Assessing and Treating Patients With Anxiety Disorders Essay

Anxiety disorder is one of the most common mental problems among adults characterized by an extreme feeling of fear and anxiousness compromising the patient’s quality of life. According to the CDC, approximately 15% of adults above the age of 18 years, experienced anxiety symptoms in 2018 as either mild, moderate, or severe (Rickels & Moeller, 2019). Due to the increasing burden of the mental disorder, several treatment options have been provided to help promote the mental health and well-being of those diagnosed with the disease, comprising of both pharmacological and psychological interventions.

The provided case study demonstrates a 46-year-old white male who presented to the emergency department claiming to be having a heart attack. he reported symptoms such as shortness of breath, chest tightness, and the feeling of impending doom. He also presents with a history of mild hypertension to date and tonsillectomy at the age of 8 years. The patient admits to taking alcohol. His score on the HAM-A scale is 26. Mental status examination results also reveal a diagnosis of generalized anxiety disorder.

The treatment plan of this patient will mainly comprise the use of medication among other psychotherapeutic interventions if need be. Several pharmacokinetic and pharmacodynamic factors will however affect the choice of medication for this patient. Such factors include the patient’s advanced age, white race, overweight, use of alcohol, past medical history of mild hypertension, and the HAM-A score of 26 which revealed GAD. The purpose of this paper is to illustrate appropriate decision-making in coming up with the patient treatment plan, and making necessary adjustments based on the patient’s factors listed above in addition to care outcome.

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Decision #1

Selected Decision and Rationale

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Based on the available treatment options, the best intervention is to initiate 10mg Paxil (Paroxetine) orally once daily. Paxil belongs to the class of selective serotonin reuptake inhibitors (SSRIs) approved by the FDA for the management of anxiety disorder among adults due to its great effectiveness and desirable safety profile as displayed by evidence-based practice (He et al., 2019).

Previous studies have reported that paroxetine, even at lower doses, displays great effectiveness in the management of anxiety disorders with a good tolerability profile, including no associated risks of dependence with relative safety even when overdosed (Rickels & Moeller, 2019). The drug is also suitable among Caucasians in low doses as a result of the variant allele CYP2D6*4 which is the main polymorphism resulting in reduced metabolism of the drug in the liver hence, increased systemic circulation (Chen et al., 2019).

The use of imipramine is not necessary especially given the patient’s age as studies report less effectiveness and safety in the management of anxiety disorder as compared to available alternatives (Strawn et al., 2018). The drug is also associated with weight gain, which will make it difficult for the patient to manage his weight gain.

Buspirone on the other hand also has an unfavorable safety profile among middle-aged and older adults, hence should only be considered when there is no other safer option (Kulenović et al., 2018). The patient is also an alcoholic, as such, the use of this medication will only lead to dependence.

Expected Outcome

With the use of paroxetine, the patient is expected to display at least 50% remission of symptoms within the next four weeks, with self-limiting side effects like headache and dizziness. The patient’s HAM-A score should decrease to less than 10.

Ethical Consideration

The PMHNP has the legal obligation of protecting the health of the patient and prevent harm (Chen et al., 2019). As such, ethical principles such as beneficence and non-maleficence must be observed in addition to upholding the patient’s autonomy when selecting the most appropriate treatment therapy.

Decision #2

Selected Decision and Rationale

Based on the patient outcome, the most appropriate intervention to take at the moment is to increase the dose of paroxetine to 20 mg orally once a day. Clinical guidelines recommend an upward titration of paroxetine dose at intervals of 10mg per day based on patient outcome, but to exceed 50mg per day (Kulenović et al., 2018).

From the initial intervention, the patient was able to experience a decrease in anxiety symptoms over the past 4 to 5 days. Her HAM-A score also decreased to 18. This shows great effectiveness and tolerance to the medication. No side effects were also reported showing a great safety profile. However, previous studies have reported that most patients take up to 8 to 12 weeks to attain the optimal dose to display maximum effectiveness in the management of GAD symptoms (Strawn et al., 2018). As such, it was necessary to maintain this drug and increase its dosage for optimum effectiveness.

Increasing the dose to 40 mg is not appropriate as this goes against the recommended approaches as outlined in clinical guidelines (Rickels & Moeller, 2019). Consequent an upward titration with a high dose compromises the patient tolerance to the medication.

Continuous use of the same drug at the same dose is also not appropriate as the patient was not satisfied with the outcome (He et al., 2019). As such, this will affect the patient compliance with the medication as no further effect in the management of the anxiety symptoms will be expected.

Expected Outcome

With dose increment, the patient is expected to display even further management of his anxiety symptoms, given that shortness of breath and chest pressure had already been resolved. As such, the HAM-A score should reduce to less than 10 as initially expected (Chen et al., 2019).

Ethical Consideration

At this point, the PMHNP has to explain to the patient adequately about the outcome, and what should be done next to involve him in decision making concerning his health (Strawn et al., 2018). Even though the nurse’s decision might be in the interest of the patient health, it is very important to ensure that they agree with the patient regarding the treatment to uphold their autonomy essential in promoting positive outcomes.

Decision #3

Selected Decision and Rationale

The last decision was to maintain the dose of paroxetine and observe the patient for further management of anxiety symptoms (Rickels & Moeller, 2019). The patient displayed a 61% reduction in anxiety symptoms which shows great adherence and tolerance to the medication.

Despite the use of paroxetine being expected to completely manage anxiety symptoms, studies show that patients who display more than 50% remission of symptoms with the use of the drug have attained the optimum dose of the drug (He et al., 2019). As such, they should continue taking the drug at the same dose and frequency to continue experiencing beneficial effects, while minimizing the risks of side effects associated with prolonged use of the drug.

Increasing the dose to 30mg was not necessary at this point given that the patient had already displayed more than 50% remission of symptoms (Kulenović et al., 2018). An increased dose above the optimum dose is associated with increased risks of toxicity and adverse effects.

Introducing another drug would have been considered only if the patient had displayed limited effect even upon reaching the maximum dose which is not the case (Chen et al., 2019). Consequently, buspirone as mentioned earlier is associated with a high risk of tolerance hence not recommended for this patient.

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Expected Outcome

With continuous use of paroxetine at the same dose, the patient is expected to experience even further managed anxiety symptoms, as shown by the great effectiveness of the reported outcome (Strawn et al., 2018). His HAM-A score should be less than 7, with reveals minimal or no anxiety.

Ethical Consideration

Based on the reported outcome, the patient seemed satisfied with how the drug was managing her anxiety symptoms (Kulenović et al., 2018). As such, the nurse needs to respect the patient’s autonomy and educate them on the need to stick to the treatment regimen to promote care outcomes.

Conclusion

Anxiety disorder is one of the most common mental problems affecting middle-aged and older adults. This mental problem is associated with several symptoms which compromise the health and well-being of the patient (Strawn et al., 2018). However, several treatment options have been proposed based on previous evidence of great effectiveness in the management of this mental condition. Several factors must be considered when selecting a specific medication for a given patient. For the patient in the provided case study, the initial intervention was to administer paroxetine 10mg orally once daily. The other two options were inappropriate as a result of an undesirable safety profile and increased risks of dependence (Chen et al., 2019). From this intervention, the patient was able to attain minimal management of anxiety symptoms with no shortness of breath or chest tightness. This led to the second decision, where the dose was increased to 20 mg once daily as recommended by most clinical practice guidelines (Kulenović et al., 2018).

The patient was able to attain more than 61% remission of symptoms within four weeks of taking 20 mg paroxetine orally once daily. Studies show that an optimal dose of the drug is normally achieved when the patient displays more than 50% management of anxiety symptoms (He et al., 2019). Consequently, no side effects were reported, showing a great safety profile of the drug. As such, it was necessary to advise the patient to continue taking the drug at the same dose to experience even further management of anxiety symptoms. For every decision made, the PMHNP ensured that the patient was well informed about the available options including both their beneficial and adverse effects (Rickels & Moeller, 2019). The autonomy of the patient was also upheld as he was involved in deciding on which medication to consider.

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

He, H., Xiang, Y., Gao, F., Bai, L., Gao, F., Fan, Y., … & Ma, X. (2019). Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults: a network meta-analysis. Journal of psychiatric research, 118, 21-30. https://doi.org/10.1016/j.jpsychires.2019.08.009

Kulenović, A. D., Serdarević, A. M., Halilović, Z., Mašnić, H., Bahto, A., Kapo, B., … & Hadžimuratović, A. (2018). Observational multicenter study of the efficacy of paroxetine film-coated tablet in the treatment of anxiety disorder. Med Glas (Zenica), 15(2), 186-191. https://orcid.org/0000-0001-7607-5429

Rickels, K., & Moeller, H. J. (2019). Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. The World Journal of Biological Psychiatry, 20(7), 514-518. https://doi.org/10.1080/15622975.2018.1500031

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

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Assignment: Assessing and Treating Patients With Anxiety Disorders
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 weekâ€™s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

To prepare for this Assignment:
Review this weekâ€™s Learning Resources, including the Medication Resources indicated for this week.
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 patientâ€™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)

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. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

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Review the following medications:

benzodiazepines
citalopram
desvenlafaxine
duloxetine
escitalopram
fluoxetine
paroxetine
sertraline
venlafaxine
vilazodone
vortioxetine
propranolol
prazosin
NO BACKGROUND OF THE PATIENT AND NO ZOLOFT. PLEASE READ INSTRUCTIONS CAREFULLY
rESOURCES
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf

https://jaacap.org/action/showPdf?pii=S0890-8567%2810%2900082-1

http://bjpo.rcpsych.org/content/2/6/e16

https://search.ebscohost.com/login.aspx?direct=true&db=pst&AN=9999-02824-000&site=eds-live&scope=site&authtype=shib&custid=s6527200

https://go.openathens.net/redirector/waldenu.edu?url=https://jama.jamanetwork.com/journals/jama/fullarticle/2719367

https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=74304456&site=ehost-live&scope=site&authtype=shib&custid=s6527200

Assessing and Treating Patients With Anxiety Disorders Essay