Assignment; NUR6630 Assessing and Treating Patients with Anxiety Disorders

Assignment; NUR6630 Assessing and Treating Patients with Anxiety Disorders

Assignment; NUR6630 Assessing and Treating Patients with Anxiety Disorders

Generalized anxiety disorder is a common diagnosis encountered in mental health practice. It affects the patient’s quality of life, health and wellbeing. Psychiatric mental health nurse practitioners (PMHNP) play a crucial role in implementing evidence-based interventions that optimize treatment outcomes such as safety, quality, patient-centeredness, and efficiency in the treatment of generalized anxiety disorder. Therefore, this paper develops a treatment for a patient that has been diagnosed with generalized anxiety disorder. The patient is a 46-year-old white male that works as a welder at a local steel fabrication factor. The patient came as a referral by his PCP for assessment.

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The patient reported feeling having a heart attack. The accompanying symptoms reported include chest tightness, feeling of impending doom, and shortness of breath. He also reported occasional feelings of impending doom and the need to escape or run from wherever he is at. He is also worried about work and reports the management at his workplace of being harsh and fears for his job. A mental status examination performed revealed that the patient was oriented to person, place, time, and event and alert. His speech was clear, coherent, and goal-oriented. His mood is ‘bleh’ and endorses being nervous.

The patient factors that will determine the treatment decisions are varied. They include his Hamilton Anxiety Rating Scale (HAMA-A) score of 26, occasional use of ETOH, consumption of 3-4 beers a night, being overweight, surgical history of tonsillectomy, and mild hypertension. This paper selects the best treatment from the given options, examines why the remaining treatments were not adopted, and the ethical considerations that would influence the treatment decisions.

Decision 1

Selected Decision

Begin Paxil 10 mg PO daily.

Why the Decision was selected

Paxil is one of the first-line drugs for use in treating generalized anxiety disorder in adult patients. Paxil is a selective serotonin reuptake inhibitor that increases the extra-synaptic concentrations of 5-HT, norepinephrine, and dopamine(Kowalska et al., 2021). Paxil is associated with significant improvements in symptoms of generalized anxiety disorder. It also has enhanced efficacy in reducing HAM-A scores as seen from studies that have found its effectiveness to be evident from the first week of treatment. It also improves patient’s social functioning as early as within the first four weeks of treatment as compared to outcomes seen in placebo(Fagan & Baldwin, 2023; Li et al., 2020). Paxil also has a high level of tolerance with minimal adverse events that correspond to those seen in its safety profile.

Why the Other Two Options Were Not Selected

Buspirone 10 mg PO BID was not selected as the first-line treatment for the patient. This is because Buspirone is considered the second-line of drug for patients with generalized anxiety disorder. Providers consider it an option when the first-line agents such as Paxil have been ineffective(Kong et al., 2020). Beginning the patient on imipramine 25 mg PO BID was not selected because of its associated safety concerns. Imipramine may increase the risk of hypertensive crises in the patient since he already has a history of mild hypertension(Baldwin, 2020). Side effects such as blurred vision, dry mouth, delirium, and urinary retention also make imipramine not the first-line drug of choice for the patient.

What I Was Hoping to Achieve

I was hoping to see a decrease in the client’s HAM-A score from 26 to at least 20 in four weeks. I was also hoping the patient would report the reduction in symptoms of generalized anxiety disorder because of the effectiveness of Paxil. Lastly, I anticipated improved social function and quality of life secondary to symptom reduction(Kaveiy et al., 2023; Li et al., 2020).

Ethical Considerations

Patient experiences with a prescribed drug may affect their decision to use of the medication or not. An occurrence of adverse reaction to Paxil such as suicidal ideation, attempts, or plans by the patient will translate into a change in the current treatment plan. The aim would be to promote safety and quality in the treatment process(Baldwin, 2020). As a result, the PMHNP will monitor closely the client’s response to treatment and change the regime accordingly based on the patient’s reaction and changes in symptoms of the disorder.

Decision 2

Selected Decision

Increase the dose to 20 mg PO daily.

Why the Decision was selected

It would be appropriate to increase the dosage of Paxil to 20 mg PO daily at this time. The patient returned to the clinic after four weeks with reports of improved symptoms of generalized anxiety disorder. The patient reports that he no longer has chest tightness or shortness of breath. He also states that his worries about work decreased over the past 4 or 5 days. The HAM-A score has also decreased to 18, which represents partial response. Paxil takes up to four weeks to produce its therapeutic effects in managing symptoms of generalized anxiety disorder. This explains the partial response and absolute resolution of some symptoms of generalized anxiety disorder. An optimal therapeutic dose and effect of Paxil has not been achieved by administering Paxil 10 mg PO daily(Kowalska et al., 2021). Therefore, it is appropriate to increase the dosage to 20 mg PO daily.

Why the Other Two Options Were Not Selected

The decision to increase the dosage of Paxil to 40 mg po daily was not selected. Such a four-fold increase in the dosage would increase the client’s risk of developing adverse reactions such as suicidal thoughts, plans, or attempts. Clinical guidelines recommend systematic titration and tapering off drug dosage to produce optimal effects, promote tolerance, and minimize the risk of adverse events. The decision not to change the drug at this time was not selected since the desired therapeutic effectiveness of Paxil has not been achieved(Laux, 2020). Maintaining the current dose will result in suboptimal outcomes in disorder management.

What I Was Hoping to Achieve

I was hoping to achieve a further reduction in HAM-A score because of Paxil being at its optimal dosage and serum concentration. I was also hoping the client would report further reduction in worries about his job and possible resolution by the end of four weeks. I also anticipated improved functioning following the resolution of these distressing symptoms(Li et al., 2020).

Ethical Considerations

PMHNP must promote ethical care in their practice. This includes relying on best sources of evidence and clinical guidelines in making treatment decisions. Sources of evidence-based data and clinical guidelines recommend gradual titration or tapering off drugs based on client’s response(Butts & Rich, 2022). As a result, this informed the decision not to raise the dosage of Paxil to 40 mg, as it would increase the risk of harm, hence, safety and quality issues in psychiatric practice.

Decision 3

Selected Decision

Maintain current dose.

Why the Decision was selected

The patient returned to the clinic after four weeks with reports of further reduction in the symptoms of generalized anxiety disorder. The client reported an even further reduction in the symptoms of generalized anxiety disorder. He also reported that his HAM-A score has not reduced to 10. The improvements translate into 61% reduction in symptoms. The client’s data shows that the optimal therapeutic dose and effectiveness of Paxil has been reached(Li et al., 2020). The PMHNP should not change the current dosage to ensure sustained symptom improvement and tolerance to treatment, hence the decision to maintain the current dose.

Why the Other Two Options Were Not Selected

The decision to increase the dosage of Paxil to 30 mg PO daily was not selected. This decision would increase the risk of the patient developing adverse reactions such as suicidal thoughts, plans, or attempts. The drug’s optimal therapeutic dose and efficiency has been achieved, hence not need for a further increase or decrease in the dosage. The decision to add augmentation agent such as BuSpar (buspirone) was also not selected. Augmentation is only recommended if the current treatment produces mild improvement in symptoms(Laux, 2020). The current dose has produce optimal symptom improvement, which rules out the need for augmentation.

What I Was Hoping to Achieve

I was hoping to promote tolerance to the current dose of Paxil. I was also hoping to witness a further reduction in the client’s HAM-A score in the next visit to the hospital. These changes would have translated into improved social and occupational functioning(Baldwin, 2020).

Ethical Considerations

The promotion of patient’s autonomy in the treatment process is imperative for optimum treatment outcomes. PMHNP must respect patient’s values, beliefs, and preferences in the treatment process. The patient’s decision to accept or reject the use of Paxil in the treatment of generalized anxiety disorder would affect treatment outcomes. The PMHNP should also involve the patient in treatment decisions and prioritize his needs(Butts & Rich, 2022). Through it, patient-centeredness would be promoted, hence, ethics in practice.

Conclusion

The use of Paxil proved effective in treating the symptoms of generalized anxiety disorder in this case study. The existing evidence recommends the use of Paxil as the first-line treatment for generalized anxiety disorder. Paxil is a selective serotonin reuptake inhibitor that increases the levels of norepinephrine and dopamine to improve mood and mental health wellbeing. Paxil has high safety profile and tolerance level when used for generalized anxiety disorder. The decision to increase the dosage of Paxil to 20 mg in the second step was effective(Kaveiy et al., 2023). The increase in dosage led to the desired therapeutic effectiveness and serum concentration of Paxil, hence, 61% reduction in symptoms. The given alternatives such as the administration of buspirone and imipramine were not considered since they are not the first-line agents for use in generalized anxiety disorder.

Ethical considerations influenced the treatment decisions made in this case study. First, the treatment selection was made with the aim of optimizing treatment outcomes. The selection of Paxil aimed at ensuring minimum risk of harm while optimizing symptom management. The treatment choices would have also been changed based on the patient’s response to the treatment. For example, the development of adverse reactions to Paxil would have led to the consideration of second-line drugs for use in the treatment of generalized anxiety disorder. Patients have the right to accept or decline a treatment. PMHNP must respect the patient’s decisions in the treatment process to promote autonomous care(Butts & Rich, 2022). Therefore, the client’s decision to reject the use of Paxil would have affected the treatment decisions.

References

Baldwin, D. S. (2020). Pharmacological Treatment of Generalized Anxiety Disorder (GAD). In Generalized Anxiety Disorder and Worrying (pp. 297–318). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781119189909.ch14

Butts, J. B., & Rich, K. L. (2022). Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.

Fagan, H. A., & Baldwin, D. S. (2023). Pharmacological Treatment of Generalised Anxiety Disorder: Current Practice and Future Directions. Expert Review of Neurotherapeutics, 0(0), 1–14. https://doi.org/10.1080/14737175.2023.2211767

Kaveiy, M., Toozandejani, H., Taher, M., & Zendehdel, A. (2023). Comparing the effectiveness of modular cognitive-‎behavioral therapy, ‎‏‏pharmacotherapy (paroxetine) and their combination in intolerance of uncertainty and meta-worry‎ in female university students with generalized anxiety disorder. Razavi International Journal of Medicine, 11(1). https://doi.org/10.30483/rijm.2023.254446.1263

Kong, W., Deng, H., Wan, J., Zhou, Y., Zhou, Y., Song, B., & Wang, X. (2020). Comparative Remission Rates and Tolerability of Drugs for Generalised Anxiety Disorder: A Systematic Review and Network Meta-analysis of Double-Blind Randomized Controlled Trials. Frontiers in Pharmacology, 11. https://www.frontiersin.org/articles/10.3389/fphar.2020.580858

Kowalska, M., Nowaczyk, J., Fijałkowski, Ł., & Nowaczyk, A. (2021). Paroxetine—Overview of the Molecular Mechanisms of Action. International Journal of Molecular Sciences, 22(4), Article 4. https://doi.org/10.3390/ijms22041662

Laux, G. (2020). Serotonin Reuptake Inhibitors: Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, and Sertraline. In P. Riederer, G. Laux, T. Nagatsu, W. Le, & C. Riederer (Eds.), NeuroPsychopharmacotherapy (pp. 1–13). Springer International Publishing. https://doi.org/10.1007/978-3-319-56015-1_413-1

Li, X., Hou, Y., Su, Y., Liu, H., Zhang, B., & Fang, S. (2020). Efficacy and tolerability of paroxetine in adults with social anxiety disorder. Medicine, 99(14), e19573. https://doi.org/10.1097/MD.0000000000019573

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Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.

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)

• 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).
• 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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. 

REFERENCES 5

RESOURCES:

• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
  • Chapter 8,  “Anxiety, Trauma, and Treatment” (pp. 359-378)

• American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf
• American Psychiatric Association. (2010c). Practice guideline for the treatment of patients with panic disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
• Bendek, D. M., Friedman, M. J., Zatzick, D., & Ursano, R. J. (n.d.). Guideline watch (March 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
• Cohen, J. A. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 49(4), 414–430. https://jaacap.org/action/showPdf?pii=S0890-8567%2810%2900082-1
• Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16–e18. 10.1192/bjpo.bp.116.003707. http://bjpo.rcpsych.org/content/2/6/e16
• Hamilton, M. (1959). Hamilton Anxiety Rating Scale (HAM-A). PsycTESTS. https://doi.org/10.1037/t02824-0
• Ostacher, M. J., & Cifu, A. S. (2019). Management of posttraumatic stress disorder. JAMA, 321(2), 200–201. https://doi.org/10.1001/jama.2018.19290
• Strawn, J. R., Wehry, A. M., DelBello, M. P., Rynn, M. A., & Strakowski. S. (2012). Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder. Depression and Anxiety, 29(4), 328–339. https://doi.org/10.1002/da.21913