Title: NURS 6630 Assessing and Treating Patients With Anxiety Disorders<\/strong><\/h2>\nGeneralized anxiety disorder (GAD) is a common psychiatric condition that presents with excessive and uncontrollable anxiety or worries about various things or events. The anxiety or worry occurs for more days than not for more than six months. The cause of GAD is unknown, but it usually coexists in individuals with panic disorder, major depression, and alcohol use disorder (Strawn et al., 2018). The purpose of this paper is to describe the treatment for a patient with GAD.<\/span>\u00a0<\/span><\/p>\nIntroduction to the Case<\/span><\/b>\u00a0<\/span><\/h2>\nThe case depicts a 46-year-old man who comes to the psychiatric clinic following a referral by the PCP. The patient had gone to the ER after he experienced symptoms resembling a heart attack, including chest tightness, dyspnea, and a feeling of coming doom. He has a history of mild hypertension managed through a low sodium diet and weighs around 115 lbs. In addition, he has a history of tonsillectomy but no significant medical history. The patient’s EKG and physical exam were within the normal limits in the ER, and Myocardial infarction was excluded as a possible diagnosis. However, the patient mentions that he still experiences chest tightness and episodes of dyspnea. Besides, he experiences sporadic feelings of imminent doom and a need to flee from where he is.\u00a0<\/span>\u00a0<\/span><\/p>\nThe patient reports occasionally taking alcohol to alleviate work-related worries. He is single but is trying to take care of his old parents. He states that his workplace management is harsh and worries for his job. The MSE findings are unremarkable except for the endorsement of nervousness and blunted affect that improves severally during the assessment. The patient was administered the HAM-A, which he scored 26, and was diagnosed with GAD. Specific patient factors that may influence treatment decisions include the patient’s age, medical history of hypertension, the severity of GAD, and the patient\u2019s overweight state (Garakani et al., 2020). Therefore, the treatment interventions used should have no potential effect on the patient\u2019s weight and blood pressure to avoid worsening his medical condition.\u00a0<\/span>\u00a0<\/span><\/p>\nDecision Point One<\/span><\/b>\u00a0<\/span><\/h2>\nStart Zoloft 50 mg orally daily.<\/span>\u00a0<\/span><\/p>\nWhy I Selected This Decision<\/span><\/b>\u00a0<\/span><\/h2>\nZoloft was the ideal drug because it is recommended in the first-line treatment of GAD in adults, among other SSRIs (Strawn et al., 2018). Guaiana et al. (2018) found that SSRIs are superior in alleviating GAD symptoms, and Zoloft was established to be effective and well-tolerated due to its modest side effects.<\/span>\u00a0<\/span><\/p>\nWhy I Did Not Select the Other Options\u00a0<\/span><\/b>\u00a0<\/span><\/h2>\nImipramine was not selected because of its documented antihistaminic effects as a TCA, which increase appetite resulting in weight gain. This would worsen the client\u2019s overweight condition. Garakani et al. (2020) explain that although TCAs have similar efficacy to SSRIs, they are rarely prescribed because of side effects like weight gain, sedation, dry mouth, urinary hesitancy, arrhythmias, and mortality risk with overdose. Buspirone was not the best option because it has been established to have a delayed onset of action and is weak effective (Strawn et al., 2018). Thus, it cannot be prescribed as monotherapy in GAD, limiting its use in this patient.<\/span>\u00a0<\/span><\/p>\nWhat I Was Hoping To Achieve<\/span><\/b>\u00a0<\/span><\/h2>\nThe clinician anticipated that Zoloft would reduce the GAD symptoms and lower the HAM-A score by half. The patient reported a significant decrease in worry, dyspnea, and feeling of imminent doom. Lewis et al. (2019) found that Zoloft improves anxiety, self-rated mental health, and quality of life in GAD patients, which is clinically important. Besides, Strawn et al. (2018) established that SSRIs like Zoloft <\/span>have a significant treatment response rate of 30-50% in patients with GAD and would thus significantly reduce the patient\u2019s GAD symptoms.\u00a0<\/span>\u00a0<\/span><\/p>\nEthical Considerations Impact on the Treatment Plan and Communication<\/span><\/b>\u00a0<\/span><\/h2>\nThe ethical principle of beneficence may affect the treatment since the clinician has to select the intervention established to have the best outcomes in GAD. For example, the PMHNP selected Zoloft because studies support its efficacy in suppressing GAD symptoms and is tolerable. In addition, autonomy may affect communication since the PMHNP had to obtain consent from the patient to begin treatment.<\/span>\u00a0<\/span><\/p>\nDecision Point Two<\/span><\/b>\u00a0<\/span><\/h2>\nIncrease dose to 75 mg OD.<\/span>\u00a0<\/span><\/p>\nWhy I Selected This Decision<\/span><\/b>\u00a0<\/span><\/h2>\nZoloft was increased because of the evident improvement in the patient\u2019s GAD symptoms and partial decrease in HAM-A score with Zoloft therapy. According to Edinoff et al. (2021), SSRIs like Zoloft should be gradually increased to enable the clinician to monitor the adverse effects. Strawn et al. (2018) found that patients increasingly demonstrated improvement in anxiety symptoms when the Zoloft dose was increased by 25 mg.\u00a0<\/span>\u00a0<\/span><\/p>\nWhy I Did Not Select the Other Options\u00a0<\/span><\/b>\u00a0<\/span><\/h2>\nIncreasing Zoloft to 100 mg was not the best option because the PMHNP may be unable to monitor side effects with a high dose increase. Edinoff et al. (2021) explain that patients can be sensitive to SSRIs, and thus, gradually increasing SSRIs is vital in achieving the desired treatment outcomes. The dose was not also maintained at 50 mg since the client demonstrated only a partial response to treatment. Lewis et al. (2019) established that Zoloft leads to decreased anxiety symptoms and improved mental health within six weeks, but a complete reduction of symptoms takes longer and is more modest. Thus, maintaining the dose would have delayed achieving complete remission of GAD.\u00a0<\/span>\u00a0<\/span><\/p>\nWhat I Was Hoping To Achieve<\/span><\/b>\u00a0<\/span><\/h2>\nThe clinician expected that the patient\u2019s GAD symptoms would decrease further with an increased dose, and the patient would achieve a better clinical response after four weeks. Mangolini et al. (2019) found that increasing the SSRI dose results in a better clinical response in GAD. Furthermore, Edinoff et al. (2021) found sertraline to be more effective in the acute phase (6-12 weeks) of treatment than other SSRIs.\u00a0<\/span>\u00a0<\/span><\/p>\nEthical Considerations Impact on the Treatment Plan and Communication<\/span><\/b>\u00a0<\/span><\/h2>\nThe ethical principle of nonmaleficence (do no harm) impacted the treatment since the PMHNP had to make the decision associated with the least adverse effects. For example, the dose was increased to 75 mg rather than 100 mg for the clinician to monitor side effects. The right to autonomy affected communication since the PMHNP had to involve the patient in decision-making. The client was asked about his treatment response and was involved in deciding whether to increase the dose.<\/span>\u00a0<\/span><\/p>\nDecision Point Three<\/span><\/b>\u00a0<\/span><\/h2>\nMaintain the Zoloft 75 mg dose.<\/span>\u00a0<\/span><\/p>\nWhy I Selected This Decision<\/span><\/b>\u00a0<\/span><\/h2>\nThe PMHNP maintained Zoloft at 75 mg because the patient exhibited a satisfactory positive response to the dose, with a 61% reduction in anxiety symptoms. Furukawa et al. (2019) found that 80% occupancy of serotonin transporters occurs at minimum therapeutic doses in Zoloft. Besides, increasing transporter occupancy > 80% does not lead to better treatment efficacy. Strawn et al. (2018) also assert that SSRIs in the lower therapeutic range (50 mg-100 mg) are adequate in achieving the desired effect.\u00a0<\/span>\u00a0<\/span><\/p>\nWhy I Did Not Select the Other Options\u00a0<\/span><\/b>\u00a0<\/span><\/h2>\nIncreasing Zoloft to 100 mg was not ideal because the patient had achieved a satisfactory therapeutic response. According to Edinoff et al. (2021), increasing Zoloft can lead to further reduction of symptoms, but it increases the risk of side effects, compromising treatment compliance. Augmenting treatment with Buspirone was not ideal since the client had an adequate therapeutic response with Zoloft. Mangolini et al. (2019) assert that augmentation causes polypharmacy and should thus be avoided if there is an adequate response with monotherapy.\u00a0<\/span>\u00a0<\/span><\/p>\nWhat I Was Hoping To Achieve<\/span><\/b>\u00a0<\/span><\/h2>\nThe practitioner hoped that continuing with the 75mg dose would increasingly alleviate GAD symptoms and help achieve complete remission of symptoms within 4-6 weeks (Furukawa et al., 2019). Strawn et al. (2018) established that flexibly dosing Zoloft significantly reduces GAD symptoms.<\/span>\u00a0<\/span><\/p>\nEthical Considerations Impact on the Treatment Plan and Communication<\/span><\/b>\u00a0<\/span><\/h2>\nBeneficence (duty to do good) and confidentiality may impact treatment and communication in this case. For example, beneficence impacted treatment as the PMHNP had to select the decision that would have the best outcomes without compromising patient safety. Besides, the PMHNP has to be confidential with the patient\u2019s information and seek consent before sharing it with other providers.<\/span>\u00a0<\/span><\/p>\n