Generalized Anxiety Disorder Paper

Decision Selected

Starting Zoloft 50mg PO daily

Reason for Selecting This Decision

Zoloft is a selective serotonin reuptake inhibitor whose mode of action is linked to its ability to inhibit the uptake of serotonin. Zoloft blocks the uptake of serotonin into the platelets with weak effects on the reuptake of dopamine and norepinephrine via the neurons. It also has very minimal or no significant affinity for cholinergic, dopaminergic, histaminergic and adrenergic receptors (Kavan, Elsasser & Barone, 2009). Therefore, Zoloft functions by increasing the levels of serotonin in the brain which helps in reducing anxiety attacks, unwanted thoughts and to restore a person’s interest in activities of daily life. Although it has not been approved by the FDA for the management of generalized anxiety disorder, it can be used off label since it has not been prohibited for this use. Besides, the side effects of Zoloft are less severe as compared to those of other medications indicated for the same purpose based on the client’s presentation.

Imipramine 25 mg PO BID could also be an alternative but it has high levels of dizziness as a major side effect and going by how the client presented, it could only worsen his health status. Besides, without close monitoring, imipramine can potentially lead to orthostatic hypotension, a potentially transient side effect that can significantly worsen the patient’s clinical status, having in mind that he is hypertensive (Craske & Bystritsky, 2016).

Buspirone 10mg PO BID, an azapirone could also be an alternative choice since it is an anti-psychotic and anxiolytic that affects brain neurotransmitters such as dopamine and serotonin. Therefore, it increases the action at the receptors of serotonin which helps in anxiety alleviation.  However, due to high chances of ineffectiveness, the FDA recommends that it should be taken as an add-on to other medication, preferably a selective serotonin reuptake inhibitor in managing anxiety, as compared to using it as a first-line treatment (Craske & Bystritsky, 2016).Generalized Anxiety Disorder Paper

Expected Outcome

By starting the client on Zoloft 50mg PO daily, it was expected that the client’s symptoms of frequent anxiety attacks would significantly reduce and that he would no longer have feelings of impending doom or the urge to escape or run at any given time.  Apart from getting relief from shortness of breath and chest tightness, it was expected that the client’s affect and mood would have some improvement and that his occupational life would have no difficulties.

Difference between Expected Outcome and Final Outcome

            After four weeks, the client returned to the clinic with reports that he had no shortness of breath or chest tightness. The client also stated that he had realized that his worries about work had significantly reduced. Upon administering the Hamilton Anxiety Rating Scale (HAM-A), it yielded a score of 26.  Based on the client’s presentation during this visit, it was evident that there was no significant difference between the expected outcome and the actual outcome and this can be attributed to the effectiveness and efficiency of Zoloft in managing symptoms of anxiety. Zoloft is known to slow down the reabsorption of serotonin, a brain neurotransmitter to regulate anxiety and mood (Craske & Bystritsky, 2016).

Decision #2

Decision Selected

Increase Zoloft to 75mg orally daily

Reason for Selecting this Decision

The decision to increase the dosage was influenced by the fact that the patient showed some positive improvement and a good response from the previous visits after being started on Zoloft 50mg PO daily as evidenced by a 50% reduction of his symptoms. On presentation, he also didn’t report of any side effects. Based on this information, it was therefore likely that, by increasing the dosage, a further decrease in symptoms could be realized which was the major therapeutic goal in this case (Baek & Khan, 2017). However, increasing the dosage will also mean that the client’s risk to experience side effects would increase. This would, therefore, require close monitoring and follow-up with his primary care physician.Generalized Anxiety Disorder Paper

Increasing Zoloft to 100mg couldn’t be a good alternative since it could increase the evasiveness of the client’s symptoms which could automatically make the client stop taking his medication. Besides, a dosage of 100mg increases the difficulty in erecting which could negatively impact the patient’s ability to take any other drugs. It should be noted that sexual dysfunction which can be expressed through difficulty erecting or maintaining an erection,  delayed ejaculation, lacking orgasms, and reduced libido is common side effects of selective serotonin reuptake inhibitors which Zoloft is a class of (Sarkar, Harihar & Patra, 2016). Similarly, continuing the client on the same dosage couldn’t be a good reason since there could be no additional decrease in the client’s symptoms of anxiety which could make the medication ineffective for him.            Expected Outcome

By increasing the dosage to 75 mg orally daily, it was expected that the client would realize a further reduction of his symptoms and that is occupation life could improve and that he could experience lesser incidences of anxiety attacks. Increasing the dosage of Zoloft increases the ceiling effect for the best therapeutic outcomes with a modest margin (Craske & Bystritsky, 2016).

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Difference between Expected Outcome and Actual Outcome

After four weeks, the client returned to the clinic with reports that his symptoms had even reduced further. Upon administering the Hamilton Anxiety Rating Scale (HAM-A), it was notable that the score had now decreased to 10 from the previous 26. Therefore, there was no significant difference between the expected outcome and the actual outcome. A Zoloft dosage of 75mg is within the recommended dosages for patients who respond well to lower doses and show the potential to do better when prescribed higher dosages (Craske & Bystritsky, 2016).

Decision #3

Decision Selected

Continue with the same dose and reassess the client in 4 weeks

Reason for Selecting This Decision

Based on the client’s previous visit, it was clear that she was responding well to the previously prescribed medication. Therefore, allowing her to take the drugs for some more time and evaluate its full effect afterward was the only best course of action. Increasing Zoloft to Generalized Anxiety Disorder Paper

Similarly, augmenting his treatment with an agent such as Buspar could not be a potential solution since in this case, the patient was evidently showing some good response to the medication. Besides, adding Buspar as an augmenting agent could be an indicator of polypharmacy yet his symptoms could effectively be managed by one drug: Zoloft (Clifford et al., 2015).

Expected Outcome

By maintaining a dosage of 75mg, it was expected that the client would continue to show a good response in terms of mood and effect improvement, reduced anxiety attacks, ability to perform well and concentrate at work. Zoloft 75mg orally daily helped to slow down the reabsorption of serotonin in the brain thus playing a huge role in regulating anxiety and mood (Craske & Bystritsky, 2016).

Difference between Expected Outcome and Actual Outcome

            The client returned to the clinic after four weeks with reports that his symptoms had totally reduced and that he was able to efficiently perform activities of daily life and perform well in his professional career. Maintaining the current dosage for at least 12 weeks helped to evaluate the full effects of the medication and allowed the patient time to fully recover (Er, 2015).

How Ethical Considerations Might Impact the Treatment Plan and Communication with Clients

            Patients requiring anxiolytic treatment will always present with symptoms related to anxiousness which affects their daily life.  A major ethical consideration, in this case, is patient confidentiality, autonomy, non-maleficence, and beneficence (Craske & Bystritsky, 2016). For instance, the patient needs to be informed of the treatment options available before being given the opportunity to choose that which he prefers which the mental health practitioner should respect and go by (Craske & Bystritsky, 2016). The ethical issue of beneficence and non-maleficence emphasize on the need of ensuring that the choice of the treatment made by the patient does more good than harm to the client and that it’s in the best interest of a client.Generalized Anxiety Disorder Paper

References

Baek, J., & Khan, F. (2017). A systematic review of anxiety disorders among older adults: focus on the treatment of generalized anxiety disorder. JGCR, 4(1), 3.

Clifford, K. M., Duncan, N. A., Heinrich, K., & Shaw, J. (2015). Update on managing generalized anxiety disorder in older adults. Journal of gerontological nursing, 41(4), 10-20.

Craske, M., & Bystritsky, A. (2016). Approach to treating generalized anxiety disorder in adults. Waltham, MA: UpToDate.

Er, I. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician, 91(9), 617-624.

Kavan, M. G., Elsasser, G. N., & Barone, E. J. (2009). Generalized anxiety disorder: practical assessment and management. American family physician, 79(9).

Sarkar, S., Harihar, S., & Patra, B. N. (2016). Sexual dysfunction due to SSRI antidepressants: How to manage?. Apollo Medicine, 13(2), 97-101.Generalized Anxiety Disorder Paper