Assignment: Assessing and Treating Patients With Anxiety Disorders

Assignment: Assessing and Treating Patients With Anxiety Disorders

Walden University Assignment: Assessing and Treating Patients With Anxiety Disorders-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University Assignment: Assessing and Treating Patients With Anxiety Disorders assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for Assignment: Assessing and Treating Patients With Anxiety Disorders                           

Whether one passes or fails an academic assignment such as the Walden University Assignment: Assessing and Treating Patients With Anxiety Disorders depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for Assignment: Assessing and Treating Patients With Anxiety Disorders                         

The introduction for the Walden University Assignment: Assessing and Treating Patients With Anxiety Disorders is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for Assignment: Assessing and Treating Patients With Anxiety Disorders                         

After the introduction, move into the main part of the Assignment: Assessing and Treating Patients With Anxiety Disorders assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for Assignment: Assessing and Treating Patients With Anxiety Disorders                         

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for Assignment: Assessing and Treating Patients With Anxiety Disorders                           

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6630 Assignment: Assessing and Treating Patients With Anxiety Disorders

The case highlights a 46-year-old white male presenting with chest tightness, shortness of breath and feeling of impending doom. The patient has a history of mild hypertension and tonsillectomy, which has been accompanied by unremarkable medical history. The patient cites occasional shortness of breath, chest tightness, feelings of impending doom and the need to ‘escape’ or ‘run’ from one place. He confesses using ETOH to combat worries about work since the management at his place of work is harsh, and he fears for his job. The patient’s symptoms are characteristic of generalized anxiety disorder.

Anxiety can be a normal part of life, with concerns such as health, family challenges and money temporarily dominating individual experiences. Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder characterized by nightmares, flashbacks, and intrusive thinking related to catastrophic events in an individual’s life (Ostacher & Cifu, 2019). Exposure to traumatic and terrifying events triggers PTSD. It is a potentially debilitating condition that affects direct victims or witnesses of traumatic events such as accidents, natural disasters, loss of loved ones, violent assaults like rape, war and other life-threatening events. The events can trigger an obsessive, recurrent and repetitive behavior that increases the feeling of fear, worry, helplessness, and hopelessness (Osta

cher & Cifu, 2019). Nightmares, intrusive memories and flashbacks are common in individuals with past traumatic experiences increasing the risk of panic disorders.

Generalized anxiety disorders are common in adults with PTSD manifestations evident several months after the exposure to the traumatic and terrifying event. The symptoms of the anxiety disorders can be detrimental, although they subside, reducing the struggle with coping and self-care. According to Holmes (2022), anxiety disorders are mental conditions that deteriorate the quality of life by altering the action of neurotransmitters. Individuals with anxiety disorders have elevated worry and fear.

Psychopharmacological therapy targets relieving symptoms rather than curing the disorders. The recommended

medications in the management of anxiety disorders include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, beta and adrenergic medications, antihistamines and GABAergic medications (Garakani et al., 2020). The treatment decisions will reflect the drug pharmacokinetics, pharmacodynamics, and ethical considerations in using the pharmacotherapeutic approach. The paper highlights three decisions on Generalized Anxiety Disorders.

Decision One,

Which Decision did you Select?

The first-line treatment for the patient will be the first-line SSRI, oral paroxetine 10 mg daily.

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Why did you select this Decision?

Anxiety disorders are managed using different pharmacological regimens. The approaches focus on alleviating the symptoms and restoring social, mental and physical wellbeing. However, SSRIs and SNRIs are recommended for the treatment of PTSD, although sertraline and paroxetine are FDA-Approved as the first-line medication for PTSD management. According to Ostacher and Cifu (2019), benzodiazepines are contraindicated in PTSD. Paxil is FDA-approved for treating anxiety disorders and PTSD and is considered the first-line pharmacotherapeutic option for anxiety disorders. Paxil is an SSRI that potentiates the serotonin action influencing the serotonergic neurotransmission (Davidson 2016). The medication restores serotonin balance, regulates mood changes, and reduces anxiety, fear, and panic attacks. Paxil has minimal anticholinergic and sedative effects and has a low cardiovascular impact. Its therapeutic window can range from 4-6 weeks and is significant in managing generalized anxiety disorder. It has less anticholinergic, adrenergic and antihistamine activity than tricyclic antidepressants.

Why did you not select the other two options provided in the exercise?

Paxil is safer and tolerable in diverse patients than other medications such as Buspirone and Imipramine, which have adverse reactions such as increased drowsiness, blurry vision, and dizziness. Besides, they are not approved for first-line treatment of anxiety and PTSD hence my choice of Paxil for anxiety treatment.

What were you hoping to achieve with this Decision?

Paxil is slowly absorbed with its half-life ranging between 11 to 20 hours and attains its peak concentration within 4 to 10 hours. It works by elevating the serotonin levels, which establish a mental balance. According to Strawn (2018), Paxil can elicit minimal adverse reactions and alleviate symptoms such as fear, worry, helplessness, chest tightness, and shortness of breath. In light, I targeted alleviating the anxiety symptoms by elevating the serotonin levels.

Explain how ethical considerations may impact your treatment plan and communication with patients

Paxil has minimal adverse effects that undermine individual ethical values and treatment models. Patient safety is at the center of the pharmacological therapeutic approaches hence a key consideration in medical ethics. However, the patient is not incapacitated and capable of making individual decisions; thus, the psychiatrist needs to highlight the psychotherapeutic and pharmacotherapeutic models available and educate the patient appropriately before consenting to the treatment.

Decision Two

The first-line medication for the treatment of anxiety and PTSD is the most likely option for managing the patient. However, I would opt to retain Paxil as my second decision rather than change the medications. However, I will increase the dose from 10mg to 20mg daily to enhance the therapeutic effect.

Why did you select this decision?

The reaction response to Paxil may take long to manifest. To boost the HAM-A score, I would opt for a higher dose. Paxil is well-tolerated in the body and elicits minimum side effects (Strawn, 2018). Although the drug’s reaction is slow, it attains its therapeutic effect after a significantly more longer period. Therefore, increasing the dose can immediately impact mood and anxiety symptoms. According to Slee (2022), using a higher SSRIs dose can elevate serotonin levels in the brain and enhance the treatment outcome. The client’s compliance with the treatment can HAM-A score and attain best results.

Why did you not select other options in this exercise?

The anxiety medications exhibit diverse adverse effects. However, Paxil is well tolerated, with minimal side effects reported. In light, rather than changing to another first-line SSRIs with a similar pharmacokinetic and therapeutic effects, I would rather increase the dose. Besides, it is recommended as the best first-line treatment for anxiety disorders and PTSD. According to Javed and Fountoulakis (2018), Paxil significantly reduces the symptoms more than other medications such as imipramine. Therefore, I did not see the need to change the medication rather than maintain the patient on a higher dose of Paxil.

What were you hoping to achieve by making this decision?

Although the medication might take time for the client to realize a significant decline in the clinical manifestations, the main objective of the decision was to lower the HAM-A score further and stabilize mood and anxiety symptoms.

Explain how ethical considerations may impact your treatment plan and communication with patients

The major ethical concerns in medication include patient consent and safety. The medication should align with the major ethical principles that advocate for the patient’s autonomy, beneficence, and nonmaleficence. Paxil dose is well tolerated; therefore, increasing the dose implies that the medication is likely to be well tolerated. Furthermore, patient education should be advocated to allow the patient to make informed consent.

Decision Three

The third decision will be to shift to an SSRI alternative. However, the drug withdrawal process might be lengthy; hence I would opt for 10 mg of oral buspirone. Buspirone will also need close monitoring to assess the need to alter the treatment plan.

Why did you select this decision?

Buspirone is well tolerated in the body, although it is used in the short-term management of anxiety symptoms. It is also FDA-Approved for the management of Generalized Anxiety Disorder. In light, change from SSRI to Azapirone can attain a higher therapeutic effect than non-responsive paroxetine. The drug is well tolerated in the body, although it might exhibit some adverse effects.

Why did you not select the other two options provided in this exercise?

The rationale for the choice of the medications was entirely based on the efficacy and tolerability of the drugs. Buspirone is well-tolerated, exhibits minimal adverse effects, and is FDA approved for treating anxiety disorders. Therefore, I opted for drug safety and FDA recognition in the decision for combination therapy.

What are you hoping for by making this decision?

Adopting a combined therapy aimed to improve the patient’s experiences by lowering the anxiety symptoms. Buspirone regulates neurotransmitters’ actions, reducing anxiety symptoms (Javed & Fountoulakis, 2018). Changing the medications from non-responsive or slow-responding SSRIs to Azapirones can significantly reduce the HAM-A score alleviating the clinical manifestations of anxiety disorder.

Explain how ethical considerations may impact your treatment plan and communication with patients

The ethical concerns in the medical field are crucial, especially in managing mental health disorders. Patient autonomy may be impaired due to the involvement of the family members in the treatment process. However, the psychiatrist can establish the patient’s competence and compliance to determine the best approach for intervention. According to Javed and Fountoulakis (2018), buspirone elicits side effects such as chest pain, drowsiness, nausea, and increased sweating. However, some severe side effects such as blurred vision, uncontrollable shaking, agitation, hallucinations, confusion, irregular heartbeat and seizures can be reported. Clear communication should be established to allow the patient to make informed consent to the medication.

Conclusion

The management plan involved a shift from Paxil 10 mg to 20 mg once per day and further to Azapirone therapy of 10 mg buspirone twice a day. The selection of Paxil and buspirone was based on the recommendation and approval by the FDA in treating anxiety disorders and PTSD. However, due to the low response and impact on the HAM-A score, increasing the dose increased serotonin concentration, low anxiety, and regulated mood. The third decision opted against change from SSRIs to azapirone. Buspirone has partial agonist properties on serotonin and can improve serotonin levels and reduce the HAM-A score.

References

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: going beyond the guidelines. BJPsych Open, 2(6), e16-e18. http://bjpo.rcpsych.org/content/2/6/e16

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.3389/fpsyt.2020.595584

Holmes, L. (2022). The 4 Major Classes of Anxiety Medications. Verywell Mind. Retrieved 2 July 2022, from https://www.verywellmind.com/mental-health-medications-for-anxiety-2337705.

Javed, A., & Fountoulakis, K. N. (Eds.). (2018). Advances in psychiatry. Springer.

Ostacher, M. J., & Cifu, A. S. (2019). Management of post-traumatic stress disorder. JAMA, 321(2), 200-201. https://doi.org/10.1001/jama.2018.19290

Slee, A. (2022). Generalized Anxiety Disorder: Incidence and Drug Treatment (Doctoral dissertation, UCL (University College London)). https://discovery.ucl.ac.uk/id/eprint/10146430

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%2F14656566.2018.1491966

Sample Answer 2 for NURS 6630 Assignment: Assessing and Treating Patients With Anxiety Disorders

Anxiety disorders are characterized by pathologically elevated levels of anxiety. One of the common anxiety disorders is generalized anxiety disorder (GAD). It is characterized by anxiety, tension, worry, and fears about various day-to-day events and problems. Patients with GAD experience difficulties controlling excessive worries (DeMartini et al., 2019). GAD’s excessive anxiety and worry cannot be accounted for by a medical condition or substance use. The purpose of this paper is to discuss the case scenario of a patient with an anxiety disorder and describe the treatment and ethical considerations that may impact treatment.

Case Overview

The case scenario portrays a 46-year-old white male referred by his PCP after visiting the ER due to the fear of having a heart attack. The client mentions that he experienced chest tightness, dyspnea, and a feeling of impending doom. He has a history of mild hypertension and is overweight by roughly 15 lbs, but the rest of his medical history is unremarkable. His EKG and physical exam findings were normal, and myocardial infarction was ruled out. The client reports that he still experiences chest tightness and episodes of dyspnea, which he calls anxiety attacks. He also has infrequent feelings of impending doom and a need to escape. He scores 26 on the Hamilton Anxiety Rating Scale and is diagnosed with GAD.

The patient factors that may influence medication prescribing include age, the severity of the patient’s GAD, treatment preferences, current medical condition and medications, and previous medication trials (DeMartini et al., 2019). The clinician needs to consider the patient’s current hypertension and overweight and prescribe a drug that will not aggravate the conditions.

Decision #1

Start Zoloft 50 mg orally daily.

Why I Selected This Decision

Sertraline, a selective serotonin reuptake inhibitor (SSRI), was chosen because it is the most cost-effective SSRI. It is also indicated in the first-line treatment of GAD in adults. Strawn et al. (2018) found that the potential side effects of Zoloft are relatively well-tolerated, which leads to a higher compliance rate and better patient outcomes.

Why I Did Not Select the Other Options

Imipramine was not an ideal choice because it is a 2^nd line therapy used when SSRIs are unsuccessful in alleviating GAD symptoms. Besides, Imipramine is associated with anticholinergic unpleasant side effects such as dry mouth, sedation, and constipation (Strawn et al., 2018). The side effects may contribute to a low compliance rate, which delays achieving the desired treatment effects. In addition, Buspirone was not ideal since it has no antipanic activity. Thus, it would not adequately alleviate the anxiety attacks in the client. Furthermore, Buspirone has a prolonged onset of action and is not recommended as monotherapy in treating GAD (Strawn et al., 2018).

What I Was Hoping To Achieve

I hoped that Zoloft would improve the GAD symptoms by at least 50% by the fourth week, and the HAM-A score would improve to 12. According to Garakani et al. (2020), SSRIs such as Zoloft have been established to be efficacious in treating anxiety disorders.

How Ethical Considerations May Impact the Treatment Plan

Ethical principles that may affect the treatment plan include beneficence (duty to do good) and nonmaleficence (duty to cause no harm) (Bipeta, 2019). The PMHNP upheld beneficence and nonmaleficence by prescribing Zoloft, which is associated with the best treatment outcomes and least side effects. The other drugs were not prescribed due to their associated treatment outcomes and side effects.

Decision #2

Increase Zoloft to 75 mg daily.

Why I Selected This Decision

The Zoloft dose was increased because the patient’s anxiety symptoms had not fully abated. Although he reported that the chest tightness and dyspnea had abated, he still experienced some degree of worry, and the HAM-A sore showed a partial response. Increasing the dose was thus an ideal choice to promote full remission of GAD symptoms (Strawn et al., 2018). Besides, the dose increase was gradual since it allows the PMHNP to monitor the drug’s side effects adequately.

Why I Did Not Select the Other Options

Increasing Zoloft to 100 mg was inappropriate since it is a high dose increase. Thus, it does not allow the clinician to effectively monitor the drug’s effect on the patient and its side effects. It is recommended that the dose is gradually increased to promote successful therapy. In addition, changing the dose was not ideal because the patient exhibited a partial treatment response to the initial dose. Treatment guidelines recommend that the drug be changed only when there is no positive response to therapy after eight weeks or adverse effects (Garakani et al., 2020).

What I Was Hoping To Achieve

I hoped that gradually increasing the dose would help to fully alleviate the depressive symptoms while at the same time monitoring the drug’s associated side effects. The initial dose of Zoloft is 25 to 75 mg daily, while the usual dose range is 50-200 mg daily (Garakani et al., 2020). Thus, 75 mg is an acceptable dose for this patient.

How Ethical Considerations May Impact the Treatment Plan

Nonmaleficence was upheld in this decision by gradually increasing the dose, which would allow the PMHNP to monitor the drug’s effect, thus preventing harm to the patient (Bipeta, 2019). Besides, beneficence was upheld by increasing the dose to promote complete remission of symptoms and better patient outcomes.

Decision #3

Maintain the current dose.

Why I Selected This Decision

The current dose was maintained at 75 mg because the patient demonstrated an adequate positive response to the dose. The patient reported a further decrease in the depressive symptoms with a 61% reduction in symptoms, and the HAM-A score improved to 10. Besides, there were no reported side effects, and thus, maintaining the dose was ideal to avoid adverse effects if the dose was increased (He et al., 2019).

Why I Did Not Select the Other Options

Increasing Zoloft to 100 mg was not an appropriate choice because the patient had an adequate positive response to the current 75 mg dose. Increasing to 100 mg may alleviate the symptoms further but poses the risk of side effects which may affect the drug compliance rate (He et al., 2019). Besides, an augmenting agent was not added to the plan because the patient had an adequate response with Zoloft monotherapy. Besides, monotherapy is highly recommended to prevent polypharmacy.

What I Was Hoping To Achieve

I was hoping that maintaining the dose would promote a progressive remission of the GAD symptoms and further improve the HAM-A score while at the same time causing no harm to the patient through side effects. Strawn et al. (2018) found that Zoloft continues to improve GAD symptoms over time regardless of a fixed dose.

How Ethical Considerations May Impact the Treatment Plan

The ethical principle of autonomy may impact the treatment plan if the patient does not consent to the medications or requests a change in treatment due to side effects. The PMHNP must obtain informed consent and explain the benefit of the prescribed medication and potential side effects (Bipeta, 2019).

Conclusion

The specific patient factors that may influence decisions on medication in the above patient include age, the severity of GAD, patient’s treatment preferences, current medical condition and medications, and previous medication trials. The patient was initiated with Zoloft 50 mg daily. The drug was selected because it is indicated as a first-line treatment in GAD and is associated with effective treatment outcomes (Strawn et al., 2018). Besides, it is associated with minimal side effects compared to Imipramine. Buspirone was not selected due to the lack of antipanic activity, which is crucial in managing the patient’s anxiety attacks. The initial dose led to a partial decrease in GAD symptoms, which led to increasing Zoloft to 75 mg daily (Strawn et al., 2018). The aim of this decision was to alleviate the GAD symptoms further. The dose was not increased to 100 mg daily to allow monitoring of side effects. Besides, the drug was not changed because the patient demonstrated a positive response to the initial drug, and no side effects were reported.

The patient’s symptoms decreased with Zoloft 75 mg with a 61% remission in symptoms. The dose was then maintained at 75 mg to allow for a progressive decrease in symptoms and monitoring of side effects. Augmentation was not recommended to avoid polypharmacy (Garakani et al., 2020). Ethical principles of beneficence and nonmaleficence influenced the treatment plan. The clinician selected medication known to have the best treatment outcomes and the least adverse effects to promote better health outcomes (Bipeta, 2019). Autonomy should also be respected by considering the client’s decisions when developing the treatment plan.

 References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of internal medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.1176/appi.focus.19203

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

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

Sample Answer 3 for NURS 6630 Assignment: Assessing and Treating Patients With Anxiety Disorders

Generalized anxiety disorder (GAD) affects 3.1% of the US population or 6.8 million adults. Unfortunately, only 43.2% of the affected population is receiving treatment. GAD refers to a mental health disorder characterized by overwhelming fear, worry, and anxiety. Patients have excessive, persistent, and unrealistic worries related to areas like finance, health, family, or the future. GAD diagnosis is made when the patient projects symptoms like sleep disturbance, muscle tension, irritability, restlessness, difficulty concentrating, and fatigue. In line with GAD, this paper will assess a white male diagnosed with GAD and make three decisions regarding his medication.  The decisions will be guided by the patient’s pharmacokinetics and pharmacodynamic processes.

Case Study

The presented patient is a 46-year-old man with complaints of a heart attack. He works as a welder and explains that he experienced shortness of breath, chest tightness, and a feeling of impending doom. He is overweight with mild hypertension. He reports a tonsillectomy when he was 8 years but his other medical history is unremarkable. An EKG report indicates that he is normal ruling out myocardial infarction. Despite an unremarkable presentation, the patient still reports anxiety attacks with a need to “run” or “escape” from wherever he is at. He reports occasional use of ETOH to manage work-related stress and consumption of 3-4 beers every night. He is single and cares for his aging parents however the management at his place of work is harsh which increases fear about his job. The patient is AOx4 with a goal-directed, coherent, and clear speech. He reports a “bleh” mood and endorses feelings of nervousness. His affect is broad. He denies visual or auditory hallucinations and no overt delusional or paranoid thought processes are noted. His insight and judgment are intact with no suicidal or homicidal ideation. He scores 26 on the Hamilton Anxiety Rating Scale (HAM-A) confirming a GAD diagnosis.  Factors that will influence medication decisions are age, co-morbidity, and prior treatment. The patient is 46 years with mild hypertension. He has also never taken any psychotropic medication. Further, the drugs selected should have proven efficacy and reasonable tolerability to enhance treatment adherence and decrease reported side effects of pharmacotherapy. The goal of the treatment is to achieve complete remission without symptoms of anxiety and with complete recovery to premorbid functioning.

Decision 1

Begin Paxil 10 mg po daily

Reason For Selection

Generally, the recommended Paxil dosage for a patient with a generalized anxiety disorder is 20mg daily (Shresha et al., 2018). However, 10mg/day also falls within the acceptable therapeutic dose range. Strawn et al. (2018) state that paroxetine works by potentially inhibiting 5-HT reuptake and blocking some reuptake of norepinephrine. It also has a high affinity for histaminergic, serotoninergic, dopaminergic, adrenergic, and muscarinic receptors which determines both the antidepressants’ effects and side effect profile. It is advisable to initiate Paxil at a low dose to minimize side effects and allow the body to adjust to the medication. Kulenović et al. (2018) executed a study where 35.1% of patients were initiated with 10mg paroxetine while 64.9% were given 20 mg of paroxetine. The 35 % were initiated with a low dosage because they were newly discovered while 65% received a higher dosage because they had used concomitant therapy. The case study patient is newly diagnosed making it ideal to offer a low dosage to examine tolerability and compliance.

Imipramine 25mg PO BID was rejected because it falls under TCAs which are only recommended when patients do not respond to multiple trials of SSRIs, SNRIs, and adjunctive psychopharmacological interventions (Strawn et al., 2018). The drugs cause antiadrenergic and anticholinergic effects like constipation, sedation, sexual dysfunction, and orthostasis which affect patient tolerability (Carl et al., 2020). Rochester et al. (2018) outline that TCAs induce pronounced QTc prolongation compared to SSRIs which increases the risk of cardiac events. With the patient already mild hypertensive and taking medication, Imipramine usage may increase orthostatic hypotension resulting in a syncopal episode.

Buspirone 10mg is avoided because it is not a first-line agent in GAD treatment. It delays symptom relief by one to three weeks, has no impact on comorbid depression, and has a short half-life calling for two to three doses per day (Carl et al., 2020). The dosing may present adherence challenges due to multiple doses. Further many randomized clinical trials show that Buspirone is useful as an adjunct to first-line treatment with antidepressants when there is a partial response. Garakani et al. (2020) report that although Buspirone is superior to placebo when handling GAD, it has a smaller effect size compared to antidepressants. It is also not well-tolerated with many patients reporting nausea, dizziness, headache, and buspirone-induced movement disorders.

Expectations

The expectations are that the patient will report a reduction in symptoms (APA, 2010a). He should report a reduction in chest tightness, fear, and anxiety. His HAMA should reduce as an indication of a positive therapeutic response (Hamilton, 1959). The clinician also expects that the patient will tolerate the medication with no adverse events. In line with expectations after four weeks, the patient reported that he no longer experiences tightness or shortness of breath (WU, 2022). He also states that his worries have decreased and his HAM-A score decreased to 18 indicating a partial response to the drug therapy.

Ethical Considerations

An ethical consideration when handling anxious patients is informed consent. It ensures that patients make well-considered decisions by getting information and asking a question about recommended treatments (Altis et al., 2014).  A therapeutic relationship is also needed to enhance patient satisfaction, adherence to treatment, and improvement in levels of anxiety. Adherence counseling should be offered to reduce cases of non-compliance and ensure that the patient takes medications as prescribed. The patient was informed of the three available medications with their benefits and risk and consented to take Paxil. The clinician and the patient also projected an emotional bond of trust, care, and respect, agreed on the goals of the therapy and collaborated on tasks of the treatment. The adherence counseling worked because the patient reported positive outcomes in line with clinician expectations.

Decision 2

Increase dosage to 20mg PO daily

Reason for Selection

The patient therapeutic response was partial with no adverse events. The response calls for an increase in dosage to optimize the therapeutic response. Paroxetine intake guidelines recommend a dosage of 20mg orally once daily. Further, any titration should be done with an increment of 10mg/per day at weekly doses to a maximum dose of 50mg (Shrestha et al., 2018).  In the study by Kulenović et al. (2018), patients were administered 20mg and followed up for 12 months. The patients reported a statistically significant decline in the severity of anxiety disorder. Among the participants in the study, 74.4% reported none to minimal symptoms of anxiety disorders, 22.2%% reported mild symptoms while only 3.4% reported moderate symptoms. Further, an 8week randomized trial by Rickels et al. (2003) reported that paroxetine 20mg offered better response (62) and remission (30%) compared to placebo at 46% and 20% respectively.

An increment to 40mg Po daily was avoided because it was beyond the recommend weekly increment dosage. Further research shows that there is no benefit seen at doses above 20mg/day (Shrestha et al., 2018). The dosage may induce side effects because paroxetine-related adverse events are dose-dependent. Since Paroxetine 20mg and 40mg offer a positive therapeutic response (Kulenović et al., 2018), it would be ideal to start with a lower dose to reduce the risk of adverse effects. Maintaining the current dosage is not an option because it only elicited a partial response. The prudent choice is dose escalation as the patient did not report any adverse events that would warrant a switching strategy or augmentation.

Expectations

The expectations are a further reduction in symptoms with an increase in dosage. He should also tolerate the medication with no reported side effects. Following expectations, the patient reports a further reduction in symptoms after four weeks (WU, 2022). His HAM-A score also decreases to 10 indicating a 61% reduction in symptoms.

Ethical Considerations

Continued counseling on adherence is needed to ensure that the patient keeps taking medication as prescribed.  The patient should also be informed of the outcomes expected with the increase in drug dosage. Nurturing the current therapeutic relationship is equally crucial to allow the patient to open up about concerns that could lead to non-adherence later (Altis et al., 2014). The patient was informed of the benefit and risks of increasing dosage and counseled on adherence. A dialogue on the current therapy was also initiated and the patient exhibited contentment with the recommended dosage.

Decision 3

Maintain current dosage

Reason for Selection

The patient has reported a 61% decrease in symptoms. Treatment response is capped as a 50% decrease in HAM-A score compared to baseline (Hamilton, 1959). Since the patient has reported a substantial reduction in symptoms without experiencing any side effects it would be ideal to maintain the therapy for four more weeks. Kulenović et al. (2018) maintained the participants on the 20mg dosage for 12 months and reported positive outcomes. The patient can therefore continue with the dosage for 12 weeks to assess the full effect of the drug (WU, 2022). Maintaining the least effective dosage is also crucial to reducing the risk of adverse events. Even though an increase to 30mg dosage would hasten symptom improvement, the dosage is rejected to reduce the occurrence of adverse effects. Research shows that SSRIs portray a flat dose-dependency pattern where an increase in the dose above the minimum effective dose rarely enhances efficiency but causes more adverse effects (Ishino, 2021). Augmentation of the current dosage with buspirone is avoided because it is only recommended when an antidepressant is not completely effective (Ansara, 2020). The patient has achieved remarkable milestones in terms of therapeutic response and therefore should continue with the current regimen. Further, it is always ethical to avoid polypharmacy unless the patient is not responding to a monotherapy.

Expectations

The clinician expects the patient to go into remission. His symptoms should be minimal and he should not report any feeling of “running” or “escaping” from wherever he is at. Specifically, he should have a HAM-A score of below 8 as an indication of remission (Hamilton, 1959).

Ethical Consideration

Shared decision-making is needed at this juncture. The patient has recorded a positive therapeutic response and maintenance of the current dosage is appropriate. He should however be informed about the possibility of increasing the current dosage to hasten improvement and its propensity to induce unacceptable side effects (WU, 2022). It is also ethical to avoid polypharmacy because the patient has effectively responded to the recommended monotherapy.  A shared discussion ensued between the client and the clinician and they unanimously agreed to maintain the current dosage based on the risk of adverse events. A monotherapy was also sustained to avoid polypharmacy.

Conclusion

Generalized anxiety disorder causes unprecedented worry and fear that affects the patient normal functioning. An example is a 46-year-old white male complaining of chest tightness. He asserts feelings of impending doom and fear related to his work. An EKG test rules out myocardial infarction. The patient reports a “bleh” mood and endorses a feeling of nervousness. He scores 26 on the HAM-A scale confirming his GAD diagnosis. Since he has never been on any psychotropics, he is initiated on 10mg Paxil daily to minimize side effects, allow his body to adjust to the medication, and examine tolerability and compliance. The decision is based on primary research that initiated newly discovered patients with 10mg Paxil (Kulenović et al., 2018).  The use of imipramine is avoided because the patient response to SSRIs and SNRIs is not yet established and to avoid side effects like QTc prolongation which increase the risk of the syncopal episode (Rochester et al., 2018). Buspirone is also rejected because it delays symptom relief and has a short half-life that requires two to three doses per day (Carl et al., 2020). It also has a small effect size and is not well-tolerated by patients. 10mg Paxil resulted in partial response calling for a dosage increase to 20mg. The decision is made based on recommended increments and results from the study by Kulenović et al. (2018). The study offered a similar dosage to participants and recorded better response and remission compared to a placebo. Increasing the dose to 40mg was avoided since it surpassed the recommended weekly increment and could induce adverse events. Equally, continuation with 10mg Paxil could not be sustained because the patient only registered partial response which can only be countered with dose escalation in absence of adverse events. 20mg Paxil reduced the patient’s symptoms by 61% warranting the maintenance of the prescription to assess the full effects of the drugs (WU, 2022). An increase of the dosage to 30mg was avoided because antidepressants project a flat dose-dependency pattern that does not increase efficiency but rather induces adverse effects (Ishino, 2021). Augmenting the prescription with buspirone was avoided because a positive therapeutic response had been registered. Ethical consideration guided the decisions made with the clinician ensuring informed consent, therapeutic relationship, and treatment adherence.

References

Altis, K. L., Elwood, L. S., & Olatunji, B. O. (2014). Ethical issues and ethical therapy associated with anxiety disorders. Ethical Issues in Behavioral Neuroscience, 265-278. https://doi.org/10.1007/7854_2014_340

American Psychiatric Association. (2010a). Practice guidelines 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

Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician, 10(6), 326-334. https://doi.org/10.9740/mhc.2020.11.326

Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., … & Powers, M. B. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1-21. https://doi.org/10.1080/16506073.2018.1560358

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.3389/fpsyt.2020.595584

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

Ishino, R. (2021). Antidepressants: Is a higher dose always better?. Current Psychiatry, 20(3), 39-42. https://doi.org/10.12788/cp.0102

Kulenović, A. D., Serdarević, A. M., Halilović, Z., Mašnić, H., Bahto, A., Kapo, B., … & Hadžimuratović, A. (2018). Observational multicenter study of efficacy of paroxetine film-coated tablet in the treatment of anxiety disorder. Med Glas (Zenica), 15(2), 186-191. https://doi.org/10.17392/947-18

Rickels, K., Zaninelli, R., McCafferty, J., Bellew, K., Iyengar, M., & Sheehan, D. (2003). Paroxetine treatment of generalized anxiety disorder: a double-blind, placebo-controlled study. The American journal of psychiatry, 160(4), 749–756. https://doi.org/10.1176/appi.ajp.160.4.749

Rochester, M. P., Kane, A. M., Linnebur, S. A., & Fixen, D. R. (2018). Evaluating the risk of QTc prolongation associated with antidepressant use in older adults: a review of the evidence. Therapeutic advances in drug safety, 9(6), 297-308. https://doi.org/10.1177%2F2042098618772979

Shrestha, P., Fariba, K., & Abdijadid, S. (2018). Paroxetine. StatPearls Publishing, Treasure Island (FL).

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

Walden University (2022). Case Study: A Middle-aged Caucasian Man with Anxiety. https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_05/index.html