Anxiety Disorders Pharmacological Interventions

THERAPY FOR PATIENTS WITH ANXIETY DISORDERS

Therapy for Patients with Anxiety Disorders

Introduction

From the onset, it would be prudent to note that most people at some point in their lives experience anxiety. However, anxiety could be deemed abnormal or unusual when it is not only frequent, but also rather excessive or intense. Client X (a hypothetical name), a 46-year-old white male, presents with symptoms consistent with generalized anxiety disorder (GAD). It is important to note that he has been referred by his PCP following an ER visit where he complained of breath shortness, chest tightness, and an ‘impending doom’ feeling. At present, Client X indicates that he still experiences shortness of breath and chest tightness. He further indicates that he experiences the ‘impending doom’ feeling on an intermittent basis. He reports frequent alcohol use to help him cope with the aforementioned symptoms. The results of a Hamilton Anxiety Scale (HAM-A) return a score of 26. In essence, this could be interpreted as ‘moderate to severe anxiety.’ There are a number of patient factors that I would be taking into consideration in the making a decision about which pharmacological intervention would be most appropriate on this front. The said factors are inclusive of; patient’s age, occupation, and socioeconomic status. I would also be seeking to establish whether the patient is on any other medication and whether he has in the past been diagnosed with any psychiatric disorder or chronic illness. There may also be need to establish whether at this point in time, Client X has any other comorbid psychiatric disorder. The relevance of the factors highlighted above cannot be overstated when it comes to the need to minimize the probability of side effects, and further enhancement of patient convenience. In as far as the latter objective is concerned, i.e. patient convenience, it should be noted that past studies have established that this happens to be a crucial consideration in efforts to promote adherence to the treatment regimen.

Decision #1: begin Paxil 10 mg po daily

From the onset, it would be prudent to note that I opted to commence the treatment journey with Paxil 10 mg po daily prescription. I selected this particular decision owing to the fact that Paxil happens to be a selective serotonin reuptake inhibitor (SSRI). Strawn, Geracioti, Rajdev, Clemenza, and Levine (2018) point out that SSRIs happen to be an ideal first-line treatment for GAD. In the words the authors, SSRIs “inhibit the reabsorption of serotonin by neurons, so increasing the availability of serotonin as a neurotransmitter” (1059). They also have less side effects which is ideal in this case given Client X’s occupation.

I selected the SSRI indicated, as opposed to the two other options, because as Strawn, Geracioti, Rajdev, Clemenza, and Levine (2018) observe, SSRIs happen to be rather safe and are known to have fewer side effects. This is in comparison to anxiolytics (i.e. buspirone) and tricyclic antidepressants (i.e. Imipramine). Paxil 10 mg was also selected with Client X’s hypertension in mind. Unlike the SNRIs and tricyclic antidepressants such as Imipramine, Paxil 10 mg is less likely to have an adverse impact on the client’s blood pressure. More specifically, as Calvi et al. (2021) indicate, “tricyclic antidepressants have been associated with increases in blood pressure, as well as orthostatic hypotension, particularly imipramine” (113).

I expect Client X to experience relieved symptoms 2-6 weeks after commencement of treatment. He will be started on a low dose to permit his body to adjust to the drug. Essentially, “if an SSRI is effective, it is recommended to take the medication for another 6 to 12 months, and then gradually reduce the dose” (Clevenger, Malhotra, Dang, Vanle, and IsHak, 2018, p. 51).

One of the ethical considerations of relevance on this front happens to be fidelity. This relates to ensuring that patients have access to competent, safe, as well as quality care. Thus, it is my responsibility in this case to recommend an intervention that will be of benefit to Client X, i.e. in relation to the alleviation of the GAD symptoms he presents with.

Decision #2: no change in drug/dose at this time

I selected this decision because as the client has indicated, his symptoms have gotten better. As Client X notes, he no longer experiences shortness of breath or tightness in chest. Further, he points out that over the last 4-5 days, he has noticed marked decrease in work-related worries. HAM-A returned a score of 18 - interpreted as ‘mild to moderate anxiety.’ The objectives of decision #1 were, thus, met. This is more so the case given that I had expected the client to experience relieved symptoms 2-6 weeks after commencement of treatment with Paxil 10 mg – which is the period of time statistically significant results, as Strawn, Geracioti, Rajdev, Clemenza, and Levine (2018) indicate, should be expected at lower dosing.

Increasing the dose to 20 or 40 mg po daily would at this point be premature given that Client X’s symptoms have improved. The dose of an SSRI may be increased if the response from the patient happens to be unsatisfactory. There is also need to minimize the probability of dropout – especially given that a research conducted by Furukawa et al. (2019) on the optimal dose of SSRIs indicated that “the relationship between the dose and dropouts for any reason indicated optimal acceptability for the SSRIs in the lower licensed range” (603).

I hope to achieve continued decrease in anxiety. More specifically, during the next visit, I expect Client X to indicate even more decreased worries about work. Lower doses of SSRIs have less side effects than higher doses (Furukawa et al., 2019).

One of the ethical considerations of relevance on this front happens to be nonmaleficence. This has got to do with taking the precautions necessary to secure the wellbeing of the client and ensure that they are not harmed by any of the interventions instituted (McHenry, 2006). On this front, there would be need to take precautions to ensure that the dosage instituted does not adversely impact Client X‘s wellbeing and safety.

Decision #3: increase drug to 75 mg po daily

I selected this decision because the client reports no further improvement in symptoms. As a consequence, there is need to make the relevant therapeutic adaptations going forward. Increasing the drug to 75 mg po daily would be an ideal course of action. This is the maximum recommended dose (Furukawa et al., 2019). Given that the client was started at a relatively low dose and registered some improvement, an increase in dosage would likely prove beneficial.

Adding an augmentation agent would not be ideal at this point because Client X has been at a lower dose of the SSRI, i.e. Paxil 10 mg po daily. There would be need to first consider what therapeutic effect a higher dose of the SSRI would have. Switching to an SNRI would also be inappropriate at this point because as Clevenger, Malhotra, Dang, Vanle, and IsHak (2018) indicate, if an SSRI proves effective, there is need to continue a course of the same for a minimum of 6 months. The SSRI selected proved effective at a lower dose at 4 weeks follow up.

By making this decision, I expect the client’s anxiety symptoms to decrease significantly over the next few weeks. Furukawa et al. (2019) point out that where lower doses are ineffective “meta-analytic reviews suggest that higher doses of SSRIs may be more effective” (604).

One of the ethical considerations of relevance on this front happens to be autonomy. The treatment plan could be affected by patient’s refusal to take the drug. Indeed, the client has in this case questioned the efficacy of the intervention because, as he indicates, the medication might not be effective for him as he has not experienced any further decrease in anxiety. Autonomy relates to the need to embrace the patient as a unique individual – and thus respect the decision that the said patient makes in relation to available treatment options (McHenry, 2006). There may, however, be need to address the client’s concerns by way of explaining the mechanisms of actions of the drug and the need to incorporate an augmentation agent.

Conclusion

Upon factoring in the specific circumstances of this particular client, a decision was made that the best medication to start treatment with would be Paxil 10 mg po daily (an SSRI). A lower dosage was selected because of the need to ensure that the side effects of the SSRI were minimized. Available evidence indicates that SSRIs are rather safe and are known to have fewer side effects (Strawn, Geracioti, Rajdev, Clemenza, and Levine, 2018). The need to blunt the said side effects cannot be overstated owing to the fat that the client works in a sector that requires maximum concentration and focus. Some of the common SSRI side effects are inclusive of, but they are not limited to; blurred vision, dizziness, feeling agitated, etc. These side effects could be amplified at higher doses.