Generalized Anxiety Disorder and Pharmacotherapies
Life situations typically face us with a level of anxiety, and we cope despite the stress. Our recent experience with the Covid19 pandemic exposed us to fear, uncertainty, and some loss of control. We remembered being in a long Costco line and hoarding food and toilet paper, which gave us some sense of control. As the pandemic worsened, we found ourselves more anxious at work from call lights and code blues, and the added chaos at home from children we needed to home-school. No matter what we did to survive those trying moments, indeed, we experienced temporary anxiety. This pandemic left us with some unwanted memories, to an extent. In time, our anxieties resolved because we coped. Unfortunately, for some of us, the similar anxiety did not leave to the point of becoming pathological.
Rosenthal and Burchum (2021) described GAD as a chronic condition manifested by uncontrollable worrying, and a diagnosis is made if it persists for six months and more. It can exist with another psychiatric disorder, commonly depression. In addition, physical symptoms of restlessness, easy fatiguability, difficulty concentrating, irritability, muscle tension, or sleep disturbance affect the individual with GAD (Terlizzi & Villaroel, 2020). It is more common among women and highest among 18-29 years, decreasing with age. De Martini, Patel, and Fancher (2019) reported that most patients could be diagnosed and managed by primary care providers; otherwise, this can increase the risk for suicide and cardiovascular-related events and death.
Cassano, Rossi, and Pini (2022) emphasized the revolutionized approach to the treatment of a spectrum of anxiety disorders, generalized anxiety disorder (GAD), along with obsessive-compulsive disorder (OCD), panic disorder (PD), phobias, and post-traumatic disorder PTSD). This meant replacing the chronic use of benzodiazepines (BZs). For this reason—focusing on GAD management meant pharmacotherapeutic strategies with serotonergic reuptake inhibitors (SRIs) through selective serotonergic-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs); and a nonbenzodiazepine-nonbarbiturate drug (azapirones).
Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder Selective-Serotonin Reuptake Inhibitors (SSRIs)
SSRIs block the neuronal reuptake of serotonin (5-hydroxytryptamine [5-HT]), a monoamine neurotransmitter, which works in depression symptoms by increasing serotonin activity (Rosenthal, & Burchum, 2021). The use of SSRI in GAD without depression is also effective. Hou et al. (2019) accounted for biological mechanisms of cytokine imbalance that can alter the hypothalamic-pituitary-adrenal axis (HPA) via stimulant effects on the expression and release of corticotropin-releasing hormone, adreno-corticotropic hormone, and cortisol causing the continued release of chronic fear and anxiety. Thus, SSRIs demonstrated an increased pro-inflammatory response to the HPA, correcting this and promoting anxiolytic effects.
Rosenthal and Burchum (2021) presented SSRIs, Paroxetine (Paxil), and Escitalopram (Lexapro) as FDA-approved SSRIs for GAD. Chu and Wadwa (2022) described its availability in oral form, only permitting administration with or without food. Because it does little or no effect on dopamine, norepinephrine, histamine, or acetylcholine — it has fewer side effects of xerostomia, sedation, constipation, urinary retention, and cognitive impairment. This accounts for its being the first-line option, but this group still has risks, especially in accompanying conditions of depression with acute suicide risks. Common side effects are sexual dysfunction, sleep disturbances, weight changes, anxiety, dizziness, headache, and gastrointestinal disturbance. In addition, it affects the cytochrome P450 by inhibiting CYP3D6.
It is also essential to note that Citalopram can cause longer QT intervals, leading to fatal arrhythmias, torsade de pointes. In addition, a life-threatening condition similar to Neuroleptic Malignant Syndrome called Serotonin Syndrome can occur resulting from overdosing on SSRIs or combining medications that increase serotonin levels. Only supportive measures in the ICU, discontinuation of the SSRI, and BZs for agitation can address this, although there is some success on Cyproheptadine.
In pediatrics, it is available in syrup form. Therefore, an algorithmic approach to addressing this age group with GAD is encouraged (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018).
In adolescents, the impact of variants in HTR2A and serotonin transporter (SLC6A4) genes and cytochrome P450 2C19 (CYP2C19) phenotypes on response as well as CYP2C19 phenotype on escitalopram pharmacokinetics have been seen to alter drug levels (Strewn et al., 2020).
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Rosenthal and Burchum (2021) presented SNRIs, Venlafaxine (Effexor XR), and duloxetine (Cymbalta) as FDA-approved SNRIs for GAD. These drugs block the reuptake of both serotonin (5-HT) and norepinephrine with differing selectivity (Nelson, 2020). Venlafaxine has a 30-fold higher affinity for reuptake of serotonin compared to norepinephrine. Duloxetine has 10-fold selectivity to serotonin. This may be why the FDA has more approved indications among the SNRIs. The dual action of serotonin and norepinephrine appear to present more advantages than SSRI. This means weighing the benefits over the risks as therapy and pseudo-anticholinergic side effects (constipation, dry mouth, and urinary retention) despite the lack of direct effect on cholinergic receptors.
The pharmacokinetics of SNRI is affected by food, but not the degree of absorption. Nausea, being pronounced in Venlafexine, may be relieved by food, although symptom diminishes over time (Rosenthal and Burchum, 2021). Duloxetine is highly protein-bound, with clearance being primarily hepatic. The kidneys excrete the drug unchanged in the urine. This required patients with hepatic and kidney diseases to reduce the dose.
Nelson (2020) cautioned not to abruptly withdraw SNRI, common in Venlafaxine, to prevent chills, dizziness, dysphoria, fatigue, gastrointestinal distress, and myalgias. In addition, regular blood pressure checks for the first two weeks up to six months should be done. Hypertension is related to the potency of norepinephrine effects. Low dosing is observed for this reason.
Like SSRI, combining Venlafaxine with a monoamine oxidase inhibitor (MAOI) can lead to cardiotoxicity.
Azapirones
Busipirone (Buspar), a class of drug from Azapirones, is primarily prescribed for GAD as a second-line agent after SSRIs.
Rosenthal and Burchum (2021) presented buspirone providing anxiolytic efficacy that, in contrast with BZs, does not cause abuse potential and does not heighten CNS depressants. Wilson and Tripp (2021) emphasized that it has little efficacy on acute anxiolytic needs as it typically takes 2 to 4 weeks to peak. However, it is as effective as benzodiazepines for GAD.
The mechanism of action of Buspirone is by being a partial agonist to serotonin 5HT1a receptor and on a weaker degree, with serotonin 5HT2 receptor affecting the brain’s anxiety and fear circuitry, and as a weak antagonist on dopamine D2 autoreceptors. There is no GABA effect.
Absorption is reduced with food intake, while concomitant food intake also reduces the drug’s first-pass metabolism, increasing bioavailability. Therefore, providers may instruct patients to take food or on an empty stomach as long as the dosage pattern is consistent. There is a known fourteenfold increase in hepatic impairment due to its effect on cytochrome P450 and twofold among those with renal insufficiency.
The most common side effect among 10% of the patients is dizziness. A sidenote is a relief from sexual adverse effects among SSRIs if co-administered. In addition, patients should be observed for symptoms of CNS depression, akathisia from central dopamine antagonism, and serotonin syndrome.
Personal Plan of Care
BZs, medications used for GAD are alprazolam, chlordiazepoxide, and lorazepam — on acute presentation of GAD may still benefit the patient and are recommended (Rosanthal and Burchum, 2021). Warning the patients of side effects and safety risks from sedation and psychomotor slowing should be added to the instructions. History taking on substance and alcohol abuse should be considered to assess abuse potential. Monitoring the patient’s need for more frequent refills should be noted. This way, including a multi-disciplinary approach with cognitive behavior therapy with psychotherapists and social workers, should be considered.
The knowledge of the pharmacological differences of various GAD therapies is necessary for appropriate decisions on the relevance and niche depending on the situation and conditions of the patient. Understanding the possible and more serious side effects based on the drug choices will be included in the instructions, surveillance, diet (avoidance of grapefruit and alcohol), and periodic follow-up appointments. Verifying level of understanding of patients and families should also be added.
If suicide risk is noted, involving the team and family is imperative (Hou et al., 2019). In addition, instructions on the 2 to 4 weeks of initiation of therapy should alert for safety and rid the patient of an environment where he can carry out his dark plan.
Conclusion
As benzodiazepines become notorious for dependency and abuse, the pharmacotherapies above offer a promising approach to managing GAD alongside cognitive behavior therapy. These drug therapies are helpful; however, the risks of side effects should be considered and prevented.
GAD is a concerning psychiatric condition as it is a chronic and unremitting disorder. We witnessed how these patients have become frequent flyers in our health practice, presenting recurrent problems and somatic symptoms. Therefore, GAD pharmacotherapies with reinforcement for healthy coping mechanisms are essential and should prolong the intervals of remissions if we cannot wholly assist in overcoming this in our future nurse practice.
References:
Cassano, G. B., Rossi, N. B., & Pini, S. (2022). Psychopharmacology of anxiety disorders. Dialogues in clinical neuroscience .
Chu,A.,& Wadhwa,R. [Updated 2022 Jan 11]. Selective Serotonin Reuptake Inhibitors. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK554406/
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine , 170 (7), ITC49-ITC64.
Hou, R., Ye, G., Liu, Y., Chen, X., Pan, M., Zhu, F., & Tang, Z. (2019). Effects of SSRIs on peripheral inflammatory cytokines in patients with Generalized Anxiety Disorder. Brain, behavior, and immunity , 81 , 105-110.
Nelson, C. (2020). Serotonin-norepinephrine reuptake inhibitors (SNRIs): pharmacology, administration, and side effects.
Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book . Elsevier Health Sciences, 215-218, 243-247.
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.
Strawn, J. R., Mills, J. A., Schroeder, H., Mossman, S. A., Varney, S. T., Ramsey, L. B., … & DelBello, M. P. (2020). Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. The Journal of clinical psychiatry , 81 (5), 6584.
Terlizzi, E. P., & Villarroel, M. A. (2020). Symptoms of generalized anxiety disorder among adults: United States, 2019 (p. 8). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
Wilson, T.,& Tripp J. [Updated 2021, Aug 12]. Buspirone. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK531477/
Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.
Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA approved indications when referring to different medication classes used in the treatment of GAD.
To Prepare:
Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
Think about a personalized plan of care based on these influencing factors and patient history with GAD.
By Day 3 of Week 8
Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.
By Day 6 of Week 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply , you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply !
Hello Sara, your post provides a comprehensive overview of Generalized Anxiety Disorder (GAD) and the pharmacological treatments used to manage it, specifically benzodiazepines, Buspirone and venlafaxine. It’s important to have a good understanding of these treatment options when dealing with GAD. Here are some key takeaways and additional information:
Generalized Anxiety Disorder (GAD) : You’ve done an excellent job explaining what GAD is and how it can affect individuals. Mentioning that it’s more prevalent in women and that it can develop over time, starting in childhood or around the age of 30, adds valuable context
Highlighting the criteria for diagnosing GAD based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) is important (APA, 2023). It helps readers understand how healthcare providers make the diagnosis. You’ve correctly pointed out that GAD can have a genetic component and that experiencing traumatic events or being in a stressful environment can increase the risk. This information helps readers understand some of the potential causes. Your explanation of the pharmacokinetics and pharmacodynamics of benzodiazepines is informative (Mayo Clinic (2017). You’ve emphasized the importance of considering the risk of tolerance and abuse, especially in patients with a history of substance abuse. Additionally, you’ve mentioned the suitability of specific benzodiazepines for older adults (NCBI, 2023).
You’ve provided a clear description of buspirone’s characteristics, including its slower onset of action, lack of sedation, and its suitability for patients with substance abuse issues. The note on adjusting the dosage for patients with renal impairment is a valuable addition. In addition, you’ve highlighted the role of venlafaxine as a serotonin-norepinephrine reuptake inhibitor (SNRI) and its effectiveness in GAD treatment. The mention of its delayed onset of action and potential risks like suicide, particularly in younger patients, is crucial for readers to be aware of (Rosenthal, Laura D., et al., 2021).
Your conclusion provides an excellent summary of the factors that healthcare providers should consider when choosing a treatment approach for GAD. It underscores the need to individualize treatment based on a patient’s specific needs and circumstances.
In summary, your post offers a well-rounded discussion of GAD and its treatment options. It covers important aspects of diagnosis, risk factors, and the pharmacological treatment of GAD, allowing readers to better understand the condition and its management.
Reference
American Psychological Association (2023). PTSD guideline: What is exposure therapy? Retrieved October 19, 2023, from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapyLinks to an external site.Links to an external site.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier Inc.
Generalized Anxiety Disorder , www.ncbi.nlm.nih.gov/books/NBK279594/Links to an external site. . Accessed 19 Oct. 2023.
Mayo Clinic (2017). Generalized anxiety disorder. Retrieved October 19, 2023, from https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/diagnosis-treatment/drc-20361045Links to an external site.Links to an external site.
Generalized Anxiety Disorder (GAD) is a debilitating condition characterized by excessive and uncontrollable worry (Clemenza et al., 2018). It is an illness that often begins in childhood or early adulthood and persists throughout life. “GAD affects up to 5% of children and adolescents and between 3–6% of adults” (Clemenza et al., 2018, p. 1058). Anxiolytic medications are commonly prescribed for GAD, but an individualized treatment approach is crucial, considering the numerous factors that can affect pharmacokinetics and pharmacodynamics.
Pharmacogenetics is critical in determining the patient’s response to anxiolytic medications (Jancic et al., 2023). Genetic variations in drug-metabolizing enzymes and drug transporters can influence the rate of drug metabolism and bioavailability. For instance, individuals with specific CYP2D6 genetic variants may metabolize selective serotonin reuptake inhibitors (SSRIs) differently, potentially requiring dose adjustments or alternative medications. Therefore, pharmacogenetic testing is a valuable tool to guide treatment decisions and minimize adverse effects. Furthermore, gender differences can significantly impact the pharmacokinetics and pharmacodynamics of anxiolytic medications. For example, women generally metabolize drugs more slowly than men due to variations in body composition and hormonal fluctuations (Mattison & Soldin, 2009). This can result in differences in drug efficacy and side effects. It may be necessary to consider lower initial doses of medications, close monitoring for side effects, or preferential use of SSRIs, which may have a more favorable risk-benefit profile for some female patients.
Ethnicity can influence drug response due to variations in genetics and cultural factors. Certain ethnic groups may have different genetic polymorphisms, leading to differences in drug metabolism (Koenig et al., 2021). Additionally, cultural beliefs and practices can impact patient adherence to medications. Moreover, age-related changes in pharmacokinetics and pharmacodynamics are significant considerations for GAD treatment. Elderly patients may experience altered drug metabolism and an increased risk of adverse effects (Cassidy & Sheikh, 2000). This population may benefit from medications with a more predictable safety profile, such as SSRIs or serotonin-norepinephrine reuptake inhibitors (SNRIs), over benzodiazepines. Lower initial doses may also be appropriate for older patients to minimize side effects and prevent excessive sedation.
Patient behavior and lifestyle choices can have a substantial impact on treatment effectiveness. Substance use, including alcohol and illicit drugs, can interact with anxiolytic medications and alter their effects (Brady et al., 2013). Non-pharmacological interventions, like cognitive-behavioral therapy (CBT) and relaxation techniques, should be integrated into the patient’s care plan to address the behavioral aspects of GAD and enhance the effectiveness of pharmacotherapy.
Coexisting medical conditions can influence the pharmacokinetics and pharmacodynamics of anxiolytic medications. Patients with GAD and comorbid diseases like liver or kidney impairment may require dose adjustments to ensure therapeutic drug levels and prevent toxicity (Menon et al., 2022). Additionally, individuals with GAD often experience comorbid depression, which may necessitate a tailored approach to medication selection, favoring agents effective for both conditions (Clemenza et al., 2018).
A comprehensive, personalized care plan for a patient with Generalized Anxiety Disorder (GAD) should consider various influencing factors to optimize treatment outcomes. Firstly, pharmacogenetic testing should be prioritized to identify genetic variations in drug metabolism, enabling the selection of the most suitable medications and dosages tailored to the patient’s unique genetic profile (Jancic et al., 2023). Additionally, gender-specific considerations should be considered, with lower initial medication doses and close monitoring of potential side effects for female patients, and the consideration of Selective Serotonin Reuptake Inhibitors (SSRIs) as a first-line treatment option (Mattison & Soldin, 2009). Moreover, ethnicity-specific adaptations are essential, customizing medication choices and dosages based on the patient’s ethnicity and considering genetic and cultural factors (Koenig et al., 2021). For elderly patients, a preference for medications with a predictable safety profile, initiating treatment with lower doses, and careful assessment for side effects is crucial (Cassidy & Sheikh, 2000). Behavioral interventions should also be integrated into the care plan, combining anxiolytic medications with psychotherapy, such as Cognitive-Behavioral Therapy (CBT), and encouraging the adoption of healthy lifestyle choices to address the behavioral aspects of GAD (Brady et al., 2013). Lastly, disease-related adjustments should be made, considering any comorbid medical conditions to ensure that medication choices and dosages are adapted to the patient’s overall health.
When considering treatment options for Generalized Anxiety Disorder (GAD), providers need to consider various factors, such as genetics and age, and each medication’s positive and negative aspects. Benzodiazepines are effective for rapidly alleviating anxiety symptoms, making them suitable for short-term, acute anxiety episodes or as bridge therapy while awaiting the onset of action of SSRIs (Clemenza et al., 2018). However, they carry the risk of dependence and withdrawal symptoms. They can cause sedation, dizziness, and impaired cognitive function, discouraging long-term use due to the potential for tolerance and addiction.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are generally considered first-line treatments for GAD due to their safety and efficacy (Clemenza et al., 2018). They have a lower potential for dependence and addiction than benzodiazepines and are suitable for long-term use. However, their onset of action is slower, often taking several weeks to show therapeutic effects. They may also cause side effects, such as nausea, sexual dysfunction, or weight changes, and genetic factors, like CYP2D6 variations, can influence their metabolism and response (Jancic et al., 2023 & Mayo Clinic, n.d.).
Buspirone provides a non-habit-forming anxiolytic option for GAD. It is suitable for patients who cannot tolerate or prefer to avoid benzodiazepines or SSRIs and can be used as an add-on therapy to SSRIs or SNRIs for enhanced efficacy (Cassidy & Sheikh, 2000). However, it has a slower onset of action compared to benzodiazepines and may be less effective in severe cases of GAD (Gale & Oakley-Browne, 2000). Additionally, buspirone was found to cause more nausea, dizziness, and drowsiness when compared to a placebo.
Combination therapy can simultaneously address multiple aspects of GAD and enhance treatment response, particularly in treatment-resistant cases (Ansara, 2020). It may reduce the need for higher doses of a single medication. However, it increases the risk of drug-drug interactions and side effects, requiring careful monitoring and potential dose adjustments. This approach may also complicate treatment regimens and reduce patient adherence.
Cognitive-behavioral therapy (CBT) and behavioral interventions address GAD’s behavioral and psychological aspects (Ansara, 2020). They effectively teach patients coping skills and anxiety management techniques and can be used alone or as an adjunct to pharmacological treatment. However, they do not provide immediate relief from symptoms and may be less effective in individuals with severe GAD without concurrent pharmacotherapy. Patient engagement is crucial, and these approaches may only suit some. Therefore, the treatment choice for GAD should be individualized, considering each patient’s unique characteristics and preferences.
References
Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician , 10 (6), 326–334. Retrieved October 17, 2023, from https://doi.org/10.9740/mhc.2020.11.326Links to an external site.
Brady, K. T., Killeen, T. K., Hartwell, K. J., & Haynes, L. F. (2013). Substance use disorders and anxiety: A treatment challenge for social workers. Social Work in Public Health , 28 (3-4), 407–423. Retrieved October 17, 2023, from https://doi.org/10.1080/19371918.2013.774675Links to an external site.
Cassidy, E. L., & Sheikh, J. I. (2000). Treatment of anxiety disorders in the elderly. Journal of Anxiety Disorders , 14 (2), 173–190. Retrieved October 17, 2023, from https://doi.org/10.1016/s0887-6185(99)00047-xLinks to an external site.
Clemenza, K., Geracioti, L., Levine, A., Rajdev, N., & Strawn, J. R. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy , 19 (10), 1057–1070. Retrieved October 17, 2023, from https://doi.org/10.1080/14656566.2018.1491966Links to an external site.
Gale, C., & Oakley-Browne, M. (2000). Extracts from “clinical evidence”: Anxiety disorder. BMJ , 321 (7270), 1204–1207. Retrieved October 17, 2023, from https://doi.org/10.1136/bmj.321.7270.1204Links to an external site.
Jancic, J., Radosavljevic, M., Samardzic, J., & Svob Strac, D. (2023). The role of pharmacogenetics in personalizing the antidepressant and anxiolytic therapy. Genes , 14 (5), 1095. Retrieved October 17, 2023, from https://doi.org/10.3390/genes14051095Links to an external site.
Koenig, J., Olafuyi, O., Parekh, N., & Wright, J. (2021). Inter‐ethnic differences in pharmacokinetics—is there more that unites than divides? Pharmacology Research & Perspectives , 9 (6), e00890. Retrieved October 17, 2023, from https://doi.org/10.1002/prp2.890Links to an external site.
Mattison, D. R., & Soldin, O. P. (2009). Sex differences in pharmacokinetics and pharmacodynamics. Clinical Pharmacokinetics , 48 (3), 143–157. Retrieved October 17, 2023, from https://doi.org/10.2165/00003088-200948030-00001Links to an external site.
Mayo Clinic. (n.d.). Selective serotonin reuptake inhibitors (SSRIs) . Retrieved October 17, 2023, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825Links to an external site.
Menon, V., Praharaj, S., & Ransing, R. (2022). Management of psychiatric disorders in patients with hepatic and gastrointestinal diseases. Indian Journal of Psychiatry , 64 (8), 379. Retrieved October 17, 2023, from https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_18_22Links to an external site.
