patel et al., 2018).

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I did not select Imipramine 25mg PO BID since it is not a first-line medication for treating anxiety, and its only effective at higher doses, e.g., from 100mg/day. Besides, Imipramine was not selected because it is not well tolerated in the body’s system and has been associated with higher dropout rates (American Psychiatric Association [APA], 2010a). Equally, Buspirone 10mg PO BID has been shown ineffective for managing anxiety disorders, and there is limited evidence on its efficacy (APA, 2010b).

Zoloft was selected to mitigate the patient’s symptoms of GAD gradually.  Besides, it was expected that the patient’s HAM-A reading would significantly reduce in the following appointment as a sign of a positive response to medication. These assumptions were based on evidence that Zoloft is an effective medication for GAD (Patel et al., 2018). Besides, it was expected that the patient would have limited side effects of the drug considering it is an SSRI, which tends to have a minimal side effect on patients and are well tolerated (Clevenger et al., 2018).

The actual outcome was expected since the patient showed a significant reduction in GAD symptoms. For instance, the patient reported no chest tightness nor shortness of breath. Moreover, the patient reported that he no longer worried about his work since the last 4-5day following the second appointment. Equally, the patient’s HAM- score reduced significantly from 26 to 18, which is a partial response to medication and an indication of GAD’s mild severity (Hamilton, 1959).

Decision Point Two

I chose to increase the dose to 75mg orally. This decision was founded on the patient’s positive response to the original dosage of 50mg daily, as shown by the drop in HAM-A scores and the patient’s subjective data. However, a drop-in HAM-A score was considered a partial response; thus, the need to increase the dosage was crucial. According to Bui et al. (2016), a subsequent treatment strategy may be sufficient for clients who do not respond well to primary treatment. This decision was also based on the fact that the client seems to be tolerating Zoloft medication well and without any side effects.

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I did not choose to increase Zoloft to 100mg since medication dosage should be increased and titrated gradually to facilitate the patient’s tolerability of the drug and avoid unprecedented side effects resulting from sedation. On the other hand, I did not choose to continue the dosage since the patient only showed a partial response from the initial dosage. Therefore, increasing the dosage was essential in further enhancing medication response and complete response (Jakubovski et al., 2016).

Increasing the dosage to 75mg per day further increased serotonin availability in the brain to further improve the patient’s anxiety symptoms. Evidence supports the gradual increase of the SSRIs dosage if the clients are not satisfactorily responsive to the treatment (Jakubovski et al., 2016). Therefore, the choice would result in a continued reduction in anxiety symptoms and shown in the HAMA-scores in the subsequent visit. The actual outcome was expected since the patient reported a further decrease in anxiety symptoms. Moreover, the HAM-A score reduced significantly to 10, which was a 61% decrease in anxiety symptoms.

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Decision Point Three

I chose to have the patient maintain the current drug and dose, which was Zoloft 75mg orally daily. The decision was made since the patient responded well to the current quantity of Zoloft. The client showed significant signs of a reduction in his anxiety symptoms. A 50% decrease in symptoms demonstrates a substantial response, and the individual is not having any drug side effects. Evidence and clinical guidelines recommend titration of medications according to the client’s response; in this case, the client responded very well. Hence, there is no need to titrate medication any further (Jakobsen et al., 2017).

The option of increasing the dosage to 100mg daily orally was not selected, although it could reduce symptoms further. The reason for not raising the dosage was because it could expose the client to side effects. Besides, the option of adding augmentation such as buspirone was not selected because the patient was showing a positive response to the Zoloft regimen. Polypharmacy is only recommended when a patient’s symptom cannot be controlled with the initial treatment regimen (Längle et al., 2012). It was expected that the patient would have few anxiety symptoms by the time he will have his appointment. Besides, the HAM-A reading will indicate less anxiety during the subsequent appointment.

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Assessing and treating patients with anxiety disorders
Assessing and treating patients with anxiety disorders

Ethical Considerations

As a practitioner, it is crucial to embody ethical practice, and it impacts treatment regimen. For this client, it is critical to consider his consent to the treatment regimen, confidentiality to his medical information, and autonomy. According to Millum (2013), practitioners should educate the client on available treatment interventions to ensure that they are well informed to effectively contribute to their treatment plan. For instance, the client should be told why some medications were not chosen during the subsequent appointment. As such, they would develop trust and compliance with the drug. Equally, the patient should not be coerced to agree with any treatment intervention, and his medical information should be kept and not disclosed to any third party without consent.

Conclusion

Anxiety symptoms are often synonymous with other disorders with tension, withdrawal, or fidgeting, as seen in alcohol or cocaine intoxication. As such, the HAM-A tool is critical in diagnosing whether a person has an anxiety disorder and the severity of the condition. Zoloft 50 mg orally daily was initially selected for the client’s treatment before gradually increasing the dosage to 75mg per day and maintained for the last phase of the treatment plan.

The decision was founded on evidence that Zoloft is a group of SSIs and has been proven to increase and retain serotonin in the brain significantly. Serotonin is a significant hormone that regulates mood in people. Zoloft has been approved by the US Food and Drug Authority as the first-line medication for anxiety disorders and is widely available. Besides, Zoloft is moderately tolerated by most clients since it has not shown significant side effects when taken gradually.

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In this case, the chose medication, i.e., Zoloft 50mg per day – later titrated to 75mg per day exuded positive effect on the patient’s anxiety symptoms. Besides, the client reported no side effects from the treatment regimen. The overall outcome was a significant reduction in GAD symptoms, as shown by subjective data and HAM-A scores of 10 after week eight of twelve. Therefore, I recommend Zoloft medication for managing GAD for a middle-aged white male with similar symptoms. Lastly, a medical practitioner should embody medical ethics, i.e., inform and involve patients in choosing their treatment plan, show reference for patient’s confidentiality and autonomy since all these aspects of medical ethics affect the medical choice and health outcomes.

References

American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf

American Psychiatric Association. (2010b). Practice guideline for the treatment of patients with panic disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.

Clevenger S, Devvrat M, Dang J, Vanle B & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacology. 8(1): 49–58. Assessing and Treating Clients With Anxiety Disorders Sample Essay. https://doi.org/10.1177/2045125317737264

Hamilton, M. (1959). Hamilton Anxiety Rating Scale (HAM-A). PsycTESTS. https://doi.org/10.1037/t02824-0    

Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, https://doi.10.1037/t02824-0

Jakobsen J, Kumar K, Timm A, Gluud C, Ebert E et al. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry. 17(58). https://doi.org/10.1186/s12888-016-1173-2

Jakubovski E, Anjali V, Freemantle N, Taylr M & Bloch M. (2016). Systematic Review and Meta-Analysis: Dose-Response Relationship of Selective-Serotonin Reuptake Inhibitors in Major Depressive Disorder. Am J Psychiatry. 173(2): 174–183. https://doi.org/10.1176/appi.ajp.2015.15030331

Längle, G., Steinert, T., Weiser, P., Schepp, W., Jaeger, S., Pfiffner, C., … & Kilian, R. (2012). Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment. Acta Psychiatrica Scandinavica125(5), 372-381. https://doi.org/10.1111/j.1600-0447.2012.01835.x

Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017). Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders among Children Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry. 74(10), 1011–1020. https://doi.10.1001/jamapsychiatry.2017.2432

Locke A, Faafp M, Krist N & Shultz C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician.  1; 91(9), 617-624. https://www.aafp.org/afp/2015/0501/p617.html?utm_medium=referral&utm_source=r360

Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235. https://doi.10.1097/NMD.0b013e318247cb5b

Patel D, Feucht C, Brown K & Ramsay J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr. 7(1): 23–35.

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