Assignment week 6 Psychopharmacology 6630N Walden University

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Assignment week 6 Psychopharmacology 6630N Walden University

Assessing and Treating Patients With Anxiety Disorders

Anxiety disorder is one of the most common mental problems among adults characterized by an extreme feeling of fear and anxiousness compromising the patient’s quality of life. According to the CDC, approximately 15% of adults above the age of 18 years, experienced anxiety symptoms in 2018 as either mild, moderate, or severe (Rickels & Moeller, 2019). Due to the increasing burden of the mental disorder, several treatment options have been provided to help promote the mental health and well-being of those diagnosed with the disease, comprising of both pharmacological and psychological interventions.

The provided case study demonstrates a 46-year-old white male who presented to the emergency department claiming to be having a heart attack. he reported symptoms such as shortness of breath, chest tightness, and the feeling of impending doom. He also presents with a history of mild hypertension to date and tonsillectomy at the age of 8 years. The patient admits to taking alcohol. His score on the HAM-A scale is 26. Mental status examination results also reveal a diagnosis of generalized anxiety disorder.

The treatment plan of this patient will mainly comprise the use of medication among other psychotherapeutic interventions if need be. Several pharmacokinetic and pharmacodynamic factors will however affect the choice of medication for this patient. Such factors include the patient’s advanced age, white race, overweight, use of alcohol, past medical history of mild hypertension, and the HAM-A score of 26 which revealed GAD. The purpose of this paper is to illustrate appropriate decision-making in coming up with the patient treatment plan, and making necessary adjustments based on the patient’s factors listed above in addition to care outcome.

Decision #1

Selected Decision and Rationale

            Based on the available treatment options, the best intervention is to initiate 10mg Paxil (Paroxetine) orally once daily. Paxil belongs to the class of selective serotonin reuptake inhibitors (SSRIs) approved by the FDA for the management of anxiety disorder among adults due to its great effectiveness and desirable safety profile as displayed by evidence-based practice (He et al., 2019).

Previous studies have reported that paroxetine, even at lower doses, displays great effectiveness in the management of anxiety disorders with a good tolerability profile, including no associated risks of dependence with relative safety even when overdosed (Rickels & Moeller, 2019). The drug is also suitable among Caucasians in low doses as a result of the variant allele CYP2D6*4 which is the main polymorphism resulting in reduced metabolism of the drug in the liver hence, increased systemic circulation (Chen et al., 2019).

The use of imipramine is not necessary especially given the patient’s age as studies report less effectiveness and safety in the management of anxiety disorder as compared to available alternatives (Strawn et al., 2018). The drug is also associated with weight gain, which will make it difficult for the patient to manage his weight gain.

Buspirone on the other hand also has an unfavorable safety profile among middle-aged and older adults, hence should only be considered when there is no other safer option (Kulenović et al., 2018). The patient is also an alcoholic, as such, the use of this medication will only lead to dependence.

Expected Outcome

            With the use of paroxetine, the patient is expected to display at least 50% remission of symptoms within the next four weeks, with self-limiting side effects like headache and dizziness. The patient’s HAM-A score should decrease to less than 10.

Ethical Consideration

            The PMHNP has the legal obligation of protecting the health of the patient and prevent harm (Chen et al., 2019). As such, ethical principles such as beneficence and non-maleficence must be observed in addition to upholding the patient’s autonomy when selecting the most appropriate treatment therapy.

Decision #2

Selected Decision and Rationale

Based on the patient outcome, the most appropriate intervention to take at the moment is to increase the dose of paroxetine to 20 mg orally once a day. Clinical guidelines recommend an upward titration of paroxetine dose at intervals of 10mg per day based on patient outcome, but to exceed 50mg per day (Kulenović et al., 2018).

From the initial intervention, the patient was able to experience a decrease in anxiety symptoms over the past 4 to 5 days. Her HAM-A score also decreased to 18. This shows great effectiveness and tolerance to the medication. No side effects were also reported showing a great safety profile. However, previous studies have reported that most patients take up to 8 to 12 weeks to attain the optimal dose to display maximum effectiveness in the management of GAD symptoms (Strawn et al., 2018). As such, it was necessary to maintain this drug and increase its dosage for optimum effectiveness.

Increasing the dose to 40 mg is not appropriate as this goes against the recommended approaches as outlined in clinical guidelines (Rickels & Moeller, 2019). Consequent an upward titration with a high dose compromises the patient tolerance to the medication.

Continuous use of the same drug at the same dose is also not appropriate as the patient was not satisfied with the outcome (He et al., 2019). As such, this will affect the patient compliance with the medication as no further effect in the management of the anxiety symptoms will be expected.

Expected Outcome

             With dose increment, the patient is expected to display even further management of his anxiety symptoms, given that shortness of breath and chest pressure had already been resolved. As such, the HAM-A score should reduce to less than 10 as initially expected (Chen et al., 2019).

Ethical Consideration

             At this point, the PMHNP has to explain to the patient adequately about the outcome, and what should be done next to involve him in decision making concerning his health (Strawn et al., 2018). Even though the nurse’s decision might be in the interest of the patient health, it is very important to ensure that they agree with the patient regarding the treatment to uphold their autonomy essential in promoting positive outcomes.

Decision #3

Selected Decision and Rationale

            The last decision was to maintain the dose of paroxetine and observe the patient for further management of anxiety symptoms (Rickels & Moeller, 2019). The patient displayed a 61% reduction in anxiety symptoms which shows great adherence and tolerance to the medication.

Despite the use of paroxetine being expected to completely manage anxiety symptoms, studies show that patients who display more than 50% remission of symptoms with the use of the drug have attained the optimum dose of the drug (He et al., 2019). As such, they should continue taking the drug at the same dose and frequency to continue experiencing beneficial effects, while minimizing the risks of side effects associated with prolonged use of the drug.

Increasing the dose to 30mg was not necessary at this point given that the patient had already displayed more than 50% remission of symptoms (Kulenović et al., 2018). An increased dose above the optimum dose is associated with increased risks of toxicity and adverse effects.

Introducing another drug would have been considered only if the patient had displayed limited effect even upon reaching the maximum dose which is not the case (Chen et al., 2019). Consequently, buspirone as mentioned earlier is associated with a high risk of tolerance hence not recommended for this patient.

Expected Outcome

            With continuous use of paroxetine at the same dose, the patient is expected to experience even further managed anxiety symptoms, as shown by the great effectiveness of the reported outcome (Strawn et al., 2018). His HAM-A score should be less than 7, with reveals minimal or no anxiety.

Ethical Consideration

            Based on the reported outcome, the patient seemed satisfied with how the drug was managing her anxiety symptoms (Kulenović et al., 2018). As such, the nurse needs to respect the patient’s autonomy and educate them on the need to stick to the treatment regimen to promote care outcomes.

Conclusion

Anxiety disorder is one of the most common mental problems affecting middle-aged and older adults. This mental problem is associated with several symptoms which compromise the health and well-being of the patient (Strawn et al., 2018). However, several treatment options have been proposed based on previous evidence of great effectiveness in the management of this mental condition. Several factors must be considered when selecting a specific medication for a given patient. For the patient in the provided case study, the initial intervention was to administer paroxetine 10mg orally once daily. The other two options were inappropriate as a result of an undesirable safety profile and increased risks of dependence (Chen et al., 2019). From this intervention, the patient was able to attain minimal management of anxiety symptoms with no shortness of breath or chest tightness. This led to the second decision, where the dose was increased to 20 mg once daily as recommended by most clinical practice guidelines (Kulenović et al., 2018).

The patient was able to attain more than 61% remission of symptoms within four weeks of taking 20 mg paroxetine orally once daily. Studies show that an optimal dose of the drug is normally achieved when the patient displays more than 50% management of anxiety symptoms (He et al., 2019). Consequently, no side effects were reported, showing a great safety profile of the drug. As such, it was necessary to advise the patient to continue taking the drug at the same dose to experience even further management of anxiety symptoms. For every decision made, the PMHNP ensured that the patient was well informed about the available options including both their beneficial and adverse effects (Rickels & Moeller, 2019). The autonomy of the patient was also upheld as he was involved in deciding on which medication to consider.

References

Chen, T. R., Huang, H. C., Hsu, J. H., Ouyang, W. C., & Lin, K. C. (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: a network meta-analysis. Journal of psychiatric research, 118, 73-83. https://doi.org/10.1016/j.jpsychires.2019.08.014

He, H., Xiang, Y., Gao, F., Bai, L., Gao, F., Fan, Y., … & Ma, X. (2019). Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults: a network meta-analysis. Journal of psychiatric research, 118, 21-30. https://doi.org/10.1016/j.jpsychires.2019.08.009

Kulenović, A. D., Serdarević, A. M., Halilović, Z., Mašnić, H., Bahto, A., Kapo, B., … & Hadžimuratović, A. (2018). Observational multicenter study of the efficacy of paroxetine film-coated tablet in the treatment of anxiety disorder. Med Glas (Zenica), 15(2), 186-191. https://orcid.org/0000-0001-7607-5429

Rickels, K., & Moeller, H. J. (2019). Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. The World Journal of Biological Psychiatry, 20(7), 514-518. https://doi.org/10.1080/15622975.2018.1500031

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. https://doi.org/10.1080/14656566.2018.1491966