Assessing and Treating Patients With Anxiety Disorders Essay

Introduction to the Case

Anxiety disorders include a group of mental disorders characterized by significant feelings of anxiety and fear that may lead to physical symptoms such as racing heart, sweating, and shakiness. Some types of anxiety disorders are generalized anxiety disorder, panic disorder, agoraphobia, social anxiety disorder, among others (Locke et al., 2015). The client in this case study is a 46-year-old man who reported that he was having symptoms such as chest tightness, shortness of breath, and a feeling of impending doom, and the need to escape from the feeling. These are common symptoms of anxiety disorders. The client underwent ECK and ER and the findings were normal, and this ruled out myocardial infarction. The client reported that he occasionally used ETOH to relieve the anxiety and worries regarding his work. He drinks about 3-4 beers every night. He reported that his workplace was stressful and harsh. The mental status exam showed that the client was well groomed and well oriented. His speech was coherent, goal-oriented, and clear. He reported that his mood was “nervous” and “bleh”. Affect was broad and somewhat blunted. He denied hallucinations but he manifested a paranoid thought process. He denied any suicidal thoughts but the assessment indicated that his judgment and insight were grossly intact. The client was administered with the (HAM-A) scale and the score was 26. This confirmed a diagnosis of generalized anxiety disorder (GAD).

From this diagnosis, this paper will discuss three decisions regarding the treatment regimen for the client and provide the rationale for each decision. Additionally, all ethical issues allied to each treatment decision will be discussed.

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Decision Point One

The diagnosis for this client is generalized anxiety disorder (GAD). Therefore, the appropriate decision is for the client to begin Zoloft 50 mg orally daily. The rationale for choosing Zoloft is because the medication is a selective serotonin reuptake inhibitor (SSRI). SSRIs are first-line treatment choices when treating anxiety disorders. SSRIs work by elevating serotonin within the brain because serotonin is required to regulate and improve the mood (Locher et al., 2017). Therefore, SSRIs like Zoloft function by inhibiting the absorption of serotonin within the brain and this elevates the amount of serotonin within the brain, which assists to regulate the mood and in turn improves symptoms of anxiety. Moreover, studies demonstrate the efficacy of Zoloft in the treatment of symptoms of anxiety present in GAD since anxiety leads to the depletion of serotonin within the brain, and thus SSRIs like Zoloft replenish the depleted serotonin (Patel et al., 2018).

Buspirone (Buspar) and Imipramine (Tofranil) treatment choices were not chosen as they are not first-line treatment choices for anxiety disorders. Additionally, the two drugs have more side effects and are not well tolerated when compared to Zoloft.

Selection of Zoloft hoped that the symptoms of GAD for this client would gradually improve as manifested by reduced worry, normal heartbeat, and reduced HAM-A score. This is attributable to the efficacy of Zoloft in improving symptoms of GAD (Patel et al., 2018). Secondly, it is expected that the client would not experience side effects as Zoloft is well-tolerated and has a good safety profile (Clevenger et al., 2018).

As predicted, when the client reported for review, the symptoms of GAD had reduced significantly as he was not experiencing symptoms such as breath shortness, fast heartbeat, or chest tightness. This is attributable to the efficacy of Zoloft in treating GAD symptoms (Patel et al., 2018). Additionally, the client stated that he was no longer worried about his work, and the HAM-A score was reduced to 18, indication partial response to the treatment. The client did also not report any side effects.

The ethical considerations relevant to this decision include informed consent and beneficence. First, it will be necessary to seek informed consent from the patient by explaining to him all the information associated with each medication (Yip et al. 2016). Secondly, the nurse practitioner should choose the treatment decision that is for the client’s best interests.

Decision Point Two

The client manifested partial response to Zoloft 75 mg and hence the second decision was to have the dose increased to 75 mg. Increasing the Zoloft dose to 75 mg will avail more serotonin in the brain and lead to further symptom improvement. Jakubovski et al (2016) explain that gradual increase and upward titration of SSRIs dose is recommended if the patient is not manifesting adequate response to the treatment. Moreover, the decision to increase the dose to 75 mg was selected because the client was not experiencing any side effects, indicating he was tolerating the Zoloft 50 mg.

The decision of having the dose increased to 100mg was not selected since upward titration of Zoloft should be gradual to ensure the client tolerates the dose increment, without experiencing major side effects. The decision of having the client continue taking the same dose and undergo assessment after 4 weeks was not chosen since he is manifesting partial response. Therefore, it is necessary to have the dose increased to facilitate adequate response and help the client achieve complete symptom remission (Jakobsen et al., 2017).

Selecting the decision to have a Zoloft dose increased to 75 mg expects that the client would show more symptom improvement and that the HAM-A score would reduce significantly. This is due to the ability of the higher Zoloft dose to avail more serotonin within the brain, and thus increased symptom improvement (Jakubovski et al., 2016). It is also expected that he would tolerate Zoloft 75 mg and not experience side effects.

As it was expected, when the client reported for review after four weeks, there was an increased improvement of the anxiety symptoms. The client reported further symptom reduction and the HAM-A score reduced to 10. The client manifested 61% symptom reduction. This is attributable to the ability of the higher Zoloft dose to avail more serotonin within the brain, and thus increased symptom improvement (Jakubovski et al., 2016). The client did not report any side effects.

Ethical considerations for this decision include informed consent and respecting patient autonomy. It would be important for the PMHNP to explain to the client the possible side effects of the increased dose (Yip et al., 2016). The client’s decision should also be respected.

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Decision Point Three

The client is already manifesting adequate symptom improvement as he self-reported that he was no longer having anxiety symptoms and as indicated by a further reduced HAM-A score. Therefore, the third decision is the maintenance of the Zoloft 75 dose. Clinical guidelines and studies recommend that medications should be titrated as per the patient’s response. The client is manifesting adequate response to Zoloft 75 mg and therefore there is no reason to have further titration of the medication upwards (Jakobsen et al., 2017). Moreover, the client is tolerating the Zoloft 75 mg well, without any side effects.

The decision to have the current treatment augmented with Buspar was not chosen because there is no clinical reason to augment the current treatment. Similarly, the decision to have the dose further increased to Zoloft 100 was not selected because, with the Zoloft 75 mg, the client is not only showing adequate symptom improvement, but he is also tolerating the medication well. Further dose increment may lead to side effects.

Selecting the decision to have the current Zoloft 75mg maintained hopes that the client would continue responding to treatment, and finally attain complete symptom remission as manifested by further reduction of the HAM-A score and the client no longer experiencing symptoms such as chest tightness, rapid heartbeat, or any worry. This is due to Zoloft’s efficacy in improving anxiety symptoms (Jakubovski et al., 2016). It is also hoped that he will continue tolerating the medication and the dose.

The ethical considerations relevant to this decision include beneficence. The decision should be according to the client’s best interests. Moreover, it is necessary to maintain the confidentiality of his health information, including his diagnosis and fears about work (Yip et al., 2016).

Conclusion

The diagnosis for the client was generalized anxiety disorder as indicated by symptoms such as constant worrying, chest tightness, breathing issues, and a HAM-A score of 26. With this diagnosis, the initial decision was to have the client start Zoloft 50 mg. The reason for choosing this decision is because Zoloft is an SSRI and SSRIs are the first-line treatment choices in anxiety disorders. Moreover, Zoloft has been demonstrated to be effective in reducing anxiety symptoms. With this decision, the client manifested partial response to treatment and thus the second decision was to have the Zoloft dose elevated to 75 mg. This decision was selected because a higher dose of Zoloft increases serotonin levels within the brain, leading to further symptom improvement. As expected, with the 75 mg, the client reported that he was not experiencing anxiety symptoms and the HAM-A score was further reduced. The client also tolerated the Zoloft 75 mg well, without any side effects. The third decision was therefore to have the current Zoloft dose (75 mg) maintained as he is showing adequate symptom improvement as demonstrated by decreased symptoms according to the subjective data and further reduced HAM-A score. The client also tolerated the Zoloft 75 mg dose well. With this decision, expectations include that the client will finally attain complete symptom remission and not experience any side effects. The ethical considerations applicable to the treatment decisions for this client include informed consent, confidentiality, and respecting the client’s autonomy.

References

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.

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.

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).

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.

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 and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74(10), 1011–1020.

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.

Yip, C., Han, N. R., & Sng, B. L. (2016). Legal and ethical issues in research. Indian journal of anesthesia, 60(9), 684–688. https://doi.org/10.4103/0019-5049.190627

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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)

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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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