Assessing and treating an adult patient with generalized anxiety disorder

Assessing and Treating Adult Patients with Anxiety Disorders Anxiety disorders are the most common psychiatric disorders, occurring in 33.7 percent of adults at some point in life (Bandelow & Michaelis, 2015). Panic disorder with or without agoraphobia (PDA) is the most common type of anxiety disorder with a prevalence of 10.3 percent, followed by social phobia with 2.7 percent, and generalized anxiety disorder (GAD) with a prevalence of 2.2 percent (Bandelow, Michaelis & Wedekind, 2017). Patients with anxiety disorders present with sudden anxiety attacks characterized by one or more physical manifestations of anxiety including paresthesia, feelings of unreality, abdominal discomfort, chest pains, feelings of choking, dyspnea, dry mouth, tremors, sweating, and palpitations (Bendelow et al., 2019). Anxiety disorders with agoraphobia are characterized by an intense fear of places that could give rise to panic (Bendelow et al., 2019).
Anxiety disorders are treated using a combination of cognitive-behavioral and psychopharmacological interventions aimed at ameliorating anxiety symptoms. Bendelow et al. (2017) recommend that physicians consider patients’ preferences, costs, interactions, adverse effects, and efficacy in developing treatment plans for patients with anxiety disorders. This text seeks to develop an individualized treatment plan for an adult patient with general anxiety disorder. The patient’s presentation is reviewed, and upon this, three treatment decision points are selected and analyzed. The legal and ethical issues surrounding the specialized care of patients with anxiety disorders are also discussed. The Case Summary The presenting client is a 46-year-old white male referred by his primary care physician. He self-reports a feeling of impending doom, shortness of breath, and tightness in the chest. His medical history is unremarkable. Medical records indicate that the client is overweight, with mild hypertension, and normal myocardial operations. The patient reports a need to escape or run from his current life, signifying anxiety with agoraphobia. He experiences stress from work and having to take care of his aging parents, and confesses to using alcohol occasionally to combat these worries. The mental status report shows the client to be alert and oriented. He reports being in a ‘bleh’ mood, and displays a broad affect throughout the interview. He denies experiencing hallucinations or suicidal feelings, and his insight and judgment are both intact, with no evidence of paranoid thought processes. The administered Hamilton Anxiety Rating Scale (HAM-A) yielded a score of 26, signifying moderate to severe generalized anxiety disorder. The client has yet to be subjected to any psychotropic medication for the condition.
Decision Point One
At the first decision point, the psychiatric Mental Health Nurse Practitioner (PMHNP) is faced with three options to begin treatment for the presenting client: begin Zoloft 50mg orally once daily, begin Imipramine 25mg taken orally twice daily, and begin Buspirone 10mg taken orally twice a day. As the client’s PMHNP at this decision point, I would prescribe Zoloft 50mg to be taken orally once daily. Rationale for the Decision The PMHNP is required to choose the treatment option that ameliorates anxiety symptoms for the client with maximum efficacy and the lowest possible risk of adverse effects. The Food and Drug Administration (FDA) approves six main classes of medication for the treatment of anxiety disorders: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine uptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) such as Imipramine and Clomipramine; calcium modulators, Azapirones such as Buspirone, and Reversible Monoamineoxidase Inhibitors (RAMI) (Bandelow et al., 2017).
SSRIs and SNRIs are approved as first-line medications for treating anxiety disorders (Stahl & Grady, 2010). SSRIs work by inhibiting the serotonin transporters, in the process desensitizing postsynaptic serotonin receptors and restoring to normalcy the activity of serotonergic pathways (Bystritsky et al., 2013). SNRIs inhibit the norepinephrine and serotonin transporters and are basically used after inadequate response or failure of SSRIs (Bystritsky et al., 2013). Of the three treatment options available at this decision point, Buspirone has the lowest efficacy levels. Clinical trials have shown Buspirone to be superior to placebo in the remission of anxiety symptoms for patients with GAD (Canadian Agency for Drugs and Technologies in Health (CADTH), 2012). Comparisons with SSRIs have, however, shown the drug to be less efficacious in relieving GAD symptoms (CADTH, 2012). For this reason, Buspirone is recommended only as a second-line therapy or as augmentation to SSRI therapy (Bystritsky et al., 2013).
Conversely, clinical trials have shown SSRIs, SNRIs, and TCAs to be comparable in efficacy in the remission of symptoms for patients with anxiety disorders (Bystritsky et al., 2013). In view of this, the PMHNP needs to consider the potential adverse effects of both treatment options in identifying the best option for the presenting client. SSRIs have been shown to be more tolerable than TCAs, with more manageable side effects and less lethality in an overdose (Yekehtaz et al., 2013). TCAs have, for instance, been shown to increase the risk of cardiovascular complications even in patients with no prior history of cardiac disease (Glassman, 1984). They work by inhibiting fast sodium channels, slowing conduction velocity, and causing prolonged QT, QRS, and PR intervals on the ECG (Yekehtaz et al., 2013). In high doses, TCA consumption can cause ventricular fibrillation, and reentry arrhythmia, which could lead to fatalities. At therapeutic levels, TCAs are able to reduce systemic vascular resistance by blocking alpha-adrenergic receptors (Yekehtaz et al., 2013). Consequently, they are associated with a significantly high risk of hypotension particularly when used concurrently with antihypertensive medications (Yekehtaz et al., 2013). As such, TCAs are not recommended for use in patients with existing comorbidities, and more so for the presenting client, who shows signs of mild hypertension. Studies recommend usage of TCAs only with failed usage of SSRIs and SNRIs (Yekehtaz et al., 2013).
These reasons make Zoloft (Sertraline) the most appropriate treatment option for the client at the first decision point prior to the start of any alternative antidepressant drug class. Although SSRIs have their share of adverse effects including weight gain, sexual dysfunction, and sleep disturbance, troubling adverse effects often come with prolonged use (Fergusson, 2001). The PMHNP, therefore, has an option of changing to a suitable SNRI later in the treatment plan should there be a need for long-term therapy (Fergusson, 2001). Moreover, clinical trials have shown Zoloft to be more tolerable than other SSRIs such as fluoxetine, escitalopram, and paroxetine (Baldwin et al., 2011). Expected Treatment Outcomes The PHMNP expects a reduction in anxiety symptoms, reduced worry over work and family, as well as an improvement in the client’s presentation by the time of their next appointment. The overall goal of treatment is to bring about a remission of symptoms, restore the patient to their baseline psychosocial level, and minimize the risk of relapse (Stahl & Grady, 2010). The primary efficacy measure for treatment is a reduction of at least 50 percent in symptoms by the time of the next visit. In the case of the presenting client, this is evidenced by a fall in the HAM-A score from 26 to 13.

Actual Treatment Outcomes The patient returns to the clinic in four weeks and reports that he no longer has shortness of breath and tightness in chest. He reports that he has experienced decreased worries over the past four or five days. There is evidence of partial recovery, with the HAM-A score yielding a score of 18. In line with the expected outcome, there has been a remission of anxiety symptoms, as shown by the 25 percent decrease in the HAM-A score. The next decision needs to focus on reducing the symptoms further to more than 50 percent from baseline levels.
Decision Point 2
The PMHNP at decision point 2 faces three treatment options based on the client’s presentation: increase Zoloft dose to 75 mg daily, increase dose to 100mg daily, or retain the drug and dosage at current levels. The recommended action at this stage is to increase Zoloft to 75 mg daily. Rationale for the Decision The client presents with a significant reduction in anxiety symptoms and does not report experiencing adverse effects as a result of the treatment. Given that the current dosage of Zoloft has managed to reduce symptoms by close to 25 percent, there may be no need to double the dosage. Studies recommend the doubling of SSRI dosages only in cases of non-response or significantly slow response (Strawn et al., 2019; Bystritsky et al., 2013). Though it could bring about faster remission, doubling the dosage to 100mg in this case could also increase the risk of adverse effects, and consequently, discontinued usage by the client.
At the same time, it may not be plausible to retain the current dosage of 50mg daily for an additional four weeks. Thus far, the patient has reported feeling less worried, but has not self-reported any change in agoraphobic symptoms. Studies have shown that agoraphobia is often the last portion of anxiety disorders to respond to treatment, and that most patients continue to improve for 3 to 6 months (Cassano, Rossi & Pini, 2002). Retaining the current dose at 50mg would slow down the remission of the client’s agoraphobic symptoms and may drive a perception that the treatment is no longer effective, leading to discontinuation (Cassano et al., 2002). As such, the best treatment option would be to increase the current dosage to 75mg to speed up the remission of agoraphobic symptoms with minimal adverse effects. Expected Treatment Outcomes The PMHNP at the second decision point seeks to assess whether an increase in the dosage of Zoloft from 50mg to 75 mg daily would help reduce anxiety symptoms further, and move the patient closer to their baseline psychosocial level. It is expected that symptoms will have reduced by at least 50 percent by the time of the next appointment and that the client will go through the treatment without experiencing significant adverse effects that could lead to discontinuation. If the patient reported significant adverse effects with the increased dosage following this intervention, then the PMHNP could consider returning to the previous dosage of 50mg.

Actual Treatment Outcomes The patient returns to the clinic in four weeks and reports an even further reduction in anxiety symptoms. The HAM-A score has fallen to 10, representing a decrease of 61 percent. The actual reported outcome meets the primary efficacy measure for treatment of GAD, which is a reduction of at least 50 percent in the severity of symptoms measured by the HAM-A score. The patient does not also report any adverse effects as a result of the treatment in line with the expected outcome. The PMHNP’s goal moving forward then is to achieve a complete remission of symptoms and prevent a relapse.
Decision Point 3
At the third decision point, the PMHNP is required to choose the best option for the progression of treatment among three options: maintaining the current dose of Zoloft at 75 mg daily, increasing the current dose of medication to 100mg daily, and adding an augmentation agent such as Buspirone. As the PMHNP at this decision point, I would choose to maintain the current dose of Zoloft at 75mg daily. Rationale for the Decision The client is clearly showing a positive response to treatment as shown by the more than 50 percent reduction in the severity of symptoms. As such, there may be no need to further increase the dosage of Zoloft to 100mg. Further, increasing the dosage at this time when the severity of symptoms has fallen increases the risk of adverse effects, discontinuation, and relapse. The patient has not reported any adverse effects after the increased dosage, implying that the current dosage can still be maintained.
It may equally not be plausible to introduce augmentation at this point since the client is responding positively to the drug. Studies have shown that the full benefit of SSRI use for anxiety disorders is realized between 8 and 12 weeks (Bystritsky et al., 2013). For this reason, it would be proper to maintain the current dosage for an additional four weeks to evaluate the full effect of the drug on the presenting client. Expected Treatment Outcomes It is expected that anxiety symptoms will have reduced even further by the time of the next appointment as the client moves towards full remission. At this stage, the PHMNP is keen to ensure that the remission of symptoms continues, adverse effects are avoided, and relapse is prevented (Stahl & Grady, 2010). The overall goal of the treatment is complete remission of symptoms, a return to the pre-condition psycho-social level, and prevention of future relapses.