Practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.
Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive piece for the psychological disorder. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.
Middle-Aged White Male with Generalized Anxiety Disorder
BACKGROUND INFORMATION The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.
In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26. Decision Making Case Study Essay Paper
Client has never been on any type of psychotropic medication.
MENTAL STATUS EXAM The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.
You administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.
Decision 1: Select what the PMHNP should do:
• Begin Zoloft 50 mg po daily (MAKE THIS SELECTION)
• Begin Imipramine 25 mg po BID
• Begin Buspirone 10 mg po BID
My decision I chose to begin Zoloft 50 mg po daily. Outcome: RESULTS OF DECISION POINT ONE: Client returns to clinic in four weeks and informs you that he has no tightness in chest, or shortness of breath. Client states that he noticed decreased worries about work over the past 4 or 5 days. HAM-A score has decreased to 18 (partial response) Choices for Decision 2: Select what the PMHNP should do: Increase dose to 75 mg orally daily (MAKE THIS SELECTION)
Outcome: RESULTS OF DECISION POINT TWO: Client returns to clinic in four weeks and reports an even further reduction in his symptoms. HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms) Choices for Decision 3: Decision Point Three Select what the PMHNP should do next: Maintain current dose Increase current dose of medication to 100 mg orally daily Add augmentation agent such as BuSpar (buspirone) My decision: I choose to educate client regarding diet/weight loss and continue client on the same drug/dose Outcome: Guidance to Student At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug. ***Write on each decision. Make sure that this paper has at least 5 References. Please use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment.
Decision-Making Case Study
Introduction
This case study involves a 46-year-old male, who presented for assessment after experiencing fears of an impending heart attack. The client reported symptoms such as chest tightness, a feeling of impending doom, and shortness of breath. the client further reported anxiety, and especially regarding his fears about losing his job. He admitted to using ETOH to reduce anxiety. The EKG and ER findings were within the normal range and thus a heart attack was ruled out. His HAM-A score was 26, confirming the diagnosis of generalized anxiety disorder (GAD). This paper will discuss decisions about the treatment choices for this client and conclude by discussing the ethical considerations that might affect the client’s treatment plan. Decision Making Case Study Essay Paper
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Decision Point One
The first decision is for the client to start Zoloft 50 mg. This decision was chosen because the medication is an SSRI that prevents the reuptake of serotonin and thus increases the amount of serotonin within the brain (Rosenthal & Burchum, 2018). Serotonin is a neurotransmitter that regulates moods and thus it’s efficacy in treating symptoms of GAD. Additionally, Zoloft has a good safety profile and hence has minimal side effects and it is well tolerated (Stahl, 2014).
selection of this decision hoped that the client would manifest symptom improvement. This is due to the efficacy of Zoloft in improving anxiety and other symptoms associated with GAD. Moreover, it is hoped that the client would tolerate the medication and report no or minimal side effects. Evidence shows that Zoloft is well tolerated in people with GAD (Stahl, 2014).
As anticipated, the client reported symptom improvement as he did not experience symptoms like breath shortness and tightness of the chest. The client further reported that he had stopped worrying about his job. Moreover, the HAM-A scale indicated that he was partially responding to the treatment. Symptom improvement is attributable to the efficacy of Zoloft medication in treating symptoms of GAD (Stahl, 2014). The client did not report any side effect and this indicates the good safety profile and tolerability of Zoloft.
Decision Point Two
The second decision is to increase Zoloft dose to 75 mg. The rationale for this decision is to facilitate a higher treatment response for the client. According to Carvalho et al (2016), a higher Zoloft dose is likely to increase the level of serotonin in the brain and this ensures a greater symptom improvement.
The selection of the decision to increase Zoloft dose to 75 mg hoped that the client would manifest complete symptom remission due to the increased response. This is because higher doses of Zoloft lead to increased serotonin levels in the brain and thus increased symptom improvement (Steven et al., 2018). Secondly, it is hoped the client will tolerate the increased dose and therefore he will not report any major side effects.
As expected, the client reported significant symptom improvement with the increased dose. The HAM-A score further reduced. This increased symptom improvement is attributable to the increase Zoloft dose availing more serotonin in the brain and thus increasing response to treatment (Crocco et al, 2017). Moreover, the client was able to tolerate the increased dose as he did not report any side effects.
Decision Point Three
The third decision is maintaining the current dose of Zoloft (75 mg). The reason for choosing this decision is because the client is responding very well to treatment and at the same time tolerating the dose. Increased doses are associated with increased probability of side effects and therefore it is safe and logical to maintain the Zoloft dose at 75 mg (Steven et al., 2018).
Maintaining the current dose expected that the client will continue responding to treatment and eventually achieve complete symptom remission. It is also expected that he will not experience major side effects since Zoloft is well tolerated in people with GAD (Carvalho et al, 2016). Decision Making Case Study Essay Paper
Ethical Considerations
The PMHNP should seek informed consent from the client before starting any treatment. This includes giving the client all information regarding the medications, including the dependency associated with SSRIs. This will enable the client to make an informed choice concerning his treatment. The PMHNP needs to educate the client regarding the dependency associated with Zoloft and implement the appropriate strategies to prevent misuse or abuse of the medication by the client (Cartwright et al, 2016). It is also important to ensure that confidentiality of all the information the client discloses during treatment.
Conclusion
The first treatment choice was Zoloft 50 mg because of the efficacy of Zoloft in reducing symptoms of GAD. The client manifested partial response to treatment and thus the second decision was to increase the Zoloft dose to 75 mg. With the increased dose, the client showed a further response and did not report any side effects and thus the third decision was maintaining the current dose. Before starting treatment, the PMHNP should obtain informed consent from the client and ensure that the client’s confidentiality is maintained throughout the treatment period.
References
Cartwright C, Gibson K, read J, Cowan O & Dehar T. (2016). Long-term antidepressant use: patient perspectives of benefits and adverse effects. Patient Prefer Adherence, 1(10), 1401–1407.
Carvalho A, Sharma M, Brunoni A, Vieta E & Fava G. (2016). The Safety, Tolerability, and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychiatry, 85(5).
Crocco E, Aramillo S, Ortiz C & Camfield K. (2017). Pharmacological Management of Anxiety Disorders in the Elderly. Curr Treat Options Psychiatry, 4(1): 33–46.
Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0.
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Steven S, Devvrat M, Dang J, Vanle B & IsHak W. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacol, 8(1), 49–58.