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Pharmacological Management of Generalized Anxiety Disorder in a Middle-Aged Male

Task

This paper seeks to provide an analytical evaluation of the best possible pharmacological decisions in the management of a middle-aged white male who presented to the clinic with generalized anxiety disorder (GAD). The client, who is 46 years old, reported to the hospital with to set of manifestations of GAD namely psychological and psychomotor symptoms. On the psychological symptoms, the patient has excessive wariness and nervousness as evidenced by excessive fear of losing his job. He also reports that he usually feel like running or escaping from where he is. The client's HAM-A score is 26. On psychomotor symptoms, the patient complaint included episodes of chest tightness and shortness of breath. The physical assessment revealed that the client has mild hypertension and is overweight. The paper will select the most appropriate decision to treat the patient manifestations at the initial visit, the first visit and the second visit which are four weeks apart. At each visit, the paper will provide a rationale for selecting the decision, the expected outcome and then compare the outcome with the expected outcome.

The selection of Zoloft was primarily made on it proved effectiveness as the first line drug for treating GAD (Christensen et al., 2014). Zoloft, which the trade name for Sertraline, is a selective serotonin reuptake inhibitor (SSRI) which acts by blocking serotonin leading to its accumulation in the neural junction thus allowing appropriate transmission relating to emotions (Christensen et al., 2014). SSRI are known to stabilize the levels of serotonin leading to stable anxiety (Christensen et al., 2014). Additionally, the drug is known to work via the negative feedback leading to alleviation of the psychomotor symptoms culminating from GAD. The selection was also based on the review of the other pharmacological agents provided. The otherdrugs included a tricyclic antidepressant and a partial serotonin agonist namely Imipramine and Buspirone have less therapeutic effects compared to Zoloft. Another consideration made during the selection of the drug is the side effects whereby SSRI was found to be more tolerable compared to tricyclic antidepressant and Serotonin agonist due to their selective nature (Cuijpers et al., 2014).

The selection of Zoloft was aimed at resolving the client's clinical manifestation. First, the drug was expected to result in a significant reduction of the GAD symptoms by more than half in the next four weeks. The indicators for this expectation included the elimination of the chest tightness and chest congestion as well as a reduction of the HAM-A score to about 13. Secondly, the treatment aimed to have high levels of tolerability evidenced by the lack of side effects. Achievement of the expectation was based on the assumption that the patient will adhere to the dosage, frequency, and timing of the medication. Therefore, the patient is expected to accede to the medication.

Rationale

The patient reported back for the follow-up clinic after four weeks and reported that he did not have chest tightness and shortness of breath. The patient also reported that the worries had reduced significantly over the past 4-5 days. Consequently, his HAM-A score reduced partially to 18. The expectation on elimination psychomotor symptoms and reduction of psychological symptoms were met. However, the reduction of the HAM-A score was not met since the client demonstrated a partial reduction from 26 to 18 as opposed to the projected score of 13. The most probable cause of this could have been a potentially low dosage; however, other factors such as non-adherence and drug interaction as well as the lack of appropriate coping and support mechanism.

The selection of this choice was based on the assumption that the patient adhered to the medication and hence the failure to achieve the intended effects were based on a low dosage. Consequently, the patient tolerated well to the medication since no side effects and the drug showed partial therapeutic effects; hence the need to maintain the same pharmacological agent. The selection was also based on the research findings indicating that SSRI has dose-related side effects and hence the partial increase of the dosage to 75mg as opposed to the other suggestion of increasing it to 100mg (Cuijpers et al., 2014). Similarly, the progressive increase of medication dosages is known to allow health practitioners in identifying any side effects promptly as well as determine the optimal dosage for a particular medication (Cuijpers et al., 2014).

As discussed in the previous decision, SSRI is known to reduce the psychological and psychomotor symptoms of GAD (Bandelow et al., 2013). Therefore, the patient is expected to report reduced psychological symptoms whereby the worries will be eliminated. Similarly, the HAM-A score is expected to reduce to less than seven which is the optimal score of normal anxiety response (Duits et al., 2014). The psychomotor symptoms are not expected to resume, and the patient is expected to have no side effects since he has already tolerated well to the treatment regimen. Additionally, the patient is expected to adhere to the medication to ensure a maximum therapeutic response.

The patient reported to the clinic for follow-up clinic and reported a further reduction of the symptoms. Similarly, the HAM-A score reduced from 18 to 10 which was indicative of a 61% of the overall symptom reduction. Even though, the clinical manifestations indicate significant progress characterized by desirable therapeutic response and tolerance; the expected outcome was partially met. The cause of the partial may include low dosage, lack of appropriate coping mechanism, and drug interaction with other agents such alcohol (Bandelow et al., 2013).

Expected Outcome

The selection of this decision is based on the previous response to the drug as well as consideration of other options available. First, the client has demonstrated a desirable response to the medication characterized by progressive response to the medication and lack of side effects. In this context, the best option is to retain the drug. On the other hand, Zoloft is known to have dose-related side effects, and hence the addition of the dosage can predispose the patient to side effects. Augmenting the medication with Buspar is not suitable since it predisposes the patient to polypharmacy which the common cause of medication errors and exacerbate the risk of side effects (Cuijpers et al., 2014).

The maintenance of the dosage is expected to lead to a progressive reduction of the GAD symptoms. The reduction is estimated to result in an HAM-A score of less than seven which is known as the optimal score of people with GAD leading a healthy life (Duits et al., 2014). The tolerance rate is expected to remain the same whereby the patient is not expected to experience any side effects. Consequently, the patient is expected to adhere to the medications. The maintenance of the dosage also will also allow the practitioner to adopt other non- pharmacological options such as behavioral therapy (Cuijpers et al., 2014).

The outcome of the medication is not reported; however, the summary of the decision making demonstrate that the selected option is the most viable. Therefore, if the patient adheres to the medication; there is a high likelihood of a reduction of the HAM-A to less than 7 and have very minimal psychological symptoms and no psychomotor symptoms (Duits et al., 2014). Similarly, the tolerance trend is expected to continue, and hence the patient will have no side effects noted. Exploration of other augmentative therapies such as behavioral therapies is expected to foster the clients coping mechanisms leading to an enhanced reduction of worries.

The case scenario is a source of potential ethical dilemmas. First, the patient has a mental illness and hence possible alteration of the cognitive function and hence altered ability to make an informed judgment. In this case scenario, the practitioner has the obligation of providing the patient with information regarding their condition to foster self-determination as enshrined in the principle of autonomy (Butts & Rich, 2012). However, the client has altered judgment and hence the practitioner ought to override the autonomy if the client decides to refuse the prescribed medication. The bioethical principle of beneficence and non-maleficence have a significant bearing in this case study. Beneficence which dictates that the health workers should direct their decisions to benefit the client was utilized in selecting the best pharmacological agents for treating GAD (Butts & Rich, 2012). The bioethical principle of non-maleficence, on the other hand, was used to rule out the options that could predispose the patient to side effects (Butts & Rich, 2012). The case was also formulated without revealing the patient details and hence safeguarding his autonomy.

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