Pharmacotherapy of Anxiety Disorders

Introduction

This report focuses on a 46-year-old who presents with symptoms similar to the ones seen in an anxiety disorder. These symptoms included the feeling of impending doom, shortness of breath, and chest tightness. An EKG was done to rule out a myocardial infarction. No anomalies were detected on the EKG. The patient reports occasional feelings of impending doom. On the mental state exam, the patient admits to having feelings of nervousness. His effect appears blunted occasionally. A HAM-A test administered yields a score of 26. Based on these symptoms and findings, a diagnosis of generalized anxiety disorder (GAD) is made. Do you need help with your assignment ? Contact us at eminencepapers.com.

After the diagnosis, a series of decisions will be made with regard to the best treatment regimen most appropriate for this patient. A rationale for each decision will be provided, and this will be supported by clinical evidence. Of note is that the patient uses alcohol and consumes about 3-4 beers a night. This is relevant as it may impact the choice of the preferred drug. Alcohol also has effects on the pharmacokinetics and pharmacodynamics of the drugs used for the management of mental disorders (Bhatt et al., 2019). The ethical considerations that are likely to have an impact on the patient’s treatment plan will also be discussed.

Decision 1

Several drugs have been developed over the years for the treatment of anxiety disorders. The treatment of anxiety disorders usually involves the use of antidepressants. Selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line treatment for General anxiety disorder. For this patient, my decision would, therefore, be to use Sertraline (Zoloft), being that it is an SSRI. The starting dose would be 50mg PO daily. The mechanism of action of SSRIs is that they inhibit the reuptake of serotonin in the brain. This increases the concentration of serotonin in the brain and enhances serotonin activity. SSRIs have little to no effect on other brain neurotransmitters, such as norepinephrine and dopamine. Anxiety depletes the levels of serotonin in the brain. SSRIs counter this effect by exerting their action on the concentrations of serotonin. SSRIs replace the depleted levels of serotonin in the brain (Bhatt et al., 2019). This greatly improves the symptoms of anxiety.

Imipramine and buspirone were not selected because these two medications are not as well tolerated as sertraline. Imipramine is one of the traditional tricyclic antidepressants (TCAs) which is effective for the treatment of anxiety disorders. The frequency of adverse effects is, however, much higher than in SSRIs. This disqualifies it as the first choice.

Buspirone also is an antidepressant that has been shown to be effective in the treatment of GAD. Studies have, however, shown that it is not always effective in the treatment of GAD (Bandelow et al., 2017)

With Zoloft 50 mg, it is expected that the symptoms manifested by the patient will gradually clear away. It is also expected that the HAM-A score would significantly reduce. This would indicate an improvement in the symptoms. Zoloft has been shown to be effective in the treatment of GAD (Patel et al., 2018). It is also expected that Zoloft should have minimal side effects, and evidence shows that SSRIs are well tolerated (Locher et al., 2017). The expected outcome isn’t that different because when the patient comes back for a review, he manifests some improvement in the symptoms. This shows that even though it is just a partial improvement, the patient is still responding to treatment.

Decision 2

The second chosen decision is to maintain the patient on Zoloft but to increase the dose to 75mg PO daily. This is mainly due to the fact that the patient shows some improvement on this medication, as evidenced by the reduction in the HAM-A score. Even though it is only a partial reduction, it is still a positive sign that the medication works. The logical next step would be to increase the dose from 50 mg to 75 mg. This will lead to a further improvement in symptoms as it will increase the availability of serotonin. Evidence supports the increase of the dosage if the initial response to treatment is not satisfactory (Patel et al., 2018).

With the increase in dosage, I expect that the symptoms will reduce further (Clevenger et al., 2018). The HAM-A score should also drop significantly. The patient returns in four weeks with reports of further reduction in symptoms and a reduced HAM-A score. The HAM-A score is now at 10.

Increasing the dosage of Zoloft from 50mg to 100mg was not chosen because it is recommended that Zoloft should be titrated gradually. This is done to ensure the patient tolerates the drug well with minimal adverse effects. The option to continue with the same dose was not chosen because the patient had only partially responded to this initial treatment. It is, therefore, imperative to increase the dosage so as to elicit a more positive response from the patient (Bandelow et al., 2017.

Decision 3

The third decision is to continue managing the patient at the current dose of Zoloft 75 mg PO daily. This is because the patient is having a good response to the current dose. This is evidenced by a reduction in symptoms by more than 50%. The HAM-A score has also significantly reduced to 10. This shows that the patient is responding adequately to the treatment on the current dose. The patient also tolerates Zoloft well, as he does not report any side effects of the medication. Clinical guidelines recommend that medication should be titrated according to the patient’s response.

The option to increase the dose to 100 mg is not taken because the patient responds well to this dosage, and therefore, there is no need to adjust the dosage any further (Jakobsen et al., 2017). The patient should be maintained on the current dose for 12 weeks to evaluate the full effect of the drug. The option to add augmentation agents, such as buspirone, is not taken because of the satisfactory response to 75 mg. Also, polypharmacy is discouraged unless the patient doesn’t respond to her medications.

The expectation of sticking to this decision is for the client to show further improvement and have a complete remission of symptoms (Locher et al., 2017). The HAM-A score is expected to reduce significantly.

Conclusion

When managing this patient, various ethical considerations should be considered. These include patient education to ensure the patient understands his condition and treatment, including taking medications. The patient should also be educated on the expectations of treatment. The patient should also give informed consent before commencing treatment. Other considerations include modification of dosage, proper administration of medication, and confidentiality. Modification of dosage allows for dose adjustment according to the patient’s condition.

Many treatment options have been developed to help in managing anxiety disorders. This paper discusses a patient who is diagnosed with GAD and the various decisions made to treat this patient. The first decision was to start him on Zoloft 50 mg PO daily since SSRIs are the preferred first-line treatment for anxiety disorders (Bandelow et al., 2017). The second decision was to increase the dosage to 75 mg PO daily because of the slight improvement from the previous dose. The third decision was to continue with the current dose because the patient showed a reduction in symptoms by over 50%.

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Bhatt, N. V., Baker, M. J., & Jain, V. B. (2019, March 27). Anxiety Disorders. Background, Anatomy, Pathophysiology. https://emedicine.medscape.com/article/286227-.

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.

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).

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. Assessing and Treating Clients With Anxiety Disorders Sample Essay.

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Question

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.

Pharmacotherapy of Anxiety Disorders

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.

Pharmacotherapy of Anxiety Disorders