Anxiolytic Therapy & PTSD Treatment

 

Anxiolytic Therapy & PTSD Treatment

Assessing and Treating Clients with Anxiety Dis

Psychopharmacologic Approaches to Treatment of Psychopathology

June

 

Introduction

Generalized Anxiety Dis (GAD) is characterized by persistent and excessive worry about a number of different things. It affects about 6.8 million adults, or 3.1% of the U.S. population. GAD comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. The dis comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age (Anxiety and depression association of America, 2018). GAD is responsible for causing decreased productivity, increased morbidity and mortality rates, and the growth of alcohol and drug abuse in the large section of the society (Bystritsky, Khalsa, Cameron & Schiffman, 2013). GAD can also have a negative impact on the quality of life and interfere with activities of daily living of an individual (Locke, Kirst & Schultz, 2015). Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role (Anxiety and depression association of America, 2018).

The purpose of this paper is to examine a middle-aged Caucasian man with anxiety. It will make three decisions concerning the medication to prescribe to this patient while considering the factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. It will also explain the rationales behind those three decisions and discuss ethical considerations that may impact the treatment plan and communication with the client.

Decision one

Decision One: Begin Zoloft 50 mg Orally Daily

The patient has been referred to the clinic by his primary care physician due to a visit that he had to the emergency room due to feeling like having a heart attack. His symptoms were: chest tightness, shortness of breath, and feeling of impending doom. The only history that this patient has is mild hypertension, overweight, and tonsillectomy. He was medically cleared at the emergency room and physical exam was WNL.

Based on his presenting symptoms of feeling of tightness in the chest and episodes of shortness of breath, occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at, he was diagnosed with generalized anxiety dis . He scored 26 from Hamilton Anxiety Rating Scale (HAM-A).

Reason for choice

I chose Zoloft for this patient because it is a selective serotonin reuptake inhibitor (SSRI) is the preferred pharmacological treatment for GAD (Kavan, Elsasser, & Barone, 2009). It is a first-line therapy for patients with GAD because it exert its effect by inhibiting serotonin transporter and causes the desensitization of postsynaptic serotonin receptors thereby normalizing the serotonergic pathways (Bystritsky, Khalsa, Cameron & Schiffman, 2013). I also chose it because of its potential for long-term use without fear of tolerance or abuse (Kavan, Elsasser, & Barone, 2009).

Another reason is that Zoloft is known to have clinical advantages over other drugs because it has minimal drug interactions, its reduced risk of symptoms that can occur upon stooping the medication and its lack of associated electrocardiographic changes (Hoge, Hoge, Ivkovic, & Fricchione, 2012).

Other options would be to start the patient on Tofranil (imipramine) 25 mg orally BID or Buspirone 10 mg orally BID. However, tofranil belongs to a class of serotonin norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants (TCA) and even though it has a comparable efficacy to SSRIs in treating anxiety dis s, it are rarely used because it has frequent side effects such as sedation, anticholinergic effects, and cardiac conduction delay that often limit the use of TCAs at therapeutic doses (Huh, Goebert, Takeshita, Lu, & Kang, 2011). It can be potentially lethal if given in higher doses. (Bystritsky, Khalsa, Cameron and Schiffman, 2013).

Buspar which is an anxiolytic and serotonin receptor partial agonist (S-PRA) has be shown to be effective in treating GAD. However, it is not a great option for this patient because, it is frequently used as an augmentation to SSRI therapy and are recommended for short-term use (Mavranezouli, Meader, Cape & Kendall, 2013).

Goal

The goal for this patient is that, at his next four weeks clinic visits, his symptoms (shortness of breath, chest tightness, sense of impending doom) would have decreased by 50percent or more based on his HAM-A score.

Results

At the four weeks visit, the patient reports no longer experiencing chest tightness or SOB or not worrying about his work over the past four to five days. However, the patient has a partial response to the medication and his HAM-A score is at 18 which was not the intended goal for the patient. According to Hoge, Hoge, Ivkovic and Fricchione, 2012, “treatment efficacy can be measured by clinical response which is defined in most studies as a reduction of >50% in HAM-A score from baseline or remission which is defines as a final HAM-A score of ≤7” (p. 6). This is not the case for my patient at this time and therefore more decisions would have to be made.

 

Decision Two

Increase Dose to 75 mg Orally Daily

Since the patient the experienced a partial response to the 50mg of Zoloft, the next step would be to increase the dose to 75mg daily. According to Stahl, 2014b), with Zoloft, the therapeutic effect does not immediately occur. It is often delayed by two to four weeks. However, if after this period, there is no positive effect, then the dose can be increased otherwise the medication may not even work at all.

The other option of either increasing Zoloft to 100mg or not changing anything at this point is not an option. This is because increasing it too 100mg is too sudden over a short period of time and it would increase the chances of getting the notable side effects like sexual dysfunction. Increasing the dosage can cause erectile dysfunction or delayed ejaculation (Stahl, 2014b). Therefore, it is advisable to follow the principle of stating low and going slow. Since the patient is scoring at 18 with his HAM-A score, it would not be an option to not do anything after four weeks of been on the medication.

Goal

The goal at this point would be that at the next four week clinic visit, the patient will report that his symptoms have decreased more causing his HAM-A score to reduce by half from his baseline.

Results

At the four weeks visit, the patient reports a further reduction in his symptoms and is scoring at a 10 on his HAM-A score. This is a sixty-one percent reduction in his symptoms. This is great news and has exceeded the goals set for him. This is a good sign that he is heading towards remission.

Decision Three

Maintain Current Dose

Since the patient has met his goal, it will be appropriate to continue at him at the current dose. This is because the patient is having a good response as evidenced by greater than half decrease in his anxiety symptoms. His HAM-A score has reduced to 10 since been on Zoloft. The current dose should be maintained for twelve weeks to evaluate the full effect.

Increasing current dose to 100mg daily or augmenting an agent such as buspar would not be appropriate at this time. Even though increasing the dose can yield a faster reduction in his symptoms, it may greatly increase the chances of experiencing the side effects from taking Zoloft. Augmenting should only be done if his symptoms weren’t been managed by a single agent which is not the case with this patient.

The patient is already heading at the right path and to further help the patient reach remission, the patient should continue to take Zoloft 75mg daily. Once he reaches remission, the patient will still need to take the medication for a year (Shahl, 2014b).

Ethical Considerations

An informed consent should be received from patient detailing all the risk and benefits of treatment. A clear explanation should be communicated to the patient about the importance of adhering to his medication regimen as prescribed. Possible side effects of Zoloft like sexual dysfunction in men should be communicated with the patient and advised to report any side effects to the provider. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.

Since the patient also reports drinking about 3-4 beers/night, he should be educated on how alcohol may interfere with the therapeutic effect of his medication. He should be advised to either reduce it or quit and provide him resources that can help him with that if he needs it.

Also the patient had reported that even though he is single, he is attempting to care for aging parents in his home. This can also create stress that can cause his anxiety and would therefore need to be addressed. Ask him if he has a strong support system that can assist him with his parents and also provide him resources that can help assist him.

Summary

Anxiety dis s like GAD are prevalent psychiatric dis s and are associated with a high burden of illness. Anxiety dis s are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the dis . As healthcare providers, it is important to recognize and treat this dis to alleviate the distressing symptoms (Bandelow, Michaelis & Wedekind, 2017).

 

 

 

 

 

 

References

Anxiety and depression association of America (2018). Generalized Anxiety Dis (GAD). Retrieved from https://adaa.org/understanding-anxiety/generalized-anxiety-dis -gad

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety dis s. Dialogues in clinical neuroscience. 19(2): 93–107. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573566/

Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety dis s. P & T: A Peer-Reviewed Journal For Formulary Management, 38(1), 30-57.

Hoge, E., Hoge, E. A., Ivkovic, A., & Fricchione, G. L. (2012). Generalized anxiety dis : diagnosis and treatment. British Medical Journal, 345

Huh, J., Goebert, D., Takeshita, J., Lu, B. Y., & Kang, M. (2011). Treatment of generalized anxiety dis : a comprehensive review of the literature for psychopharmacologic alternatives to newer antidepressants and benzodiazepines. The Primary Care Companion For CNS Dis s, 13(2), doi:10.4088/PCC.08r00709blu

Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety dis and panic dis in adults. American Family Physician, 91(9), 617-624

Kavan, M. G., Elsasser, G., & Barone, E. J. (2009). Generalized anxiety dis : practical assessment and management. American Family Physician, 79(9), 785-791.

Mavranezouli, I., Meader, N., Cape, J., & Kendall, T. (2013). The cost effectiveness of pharmacological treatments for generalized anxiety dis . Pharmacoeconomics, 31(4), 317-333. doi:10.1007/s40273-013-0031-z

 

 

 

 

 

 

 

 

Assessing and Treating Clients with Anxiety Dis

Psychopharmacologic Approaches to Treatment of Psychopathology

June

 

 

 

 

 

 

 

 

Introduction

Generalized Anxiety Dis (GAD) is characterized by persistent and excessive worry about a number of different things. It affects about 6.8 million adults, or 3.1% of the U.S. population. GAD comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. The dis comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age (Anxiety and depression association of America, 2018). GAD is responsible for causing decreased productivity, increased morbidity and mortality rates, and the growth of alcohol and drug abuse in the large section of the society (Bystritsky, Khalsa, Cameron & Schiffman, 2013). GAD can also have a negative impact on the quality of life and interfere with activities of daily living of an individual (Locke, Kirst & Schultz, 2015). Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role (Anxiety and depression association of America, 2018).

The purpose of this paper is to examine a middle-aged Caucasian man with anxiety. It will make three decisions concerning the medication to prescribe to this patient while considering the factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. It will also explain the rationales behind those three decisions and discuss ethical considerations that may impact the treatment plan and communication with the client.

Decision one

Decision One: Begin Zoloft 50 mg Orally Daily

The patient has been referred to the clinic by his primary care physician due to a visit that he had to the emergency room due to feeling like having a heart attack. His symptoms were: chest tightness, shortness of breath, and feeling of impending doom. The only history that this patient has is mild hypertension, overweight, and tonsillectomy. He was medically cleared at the emergency room and physical exam was WNL.

Based on his presenting symptoms of feeling of tightness in the chest and episodes of shortness of breath, occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at, he was diagnosed with generalized anxiety dis . He scored 26 from Hamilton Anxiety Rating Scale (HAM-A).

Reason for choice

I chose Zoloft for this patient because it is a selective serotonin reuptake inhibitor (SSRI) is the preferred pharmacological treatment for GAD (Kavan, Elsasser, & Barone, 2009). It is a first-line therapy for patients with GAD because it exert its effect by inhibiting serotonin transporter and causes the desensitization of postsynaptic serotonin receptors thereby normalizing the serotonergic pathways (Bystritsky, Khalsa, Cameron & Schiffman, 2013). I also chose it because of its potential for long-term use without fear of tolerance or abuse (Kavan, Elsasser, & Barone, 2009).

Another reason is that Zoloft is known to have clinical advantages over other drugs because it has minimal drug interactions, its reduced risk of symptoms that can occur upon stooping the medication and its lack of associated electrocardiographic changes (Hoge, Hoge, Ivkovic, & Fricchione, 2012).

Other options would be to start the patient on Tofranil (imipramine) 25 mg orally BID or Buspirone 10 mg orally BID. However, tofranil belongs to a class of serotonin norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants (TCA) and even though it has a comparable efficacy to SSRIs in treating anxiety dis s, it are rarely used because it has frequent side effects such as sedation, anticholinergic effects, and cardiac conduction delay that often limit the use of TCAs at therapeutic doses (Huh, Goebert, Takeshita, Lu, & Kang, 2011). It can be potentially lethal if given in higher doses. (Bystritsky, Khalsa, Cameron and Schiffman, 2013).

Buspar which is an anxiolytic and serotonin receptor partial agonist (S-PRA) has be shown to be effective in treating GAD. However, it is not a great option for this patient because, it is frequently used as an augmentation to SSRI therapy and are recommended for short-term use (Mavranezouli, Meader, Cape & Kendall, 2013).

Goal

The goal for this patient is that, at his next four weeks clinic visits, his symptoms (shortness of breath, chest tightness, sense of impending doom) would have decreased by 50percent or more based on his HAM-A score.

Results

At the four weeks visit, the patient reports no longer experiencing chest tightness or SOB or not worrying about his work over the past four to five days. However, the patient has a partial response to the medication and his HAM-A score is at 18 which was not the intended goal for the patient. According to Hoge, Hoge, Ivkovic and Fricchione, 2012, “treatment efficacy can be measured by clinical response which is defined in most studies as a reduction of >50% in HAM-A score from baseline or remission which is defines as a final HAM-A score of ≤7” (p. 6). This is not the case for my patient at this time and therefore more decisions would have to be made.

 

Decision Two

Increase Dose to 75 mg Orally Daily

Since the patient the experienced a partial response to the 50mg of Zoloft, the next step would be to increase the dose to 75mg daily. According to Stahl, 2014b), with Zoloft, the therapeutic effect does not immediately occur. It is often delayed by two to four weeks. However, if after this period, there is no positive effect, then the dose can be increased otherwise the medication may not even work at all.

The other option of either increasing Zoloft to 100mg or not changing anything at this point is not an option. This is because increasing it too 100mg is too sudden over a short period of time and it would increase the chances of getting the notable side effects like sexual dysfunction. Increasing the dosage can cause erectile dysfunction or delayed ejaculation (Stahl, 2014b). Therefore, it is advisable to follow the principle of stating low and going slow. Since the patient is scoring at 18 with his HAM-A score, it would not be an option to not do anything after four weeks of been on the medication.

Goal

The goal at this point would be that at the next four week clinic visit, the patient will report that his symptoms have decreased more causing his HAM-A score to reduce by half from his baseline.

Results

At the four weeks visit, the patient reports a further reduction in his symptoms and is scoring at a 10 on his HAM-A score. This is a sixty-one percent reduction in his symptoms. This is great news and has exceeded the goals set for him. This is a good sign that he is heading towards remission.

Decision Three

Maintain Current Dose

Since the patient has met his goal, it will be appropriate to continue at him at the current dose. This is because the patient is having a good response as evidenced by greater than half decrease in his anxiety symptoms. His HAM-A score has reduced to 10 since been on Zoloft. The current dose should be maintained for twelve weeks to evaluate the full effect.

Increasing current dose to 100mg daily or augmenting an agent such as buspar would not be appropriate at this time. Even though increasing the dose can yield a faster reduction in his symptoms, it may greatly increase the chances of experiencing the side effects from taking Zoloft. Augmenting should only be done if his symptoms weren’t been managed by a single agent which is not the case with this patient.

The patient is already heading at the right path and to further help the patient reach remission, the patient should continue to take Zoloft 75mg daily. Once he reaches remission, the patient will still need to take the medication for a year (Shahl, 2014b).

Ethical Considerations

An informed consent should be received from patient detailing all the risk and benefits of treatment. A clear explanation should be communicated to the patient about the importance of adhering to his medication regimen as prescribed. Possible side effects of Zoloft like sexual dysfunction in men should be communicated with the patient and advised to report any side effects to the provider. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.

Since the patient also reports drinking about 3-4 beers/night, he should be educated on how alcohol may interfere with the therapeutic effect of his medication. He should be advised to either reduce it or quit and provide him resources that can help him with that if he needs it.

Also the patient had reported that even though he is single, he is attempting to care for aging parents in his home. This can also create stress that can cause his anxiety and would therefore need to be addressed. Ask him if he has a strong support system that can assist him with his parents and also provide him resources that can help assist him.

Summary

Anxiety dis s like GAD are prevalent psychiatric dis s and are associated with a high burden of illness. Anxiety dis s are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the dis . As healthcare providers, it is important to recognize and treat this dis to alleviate the distressing symptoms (Bandelow, Michaelis & Wedekind, 2017).

 

 

 

 

 

 

References

Anxiety and depression association of America (2018). Generalized Anxiety Dis (GAD). Retrieved from https://adaa.org/understanding-anxiety/generalized-anxiety-dis -gad

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety dis s. Dialogues in clinical neuroscience. 19(2): 93–107. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573566/

Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety dis s. P & T: A Peer-Reviewed Journal For Formulary Management, 38(1), 30-57.

Hoge, E., Hoge, E. A., Ivkovic, A., & Fricchione, G. L. (2012). Generalized anxiety dis : diagnosis and treatment. British Medical Journal, 345

Huh, J., Goebert, D., Takeshita, J., Lu, B. Y., & Kang, M. (2011). Treatment of generalized anxiety dis : a comprehensive review of the literature for psychopharmacologic alternatives to newer antidepressants and benzodiazepines. The Primary Care Companion For CNS Dis s, 13(2), doi:10.4088/PCC.08r00709blu

Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety dis and panic dis in adults. American Family Physician, 91(9), 617-624

Kavan, M. G., Elsasser, G., & Barone, E. J. (2009). Generalized anxiety dis : practical assessment and management. American Family Physician, 79(9), 785-791.

Mavranezouli, I., Meader, N., Cape, J., & Kendall, T. (2013). The cost effectiveness of pharmacological treatments for generalized anxiety dis . Pharmacoeconomics, 31(4), 317-333. doi:10.1007/s40273-013-0031-z