Assessing and Treating Patients with Anxiety Disorders Paper

Assessing and Treating Patients with Anxiety Disorders Paper

Assessing and Treating Patients with Anxiety Disorders Paper

            Anxiety Disorder is a mental illness characterized by an extreme feeling of fear, worry, or anxiousness, affecting the patient’s quality of life. Most of the time, this condition normally ends up being undiagnosed especially among adults. This normally leads to severe stages before the mental condition is detected. The DSM-V diagnostic criteria however provide an outline for the diagnosis of an anxiety disorder (Curtiss et al., 2017). Additionally, through evidence-based practice, several treatment options are available for the management of patients with anxiety disorder, comprising of both pharmacological and psychotherapeutic interventions.

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In the assigned case study, the 46-year-old Caucasian male patient presents to the clinic displaying symptoms of anxiety. Earlier, he reported to the emergency room claiming of having a heart attack, from where he was referred to our clinic for psychiatry evaluation. The signs and symptoms displayed by the patient include shortness of breath, impending doom feeling, and tightened chest. He scored 26 on the Hamilton Anxiety Rating Scale (HAM-A) which indicates a moderate to severe anxiety disorder. The patient however denies visual or auditory hallucination, potential harm to self, or suicidal ideation.

Other than the patient’s age, race, and anxiety symptoms, other factors which might affect decision-making when prescribing drugs include being overweight, since some psychotropic agents are associated with weight gain. He also has a history of mild hypertension, which was controlled by a low sodium diet. The patient also reports taking 4 bottles of beer every night for his stress. This paper demonstrates the decision-making process of the most effective medication to include in the patient’s treatment plan, while observing pharmacokinetic and pharmacodynamic factors, in addition to ethical considerations which might impact this care process.

Decision #1

Selected Decision and Rationale

The initial intervention is to start the patient on Zoloft 50 mg orally once daily. Sertraline (Zoloft) is an example of selective serotonin reuptake inhibitors (SSRIs), approved by the FDA for the management of GAD among adults (Chen et al., 2019). Most clinical guidelines recommend the use of Zoloft as the first-line for the management of anxiety disorders among adults.

Considering the patient’s specific factors, Zoloft is the best choice of drug for the management of anxiety symptoms. For instance, the API is absorbed slowly in the GIT with a peak plasma level being attained after 6 to 8 hours, necessary to elicit optimal therapeutic action. This also allows once-daily dose, convenient among adult patients (Strawn et al., 2018). Additionally, CYP2B6 and CYP2C19are major predominating enzymes among Caucasians, which promote the metabolism of Zoloft, hence limiting the side effects associated with toxic levels in the blood.

Initiating imipramine was not necessary, given that this drug is most effective in the management of depression rather than anxiety symptoms(Curtiss et al., 2017). Consequently, imipramine is a tricyclic antidepressant associated with elevated systolic blood pressure, which would otherwise worsen the patient’s mild hypertension.

Buspirone on the other hand is associated with cardiovascular side effects, hence should only be used among patients with hypertensive disorder only when there is no other option and the benefits outweigh the risks (Chen et al., 2019). The drug also leads to weight gain.

Expected Outcome

            The drug is expected to display more than 50% remission of anxiety symptoms within the next 4 to 8 weeks. As a result, HAM-A scores are expected to reduce to less than 8 from 26(Curtiss et al., 2017). Only common self-limiting side effects such as headache, dry mouth, and increased sweating might be expected.

Ethical Consideration

            Given that the patient is an adult, it will be necessary for the PMHNP to observe the ethical principles of informed consent and respect for patient autonomy(Chen et al., 2019). For example, the patient must be informed about all the available treatment options, and both their benefits and side effects, and allowed to take part in deciding on what medication to take.

Decision #2

Selected Decision and Rationale

The second decision was to increase the dose of Zoloft to 75 mg once daily. Studies show that the dose of Zoloft should be increased at intervals of 25mg to 50 mg per day once weekly when the desired therapeutic response has not been attained among adults(Curtiss et al., 2017).

This decision was based on the fact that the patient displayed great adherence and tolerance to the medication within the first 4 weeks. Studies report that it takes between 8 to 12 weeks for Zoloft to attain optimum therapeutic action in completely managing anxiety symptoms (Strawn et al., 2019). However, the dose must be increased gradually, while monitoring patient symptoms to attain an optimum dose. A HAM-A score of 18 for 26 also shows that the drug is effective but in limited amounts.

Increasing the dose to 100mg was not necessary as this would destabilize the patient’s current state and lead to increased peak plasma concentration leading to undesired side effects(Curtiss et al., 2017). Studies show that to maintain patient adherence, it is necessary to increase the dose by 25mg before going to 50mg.

Changing the treatment regimen by replacing Zoloft was also inappropriate as this would only interfere with the patient’s compliance level, given the first drug was working well (Strawn et al., 2019). Studies show that Zoloft should only be continued incase of adverse reactions or ineffectiveness, which was not the case with this patient.

Expected Outcome

            With the dose increment to 75mg, the patient is expected to display even further management of anxiety symptoms(Williams et al., 2020). He should be able to breathe well and even sleep without taking alcohol. His HAM-A scores are still expected reduce to less than 8.

Ethical Consideration

            The main ethical principle considered at this stage is beneficence. The PMHNP must promote the health of the patient and prevent harm (Strawn et al., 2019). As such, it is necessary to discuss with the patient, why it was necessary to increase the dose of Zoloft to 75mg and not 100mg. The PMHNP must also display truth-telling, to promote a healthy therapeutic relationship with the patient.

Decision #3

Selected Decision and Rationale

            The last decision was to maintain the Zoloft dose at 75mg once daily and continue monitoring the patient’s progress. Through evidence-based practice, once the optimal dose of Zoloft in the management of the patient’s symptoms has been attained, it is necessary to maintain the dose to promote the beneficial effects of the drug and prevent harm(Williams et al., 2020).

This decision was supported by the outcome displayed by the patient in the past 4 weeks. At 75mg, Zoloft was able to attain a 61% remission of the patient’s symptoms, with a HAM-A score of 10. This shows the great effectiveness of the drug in managing the patient’s condition (Strawn et al., 2019). Consequently, no side effects were reported which demonstrates great adherence andcompliance, hence the need to maintain the dose to control the patient’s symptoms completely.

As mentioned earlier, increasing the dose to 100mg could only be considered if the drug was ineffective in managing the patient’s symptoms at the previous dose(Williams et al., 2020). Consequently, it is necessary to protect the patient’s health from adverse effects that are associated with increased peak plasma concentration to undesirable levels.

Adding a new medication to the treatment regimen would also interfere with the patient’s compliance as a result of increased pill burden (Strawn et al., 2019). Additionally, buspirone as mentioned earlier is associated with cardiovascular side effects, hence must be avoided when possible among patients with heart conditions.

Expected Outcome

            The patient is expected to display completely managed symptoms within the next four weeks. His HAM-A score should be as low as 1 or 0 (Williams et al., 2020). The patient’s quality of life will improve within this time, with no side effects reported as a result of the displayed tolerance and adherence to the treatment.

Ethical Consideration

            At this point, the PMHNP must consider the ethical principle of nonmaleficence, by promoting an intervention that promotes the patient’s well-being and displays no harm (Strawn et al., 2019). The clinician must also educate the patients on what effects to observe, and the ‘redflags’ which might require immediate intervention, as he continues taking the medication

Conclusion

Anxiety disorder is among the several mental conditions which are normally undiagnosed among both children and adults. However, this disorder normally ends up compromising the patient quality of life later. As such, diagnostic guidelines such as DSM-V and treatment guidelines have been availed to help promote health and manage symptoms among patients with anxiety disorders(Curtiss et al., 2017). For instance, the patient in the provided case study displayed anxiety symptoms, which had been earlier mistaken for heart attack. However, upon administration of appropriate diagnostic tools, the patient was found to be suffering from GAD. Several pharmacodynamic and pharmacokinetic factors were considered in deciding on which medication to give to the patient in the management of his symptoms such as his age, race, and associated conditions.

From the available options, the first intervention was to initiate Zoloft 50mg once daily for 4 weeks, given the effectiveness of the drug displayed through evidence-based practice in the management of anxiety disorder among adults(Chen et al., 2019). Other options such as imipramine and bupropion were not appropriate for this patient. The patient displayed great adherence and tolerance to the medication but with limited effectiveness in managing anxiety symptoms. As such, it was necessary to increase the dose to 75mg as the second intervention(Curtiss et al., 2017). The patient displayed even further remission of symptoms, which made it necessary to consider this as the optimal dose, and continue with the intervention as the third decision while closely monitoring the patient outcome(Williams et al., 2020). Several legal and ethical considerations were encountered in each decision process. In the first decision, the PMHNP had to consider the ethical principles of informed consent and respect forthe patient’s autonomy(Strawn et al., 2019). The second and the last decisions were based on the principles of beneficence and nonmaleficence respectively. Nursing ethical guidelines require the clinician to promote the health of the patient and prevent harm.

References

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. https://doi.org/10.1016/j.jpsychires.2019.08.014

Curtiss, J., Andrews, L., Davis, M., Smits, J., & Hofmann, S. G. (2017). A meta-analysis of pharmacotherapy for social anxiety disorder: an examination of efficacy, moderators, and mediators. Expert opinion on pharmacotherapy, 18(3), 243-251. https://doi.org/10.1080/14656566.2017.1285907

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070. https://doi.org/10.1080/14656566.2018.1491966.

Strawn, J. R., Poweleit, E. A., & Ramsey, L. B. (2019). CYP2C19-guided escitalopram and sertraline dosing in pediatric patients: a pharmacokinetic modeling study. Journal of child and adolescent psychopharmacology, 29(5), 340-347 https://doi.org/10.1089/cap.2018.0160

Williams, T., McCaul, M., Schwarzer, G., Cipriani, A., Stein, D. J., & Ipser, J. (2020). Pharmacological treatments for social anxiety disorder in adults: a systematic review and network meta-analysis. Acta neuropsychiatric, 32(4), 169-176. https://doi.org/10.1017/neu.2020.6

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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.
Benzodiazepines, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, paroxetine
Sertraline, venlafaxine, vilazodone, vortioxetine, propranolol, prazosin,
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.
The Assignment: 5 pages
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.
Be aware that the writing template and grading rubric require your introduction to end with one sentence that is your thesis statement. See the writing template for format and the grading rubric for details on how you are graded on this statement.
Body of your document

The body of your document should contain three sections that are labeled as follows: decision #1, decision #2, and decision #3. Each section should address the topics below. In your writing, you should be concise, clear, and thorough. Pharmacokinetics, pharmacodynamics, and specific patient factors must be considered in your writing in order to get full credit.
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. *Ethical considerations must be clearly identified/labeled. You can identify them within the decision section (“My ethical considerations are…”), or you can identify them separately in a section labeled “Ethical Considerations.” Either option is acceptable.
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: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

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Rubric Detail
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.
9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.
The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.
Decision #1 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
Decision #2 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
Decision #3 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
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.
14 (14%) – 15 (15%)
The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.
The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no errors