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Medication Treatment Decision Tree for a 46 Year-Old White Male with Generalized Anxiety Disorder (GAD)
Anxiety disorders have been known to present with somatic symptoms that may mimic those of a heart attack or acute coronary syndrome (ACS). The patient may feel breathless and experience chest tightness just like in unstable angina or a myocardial infarction (MI). However, these would be symptoms of an anxiety disorder (Sadock et al., 2015; APA, 2013). The 46 year-old Caucasian male in this case study presented to the emergency department with the same symptoms and it was initially thought that they were having a heart attack (Laureate Media, n.d.). However, when extensive tests and physical examination were performed, it became clear that he did not have any organic malfunction or abnormalities. For instance, an ECG showed normal cardiac patterns and rhythm and cardiac enzymes were not elevated (Hammer & McPhee, 2018). This meant that the symptoms he was having could only be related to a psychiatric diagnosis for which he was referred for psychiatric evaluation. The patient works in a steel factory and is overweight with hypertension. Both of these conditions are managed in his case by dietary modifications and exercise alone. He is not on any medication treatment for them. During the psychiatric assessment interview, he admits for the first time that his symptoms could be related to anxiety. He states that he is having job security issues at work as he has been informed that he may be declared redundant any time. He admits that this has affected him so much so that he has started to drink alcohol every day after work. The patient is not in a relationship and has no children. He is administered with the Hamilton’s Anxiety Rating Scale (HAM-A) and scores 26. White Male with Generalized Anxiety Disorder Essay Example The interpretation of this is that he was having moderate to severe anxiety (Psychiatry and Behavioral Health Learning Network, 2021; Codajic (n.d.). As is usually the case, he was also taken through a mental status examination (MSE). This showed that his insight and judgment were still intact as he recognized that he was sick and needed help. He however denied having any delusions or hallucinations, as well as suicidal or homicidal thoughts. Considering his presentation and the various assessments done, the conclusion was made that this patient was suffering from the condition known as Generalized Anxiety Disorder or GAD. His symptoms and presentation met the diagnostic criteria of GAD in the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5 (Sadock et al., 2015; APA, 2013). This paper therefore aims to decide the psychopharmacologic treatment or medication that would be used to control the symptoms of this patient.
The First Decision Point (Number 1)
At the first decision point, he psychiatric-mental health nurse practitioner (PMHNP) has to choose one of three medications to treat the GAD that the patient has been diagnosed with. The three options are sertraline (Zoloft) 50 mg orally every day; OR imipramine (Tofranil) 25 mg orally twice a day; OR buspirone (BuSpar) 10 mg orally twice a day (Stahl, 2017; Laureate Media, n.d.). After a consideration of efficacy and safety profiles, the decision was made to select the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft at the initial dose of 50 mg by mouth daily. Sertraline is an atypical antidepressant that increases the levels of the neurotransmitter serotonin in the brain. It has also been shown to be an efficient anxiolytic with a better safety profile and less side effects than the typical antidepressants (Stahl, 2017; Allgulander et al., 2004). Scholarly peer-reviewed research evidence has shown that despite not being FDA-approved for the treatment of anxiety, sertraline (Zoloft) was significantly efficacious in treating GAD compared to other options. This evidence is from Allgulander et al. (2004) and it is from a well-designed randomized controlled trial that lasted for 12 weeks. According to the researchers of the study, sertraline emerged the best efficacious and with the least side effects during the study. This is the reason why this choice was made as the 46 year-old man presented with intense somatic symptoms originating from his psychiatric condition. What was hoped with this decision was that the intensity of this patient’s symptoms would be reduced within the first four weeks of treatment. This progress would be shown by a drop in the HAM-A scores.
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The choice of imipramine (Tofranil) was not taken because as much as Tofranil is efficacious in managing the psychological symptoms of GAD, it does not do well in controlling the somatic symptoms (Stahl, 2017). This patient particularly presented with intense somatic symptoms and so imipramine would have been of less benefit. On the other hand, available evidence indicates that buspirone (BuSpar) has the disadvantage of producing the side effect of rebound anxiety if the patient were not to comply with treatment and stop taking it (Stahl, 2017). This is why sertraline (Zoloft) was preferred to it. According to Haswell (2019) the bioethical principle of nonmaleficence applies when a clinician does everything to prevent the causation of intentional harm to the patient. By choosing sertraline and avoiding the other medications with known serious side effects, this principle was respected.
The Second Decision Point (Number 2)
After four weeks on the sertraline (Zoloft), the patient returns as scheduled for an evaluation of his progress on the treatment. He states during this visit that the somatic symptoms of shortness of breath and chest tightness are no longer there. He also admits that he has experienced a decrease in his worries and anxiety over work within the last four to five days. These admissions show that this patient was showing a therapeutic response to this medication and was also tolerating it well (no side effects). The confirmation of this partial response was made by the administration of the HAM-A test. This time, the Hamilton Anxiety Rating Scale (HAM-A) score was 18. A HAM-A score of 18 means that this patient’s anxiety is now mild and not moderate to severe as the baseline was. In this second decision point, therefore; three new choices were to be decided upon again. It would be to increase the sertraline (Zoloft) dose to 75 mg orally daily; OR to increase the sertraline (Zoloft) dose to 100 mg orally daily; OR to leave the dose of sertraline at the 50 mg orally once daily.
The decision made at this decision point was to raise the sertraline (Zoloft) dose to 75 mg orally daily. The reason for this decision was that the 46 year-old was already showing a partial response to the medication. Furthermore, he was also tolerating the drug as required with no obvious side effects. Increasing the dose sparing was therefore a critical clinical decision made to try and increase the therapeutic response even as side effects are avoided. The option of increasing the dose by 100% was rejected because this would place the patient at a higher risk of developing the side effects of sertraline. The other option of not doing anything with the dose would also mean that the patient remains at the partial response stage with some symptoms still lingering. The hope in making this decision was that the client would eventually show a complete therapeutic response and go into prolonged symptom remission (Stahl, 2017; Allgulander et al., 2004). The decision not to drastically increase the dose of sertraline from 50 mg to 100 mg daily was informed by the bioethical principle of nonmaleficence. Rejecting the status quo of not doing anything with the current dose of sertraline was also informed by the need to give the patient the maximum benefit of treatment or beneficence (Haswell, 2019).
The Third Decision Point (Number 3)
When the patient comes back after another four weeks for review and evaluation of treatment, he has even better news of progress. He would now have been on treatment with sertraline for a total of eight weeks or two months. During this visit, he states he has over the past four weeks seen an even further reduction of his symptoms, both somatic and psychological. This is proven when the HAM-A test is applied to him. This time, he scores just 10; meaning that his anxiety is now mild to non-existent (Psychiatry and Behavioral Health Learning Network, 2021; Codajic, n.d.). At this point, the patient had had a 61% reduction in symptoms or more than a partial response. At this third decision point, the clinician was supposed to again choose amongst three options. These were to maintain the current dose of sertraline (Zoloft) 75 mg orally daily; OR to increase the sertraline dose to 100 mg orally daily now; OR to augment sertraline with buspirone (BuSpar). White Male with Generalized Anxiety Disorder Essay Example
At this third and last decision point, it was decided that the 46 year-old male patient remains on the sertraline 75 mg orally daily. The reason for this decision was that the patient had already shown and demonstrated a therapeutic response above 61%. This could be considered as adequate therapeutic response given that he had also tolerated the medication so well up to this point. He had not experienced any side effects so far. The progressively lower HAM-A scores were a testament to the fact that the medication was working and the patient was getting better. The hope with this decision was that the patient undergoes full remission of symptoms and is restored back to full functionality. From the above discussion, there was absolutely no clinical justification for increasing the dose of sertraline. The patient had already responded so well to the 75 mg orally daily. The third option was also rejected because again there was no indication or justification for adding an “augmenting” agent. In any case, the augmenting agent that is buspirone has already been seen to be problematic with the side effect of rebound anxiety (Stahl, 2017). Nonmaleficence remained the ethical consideration in avoiding increasing the dose of sertraline to 100 mg, or adding buspirone to sertraline. These two actions would have placed the patient under a direct risk of debilitating side effects.
A Brief Description
According to the DSM-5, generalized anxiety disorder (GAD) is one of the disorders classed as the ‘Anxiety Disorders’ which is a distinct diagnostic group of mental disorders. Its DSM-5 diagnostic code is 300.02 (F41.1) (APA, 2013). It is characterized by amongst other things excessive anxiety and apprehension, difficulty to control the same, restlessness, easy fatiguability, irritability, and a disturbance in sleep patterns. These symptoms cause significant clinical distress and impairment in the victim such that they cannot function n terms of self-care, work, or interpersonal relationships. The decision steps taken above were to start the patient on the SSRI sertraline (Zoloft). Sertraline impacts the pathophysiology of GAD through its pharmacodynamics or mechanism of action. By inhibiting the reuptake of serotonin by the pre-synaptic neuron, levels of the neurotransmitter are increased. Increased concentrations of serotonin at the synaptic cleft then result in feelings of happiness and wellbeing (Stahl, 2013). These impacts inform how I suggest treatment plans for this patient in that I will, for instance; increase the dose only marginally if need be. This is because the effect at the synapse is the result of a delicate balance such that injudicious dose titration upwards may suddenly cause side effects.
Conclusion
This was a classic case of a psychiatric illness presenting with somatic symptoms. Great competence in physical examination and history taking ensured that there was no misdiagnosis. The pharmacotherapeutic choice of sertraline was made from scholarly evidence, even though the drug is not FDA-approved to treat anxiety. Used together with the Hamilton Anxiety Rating Scale (HAM-A), it was possible to demonstrate that this was the best medication for the patient’s GAD as the HAM-A scores dropped progressively.
References
Allgulander, C., Dahl, A.A., Austin, C., Morris, P.L.P., Sogaard, J.A., Fayyad, R., Kutcher, S.P., & Clary, C.M. (2004). Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. American Journal of Psychiatry, 161(9), 1642-1649. https://doi.org/10.1176/appi.ajp.161.9.1642
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Author.
Codajic (n.d.). Hamilton Anxiety Rating Scale (HAM-A). http://www.codajic.org/sites/www.codajic.org/files/2.%20Hamilton%20Anxiety%20Rating%20Scale%20(HAM-A).pdf
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 7th ed. McGraw-Hill Education.
Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177
Laureate Media (n.d.). generalized anxiety disorder: Middle-aged white male with anxiety. https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/index.html
Psychiatry and Behavioral Health Learning Network (2021). Hamilton Anxiety Rating Scale (HAM-A). https://www.psychcongress.com/saundras-corner/scales-screeners/anxiety-disorders/hamilton-anxiety-rating-scale-ham
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences/ clinical psychiatry, 11th ed. Wolters Kluwer.
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4th ed. Cambridge University Press. White Male with Generalized Anxiety Disorder Essay Example