Case Scenario (decision Tree): A Middle-Aged Caucasian Man With Anxiety
Anxiety disorders are the most common types of psychiatric illnesses characterized by excessive fear and anxiety-related disturbances. Affected individuals find it difficult to concentrate, sleep, and perform routine activities. Many patients with this disorder experience physical symptoms often associated with muscle tension and vigilance which necessitates assessment for self-harm and other social difficulties. The elderly population is among the most frequently affected especially those with underlying conditions such as cardiovascular diseases and neurological conditions. However, proper diagnosis and treatment can lead to effective coping and alleviation of symptoms.
This discussion focuses on anxiety disorder and its management using different medications. The client is a 46-year old white male who presents to the emergency room with symptoms of a heart attack. Upon examination, the patient has chest tightness, shortness of breath, and a feeling of impending doom. Further examination reveals that he is about 15lbs overweight and has mild hypertension that is currently managed with a low sodium diet. An EKG done in the ER to rule out myocardial infarction reveals normal heart functioning but the patient still has the presenting symptoms. Further history taking reveals that he occasionally experiences anxiety, feels like running from wherever he is at, and uses ETOH to combat worries at work.
The above symptoms lead to an impression of anxiety which prompts further health assessment as follows. A Hamilton Anxiety Rating Scale (HAM-A) is administered and a score of 26 is observed. The mental status examination reveals that the client is alert, well-oriented, and has clear and coherent speech. He reports a ‘blah’ mood and does feel nervous even during the examination. He denies visual or auditory hallucinations, no paranoid thought process, and his judgment is grossly intact. The above presentation leads to a diagnosis of generalized anxiety disorder. The primary mental health nurse practitioner has a variety of choices to prompt the treatment of the patient as discussed below.
Decision #1: Begin Zoloft 50mg PO daily
The PMHNP has three decisions at this stage: to begin Zoloft 50 mg PO daily, begin Imipramine 25 mg PO BID, or begin Buspirone 10 mg PO BID. I chose to begin Zoloft 50 mg PO daily.
Zoloft is a drug belonging to a class of drugs known as selective serotonin reuptake inhibitors (SSRI) that are the first-line choice for the management of anxiety disorders (Crocco et al., 2017). Individuals with anxiety normally have an imbalance of serotonin and Zoloft works to increase the level of the substance in the brain through inhibition of its reuptake. I choose to begin with this drug because it has mild side effects in patients which include sweating, insomnia, and loss of appetite.
The other two available options are to begin Imipramine 25mg PO twice daily or begin Buspirone 10mg PO twice daily. I decline to choose either option because Imipramine is a tricyclic antidepressant that is mainly available for individuals with anxious moods and depressive symptoms. Buspirone on the other hand is only available as a second-line drug for anxiety management when the use of SSRIs does not yield any positive effects (Thom et al., 2020). Additionally, Buspirone only provides a short term relief of symptoms compared to Zoloft which can be used for long-term therapy.
Selective serotonin reuptake inhibitors are the first-line choice for the treatment of anxiety. By selecting Zoloft, it was anticipated that the symptoms could reduce within the four weeks of treatment. I was hoping to reduce fear and other symptoms such as shortness of breath resulting from excessive anxiety. I also expected the patient to find some sleep, although I knew Zoloft could sometimes cause insomnia. While making these choices, ethical decisions such as beneficence and non-maleficence should apply (Schneider, 2016). For example, selecting the right drug for treatment will prevent harm and further deterioration of the patient’s condition.
Decision #2: Increase the dose to 75mg PO once daily
After the first choice of treatment with Zoloft 50mg PO was made, the patient returns and reports that chest tightness, shortness of breath, and worrying at work has decreased. The HAM-A score has partially decreased to 18. The other two available options are to increase Zoloft to 100mg PO once daily or make no change on Zoloft dosage at this time. My choice is to increase the Zoloft dosage to 75mg PO once daily and reassess after four weeks.
I choose to increase the dosage because the patient is responding well to the drug and the side effects are well tolerated. A gradual dose increase is the best option because the HAM-A sale has partially reduced but not to the acceptable levels. A score of 18 indicates moderate anxiety for the patient and also shows a slight improvement of symptoms (Strawn et al., 2018). I believe increasing the dosage will reduce symptoms by more than 50%.
The other two available options are to increase Zoloft to 100mg PO once daily or make no change on Zoloft dosage at this time. I did not choose to increase the dosage to 100mg because it will not demonstrate a gradual dosage increase as recommended during treatment. Secondly, the high dose is recommended for severe anxiety, and when lower doses do not yield results. the other option available is not to alter the dosage of the drug which I believe will prolong the period of treatment and delay achievement of set goals (Crocco et al., 2017). With a HAM-A score of 18, it is recommended to increase the dosage to further reduce symptoms.
By choosing to increase the dosage of Zoloft to 75mg, I expect that the patient will report a further reduction in symptoms. The HMA-A sore should also reduce as the symptoms decrease and I believe the patient is going to experience mild side effects such as insomnia and fatigue. While making these choices, I understand that I should make a decision that is good for the patient. For example, deciding to increase the dose to 100mg will mean harm to the patient because of the side effects. Failure to adjust the dosage will also indicate negligence because it will take the patient more time to recover.
Decision 3#: Maintain current dose
After increasing the previous Zoloft dose to 75mg, the patient reports even further reduction in symptoms. The HMA-A score has decreased to 10 which indicates a 61% reduction in symptoms. The available options are to maintain the current Zoloft dose at 75mg, increase the dose to 100mg, or to augment with Buspirone. I choose to maintain the current dose of Zoloft 75mg PO once daily for the next month.
It is clear that the client is having a good response to the drug and current dosage as evidenced by more than 50% reduction of symptoms. The patient is also able to tolerate the side effects which indicates that the current management suits the patient’s needs. I did not select to increase the dosage to 100mg of Zoloft because the patient is doing well with the current management and increasing the dosage will only lead to undesirable side effects (Lewis et al., 2019). The other available option is to augment with Buspirone which I find unnecessary because augmentation or change of drugs is only recommended when the first line management does not yield desirable outcomes.
Maintaining the dose at 75mg for the next one month will definitely lead to further reduction of symptoms. I intend to achieve total alleviation of symptoms such as fear, increased heart rate, and insomnia. I also intend to decrease the HMA-A sore to below 10 which will indicate a marked reduction of anxiety. Ethical considerations at this stage include making the right choices for the patient to demonstrate beneficence alongside explanation to the patient about possible side effects of increasing the dosage and augmentation (Schneider, 2016).
The primary diagnosis of the patient is a generalized anxiety disorder which presents with signs of fear, insomnia, increased heart rate, and feeling of impending doom. Upon assessment, I believe Zoloft is the best choice for the management of the patient’s condition. The drug is an SSRI which is recommended as the first-line choice for the management of anxiety (Lewis et al., 2019). Imipramine and Buspirone are also other available options but both are used as second-line choices when SSRIs do not yield expected results.
Upon treatment with Zoloft 50mg, the patient comes back after four weeks with decreased symptoms of anxiety and a HAM-A score of 18. At this point, I realize that the patient is doing well and a slight increase in the Zoloft dose will yield better results. instead of increasing the dose to 100mg, I choose to increase it to 75mg for better toleration of side effects. Eventually, the patient comes back with a much more improved HMA-A score and decreased symptoms. Maintaining the dosage at 75mg at this point for the next one month is the best option for effective management of the anxiety symptoms.
Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological management of anxiety disorders in the elderly. Current treatment options in psychiatry, 4(1), 33-46. DOIhttps://doi.org/10.1007/s40501-017-0102-4
Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry, 6(11), 903-914. https://doi.org/10.1016/S2215-0366(19)30366-9
Schneider, M. R. (2016). Clinical and Social Contexts of Ethical Issues in Mental Health Care. AMA Journal of Ethics, 18(6), 567-571. https://journalofethics.ama-assn.org/article/clinical-and-social-contexts-ethical-issues-mental-health-care/2016-06
Strawn JR, Geracioti L, Rajdev N, Clemenza K, Levine A. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opin Pharmacother. 2018;19(10):1057-1070. doi: 10.1080/14656566.2018.1491966
Thom, R. P., Keary, C. J., Waxler, J. L., Pober, B. R., & McDougle, C. J. (2020). Buspirone for the Treatment of Generalized Anxiety Disorder in Williams Syndrome: A Case Series. Journal of Autism and Developmental Disorders, 50(2), 676-682. DOI: 10.1007/s10803-019-04301-9
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