Case Overview Of Treating Patients With Anxiety Disorders

Case Overview Of Treating Patients With Anxiety Disorders

Case overview

A 46-years old male presents at the clinic complaining of the feeling of heart attack, chest tightness, shortness of breath, impending doom, and the occasional need to run from wherever he is. He denies the use of psychotropics and has mild hypertension that he treats with a low sodium diet. He has a history of tonsillectomy at the age of 8 years. He is single and takes care of his aging parents in his home. He works as a welder in a local steel fabricator industry and states that the work station’s management is harsh and fears for his job. He confesses occasional use of ETOH to combat work worries and consumes 3-4bottles of beer every night. He has no myocardial infarction, EKG, and physical examination is within normal limits. On mental state examination, he is nervous, has a bleh mood, and blunted affect. The HAM-A score is at 26, making the diagnosis of generalized anxiety disorder. Case Overview Of Treating Patients With Anxiety Disorders

ORDER A PLAGIARISM-FREE PAPER HERE

Anxiety Disorder

Generalized anxiety disorder is a psychiatric disorder presenting with excessive fear and worry about everyday life but not focused on a specific situation or incidence. Fear and worry reduce the patient’s ability to concentrate and change behavior affecting their personal and social life (DeMartini, et al, 2019)Case Overview Of Treating Patients With Anxiety Disorders. Causes of generalized anxiety disorder are genetic predisposition or family history of generalized anxiety disorder, stressful events, disrupted attachments, conflicts, and substance abuse. When the patient becomes anxious, the CNS mediators; norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid. These neurotransmitters trigger increased blood pressure, shortness of breath, pounding of the heart, and restlessness. Hence, the symptoms; are chest tightness, shortness of breath, restlessness, and feeling of a heart attack.

The diagnosis of generalized anxiety disorder is made through clinical presentations and screening. Screening tools are beck anxiety inventory, generalized anxiety disorder, Penn state worry questionnaire, and Hamilton Anxiety rating scale. Psychotherapy and antidepressants are the mainstay treatment methods for generalized anxiety disorder. Psychotherapy involves cognitive and behavioral training to restore social skills and emotional intelligence. In this paper, I will describe the three decisions for treating a patient with generalized anxiety disorder, including the ethical principles.

Decision #1

Which decision did you select?

Paxil 10mg PO daily

Why did you select this decision?

Paxil is a selective serotonin reuptake inhibitor FDA approves for depressive mood, social anxiety, panic disorders, and generalized anxiety disorder. It has a little affinity for muscarinic and cholinergic receptors and blocks serotonin reuptake, down-regulating its concentration (Shrestha, et al, 2018)Case Overview Of Treating Patients With Anxiety Disorders. It produces effects of calmness, improved mood, and increased concentration. It is taken orally and has a plasma peak of 5 to 8 hours with immediate effect. It is 95% protein bound with a plasma half-life of 21hours. I selected Paxil 10mg because is effective and well-tolerated with no adverse side effects.

Why did you not select the other two options provided in the exercise?

Imipramine is a tricyclic antidepressant FDA approved for anxiety disorders and severe depression. It blocks the reuptake of serotonin and norepinephrine with a higher affinity to the serotonin receptors. It blocks the antimuscarinic and alpha-adrenergic receptors. It is completely absorbed in the body and has an onset of action after two weeks. It has a shorter plasm half-life of 18 hours. I did not select imipramine because of its anticholinergic side effects like dry mouth, blurring of vision, constipation, drowsiness, hallucinations, and memory problems (Fayez, R., & Gupta, V. 2021). Additionally, it achieves its therapeutic effects after two weeks of drug intake. Buspirone is an antipsychotic drug with anxiolytic features. It is effective when used as an augmentation of selective serotonin reuptake inhibitor (Kim, et al, 2021). I did not select the drug because it does not achieve its therapeutic effects on its one, taker 4-6weeks to achieve therapeutic goals, and it is not effective in acute anxiety disorders.

What were you hoping to achieve by making this decision?

The expectations of administering Paxil 10mg PO are to reduce the HAM-A scale and reduce the symptoms such as restlessness, chest pain, the feeling of heart attack, and shortness of breath.

How ethical considerations may impact your treatment plan and communication

Ethics are the values that give guidance to healthcare practice to ensure quality and patient satisfaction. At this decision point, the nurse uses the principle of justice and fairness. Justice is giving an individual what she deserves with kindness. The patient deserves proper physical and mental assessment, appropriate diagnosis, and effective treatment method. The nurse guides the physical findings, mental state examination, and diagnostic investigations Case Overview Of Treating Patients With Anxiety Disorders.

Decision #2

Which decision did you select?

Increase the dose to Paxil 20mg

Why did you select this decision?

I increased the dose of Paxil to 20mg because it is the recommended adult dose. The patient responded well to Paxil 10mg, increasing the dose produces the desired therapeutic goal for the patient.

Why did you not select the other two options provided in the exercise?

I did not increase the dose to 40mg because it is not the recommended adult dose. Moreover, the American psychiatric association recommends 10mg weekly intervals monitoring the effectiveness and side effects. The dose increment should only be after the patient does not show an adequate therapeutic response after three weeks of treatment. Increasing the drug dosage abruptly produces undesirable side effects. I did not maintain Paxil 10mg because it does not achieve its therapeutic goal.

ORDER HERE

What were you hoping to achieve by making this decision?

The objective of increasing the dose to 20mg was to achieve the optimal dose. The expectations further improve the HAM-A scale score and the symptoms.

How ethical considerations may impact your treatment plan and communication

At this decision point, the nurse incorporates beneficence. Beneficence is the obligation to help a patient and promote their welfare (Bester, J. C. 2020)Case Overview Of Treating Patients With Anxiety Disorders. The nurse initiates the optimal treatment for a patient to achieve the therapeutic goal. Initially, she started the patient on a smaller dose as recommended by the American psychiatric association and gradually increase the dose observing for tolerance and adverse reactions.

Decision #3

Which decision did you select?

Maintain the current dose.

Why did you select this decision?

At this point, the efficiency of the drug has been observed with no side effects. The symptoms have improved up to 61%. The drug will gradually improve the symptoms.

Why did you not select the other two options provided in the exercise?

I did not increase the dose to Paxil 30mg because the therapeutic goal has been achieved. Additionally, the optimal adult dose is 20mg. I did not augment Paxil with buspirone because it is effective for the patient. Buspirone augments the incidence of no improvement of the symptoms three weeks after drug administration.

What were you hoping to achieve by making this decision?

The expectation of maintaining the current dose is to improve the symptoms to 100% and restore function to the patient.

How ethical considerations may impact your treatment plan and communication

The recommended psychiatric follow-up sessions are the first three after initiating treatment to monitor drug effectiveness and side effects. At this point, the nurse incorporates the principle of autonomy. Autonomy is the freedom to decisions making about health issues. The nurse gives the patient the free will to decide on the continuation of the follow-up clinic and start psychotherapy sessions.

Conclusion

Generalized anxiety disorder is a psychiatric disorder presenting with excessive fear and worry about everyday life but not focused on a specific situation or incidence. Excessive fear and worry reduce the patient’s ability to concentrate and change behavior affecting their personal and social life. Psychotherapy and antidepressants are the mainstay treatment methods for generalized anxiety disorder. Antidepressants are selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants. Anxiolytics are also recommended for treating generalized anxiety disorder when augmenting with selective serotonin reuptake inhibitors. However, selective serotonin reuptake inhibitors are the best for generalized anxiety disorder because they have no anticholinergic adverse effects. Ethics are the values that give guidance to healthcare practice to ensure quality and patient satisfaction. Justice is giving an individual what she deserves and with kindness, beneficence is the obligation to help a patient and promote their welfare, and Autonomy is the freedom to decision making Case Overview Of Treating Patients With Anxiety Disorders.

References

Bester, J. C. (2020). Beneficence, interests, and wellbeing in medicine: what it means to provide benefit to patients. The American Journal of Bioethics, 20(3), 53-62. https://doi.org/10.1080/15265161.2020.1714793

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Fayez, R., & Gupta, V. (2021). Imipramine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557656/

Kim, JK., Han, SK., Joo, MK. et al. Buspirone alleviates anxiety, depression, and colitis; and modulates gut microbiota in mice. Sci Rep 11, 6094 (2021). https://doi.org/10.1038/s41598-021-85681-w

Shrestha, P., Fariba, K., & Abdijadid, S. (2018). Paroxetine. PMID: 30252278

Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page) Case Overview Of Treating Patients With Anxiety Disorders

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature)Case Overview Of Treating Patients With Anxiety Disorders.
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

BACKGROUND INFORMATION

The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.
You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.
Diagnosis: Generalized anxiety disorder

RESOURCES
§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision point one Decision point two Decision point three

Begin Paxil 10 mg po daily

RESULTS OF DECISION POINT ONE

-Client returns to clinic in four weeks
-Client informs you that he has no tightness in chest, or shortness of breath
– Client states that he noticed decreased worries about work over the past 4 or 5 days
-HAM-A score has decreased to 18 (partial response)

Increase dose to 20 mg po daily

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks
-Client reports an even further reduction in his symptoms
-HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)Case Overview Of Treating Patients With Anxiety Disorders

ORDER NOW

-Maintain current dose
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.

-Increase to 30 mg po daily
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
-Add augmentation agent such as Buspar(buspitone)
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.

Increase dose to 40 mg po daily

-Client returns to clinic in four weeks
-Client is a bit evasive about his symptoms. Eventually he admits that he stopped taking the medication about a week ago because he was experiencing difficulty acquiring an erection Case Overview Of Treating Patients With Anxiety Disorders.

-Discontinue Paxil and begin Celexa at 20 mg orally daily
Erectile dysfunction with SSRIs may be dose dependent and may resolve with the passage of time. You should discuss this course of action with the client and determine whether he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Celexa- although Celexa is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Cialis. This would have to be used with caution in consideration of the clients HTN.

-Add agent to treat side effects
You should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. You should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.

-Begin Lexapro 5 mg orally daily.
You should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. You should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN. Case Overview Of Treating Patients With Anxiety Disorders

No change in drug/dose at this time

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks
-Client reports no further decreases in anxiety and is wondering if this means that the medication will not be effective for him

-Increase drug to 75 mg po daily
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose)Case Overview Of Treating Patients With Anxiety Disorders. Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.

-Consider addition of augmentation agent such as Buspar(Buspirone)
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.

Switch to Serotonin norepinephrine reuptake inhibitor(SNRI) such as Effexor(venlafaxine)

Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose)Case Overview Of Treating Patients With Anxiety Disorders. Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.

Decision point one
Decision point two
Decision point three

Begin Imipramine 25 mg orally BID

RESULTS OF DECISION POINT ONE

-Client returns to clinic in four weeks
-Client reports a “slight” decrease in symptoms
-Client’s states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath
-HAM-A score decreased from 26 to 22

Increase Tofranil to 50 mg orally BID

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks
-Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode. -Restart Tofranil at 25 mg orally BID
At this point, it is important that you discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction Case Overview Of Treating Patients With Anxiety Disorders.

The most appropriate course of action for you to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.
-Discontinue Tofranil and begin SSRI
At this point, it is important that you discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

-Discontinue Tofranil and begin BuSpar at 5 mg orally TID
At this point, it is important that you discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken Case Overview Of Treating Patients With Anxiety Disorders.

Continue current dose and reassess in 4 weeks

RESULTS OF DECISION POINT TWO
-Client returns to clinic in four weeks
Client reports that he has had no change in his level of anxiety
Client reports that his anxiety may be getting a bit “worse” because he has been having the strange bouts of dizziness -Increase Tofranil to 50 mg orally BID
Tofranil can cause orthostatic hypotension. This may be a transient side effect and you should discuss this with the client as these symptoms can be dangerous.
Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.
While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.
Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea)Case Overview Of Treating Patients With Anxiety Disorders.
-Explain that the dizziness will pass and maintain current dose until next appointment
Tofranil can cause orthostatic hypotension. This may be a transient side effect and you should discuss this with the client as these symptoms can be dangerous.
Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.
While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.
Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).

-Discontinue Tofranil and begin Lexapro 5 mg orally daily for 7 days, then increase to 10 mg orally daily until next appointment

Tofranil can cause orthostatic hypotension. This may be a transient side effect and you should discuss this with the client as these symptoms can be dangerous.
Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.
While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.
Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea)Case Overview Of Treating Patients With Anxiety Disorders.
-Add augmentation agent such as Buspar(buspitone) 5 mg orally TID

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks
-Client reports that symptoms are pretty much unchanged”
– HAM-A score decreased from 22 to 19. He is still troubled by dizziness -Increase Tofranil to 75 mg orally BID
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effect has not gone away is probably concerning to the client and may impact his quality of life.
Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.
At this point, you can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for you to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.

– Increase BuSpar to 10 mg orally TID
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effects has not gone away is probably concerning to the client and may impact his quality of life. Case Overview Of Treating Patients With Anxiety Disorders

Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.

At this point, you can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for you to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.
-Discontinue Tofranil and BuSpar and begin Paxil 20 mg orally daily.
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effects has not gone away is probably concerning to the client and may impact his quality of life.
Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.
At this point, you can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for you to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.
Decision point one Decision point two Decision point three

Begin Buspirone 10 mg po BID

RESULTS OF DECISION POINT ONE

– Client returns to clinic in four weeks
– Client reports slight decrease in symptoms
-Client states that he still feels very anxious
HAM-A score decreased from 26 to 23 Case Overview Of Treating Patients With Anxiety Disorders

Increase buspirone to 10 mg orally TID

RESULTS OF DECISION POINT TWO

– Client returns to clinic in four weeks
-Client reports no change in his anxiety
-HAM-A score has decreased from 23 to 22 – Continue current dose and reassess in 4 more weeks
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, you can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. You should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
– Augment with ativan(Lorazepam) 0.5 mg orally TID
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, you can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily. Case Overview Of Treating Patients With Anxiety Disorders

– Discontinue buspirone and begin Zoloft 50 mg orally daily.
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, you can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

-Increase buspirone to 20 mg orally TID

RESULTS OF DECISION POINT TWO

– Client returns to clinic in four weeks
-Client reports nausea, dizziness, nervousness, headaches, and dry mouth
-HAM-A score reveals no change and he reports that he still feels anxious -Decrease BuSpar to 15 mg orally TID

It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.

The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
– Explain to the client that these are normal side effects of buspirone and maintain current dose for another 4 weeks.
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal)Case Overview Of Treating Patients With Anxiety Disorders. The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

-Discontinue buspirone and begin Zoloft 50 mg orally daily
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

Discontinue buspirone and begin lexapro 10 mg orally daily.
RESULTS OF DECISION POINT TWO

– Client returns to clinic in four weeks
-Client reports that he feels “great”
-Client states that his anxiety is getting “better”
-HAM-A score has decreased from 23 to 13
-Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon -Increase Lexapro to 15 mg orally daily in AM

At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. You could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.

– Continue same dose of Lexapro but change administration time to bedtime

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.

– Re-start BuSpar at 10 mg orally TID
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. You could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

ORDER TODAY

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response Case Overview Of Treating Patients With Anxiety Disorders