Sample Treatment Plan Anxiety

PLEASE I WILL PREFER WRITER 1747 TO COMPLETE THIS ASSIGNMENT. PLEASE FOCUS ON THE RUBRIC. COPY AND PASTE THE LINK BELOW FOR THE CASE STUDY

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/DT/week_05/index.html

The Assignment: 5 pages

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.

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RUBRICS

1) 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.Sample Treatment Plan Anxiety

2) 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.

3) 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.

4) 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.

5) 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.Sample Treatment Plan Anxiety

Selective Learning Resources

Required Readings (click to expand/reduce)

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.

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

Psycho pharmacologic Management of a 46-Year-Old Caucasian Male with Generalized Anxiety Disorder (GAD)

The patient is a 46-year-old Caucasian male referred for psychiatric assessment by his primary care physician. He is a blue-collar worker at a steel factory. He had earlier presented to the emergency department with symptoms suggestive of a heart attack (tightness of the chest and dyspnea). After a thorough physical examination and collection of objective information including an ECG reading at the ER, it was however determined that the client was not suffering from acute coronary syndrome (ACS). Myocardial infarction (MI) is a part of ACS. The rest of the physical examination had also revealed nothing physically wrong with the client. He does suffer from mild hypertension that is managed by dietary restrictions. He has also been determined to be overweight (25 kg/m²<BMI<30 kg/m²). During the psychiatric interview, the client insists that he still has dyspnea and tightness of the chest but which he now attributes to some sort of “anxiety.” He admits to drinking alcohol (about 3 or 4 beers a night) due to work stress. He is single but cares for his old parents from time to time. He admits to lacking psychological safety at his place of work and states that he is afraid he might lose his job. To measure the severity of the client’s anxiety, he is administered with the Hamilton Anxiety Rating Scale (HAM-A). He scores 26, which indicates moderate to severe anxiety (Psychiatry and Behavioral Health Learning Network, 2021; Codajic, n.d.). The mental status examination (MSE) reveals that the client is alert and oriented in all respects. He is appropriately dressed for the weather and time of the day but describes feeling nervous. He displays broad affect that at some points appears blunted. He denies delusions and/ or hallucinations as well as homicidal or suicidal thoughts. His judgment and insight are intact and he understands that he needs treatment for his psychiatric condition. A diagnosis of generalized anxiety disorder (GAD) is made as per the diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5 (Sadock et al., 2015; APA, 2013). This paper is about the psychopharmacologic choices that are to be made to treat the client’s GAD.Sample Treatment Plan Anxiety

Decision Point Number 1

The decision selected for the psychopharmacologic treatment of the client’s GAD was sertraline (Zoloft) at a starting dose of 50 mg orally every day. Sertraline is an atypical antidepressant and anxiolytic belonging to a class of psychoactive medications referred to as selective serotonin reuptake inhibitors or SSRIs. Despite its efficacy in treating GAD which informed its selection and not the other two options, it is not FDA-approved for treating the condition (Stahl, 2017). The reason why this choice was made was that sertraline (Zoloft) has shown statistically and clinically significant efficacy in trials in the treatment of generalized anxiety disorder. One particular study stands out in this respect. It is a study that was carried out by Allgulander et al. (2004) to evaluate the efficacy of sertraline in treating GAD. The results of the 12-week trial showed definitively that sertraline was efficacious in treating GAD and reducing the symptoms substantially. They also determined that the drug is well tolerated and does not produce many side effects that affect the subject’s functionality. In particular, the researchers determined that the anxiolytic effects of sertraline were not only greatly efficacious in alleviating the psychic symptoms. They also effectively reduced the somatic symptoms displayed by the participants. It is for this reason that Zoloft was chosen over the other two options. This 46 year-old client has extensive somatic manifestation of his anxiety in the form of chest tightness, a feeling of impending doom, and dyspnea. From the study results by Allgulander et al. (2004), sertraline should be able to relieve these somatic anxiety symptoms.

Imipramine was not selected because it has shown greater efficacy in alleviating psychological symptoms of GAD as opposed to somatic anxiety symptoms (Stahl, 2017). For this reason, sertraline (Zoloft) that alleviates somatic symptoms better according to evidence-based practice (EBP) was chosen. Buspirone was also not selected because it carries a greater risk of rebound anxiety in the event that the client turns out to be noncompliant with treatment (Stahl, 2017). By making the decision of prescribing sertraline (Zoloft), it was expected that the client would experience a reduction of his somatic symptoms within the first four weeks of treatment (Allgulander et al., 2004). This would be apparent from assessment by the HAM-A tool. Ethical considerations of nonmaleficence and beneficence impact my treatment plan in that I only choose the drug that will bring the greatest benefit and the least suffering in terms of side effects. And that rug in this case is Zoloft.

Decision Point Number 2

After the first decision of commencing the client on sertraline 50 mg orally daily, the patient returns with news of welcome improvement. After four weeks of using the Zoloft as prescribed, he now reports the absence of chest tightness and dyspnea. He is also reporting a decrease in his anxiety about his work situation in the last few days. Most importantly, he now scores just 18 on the HAM-A anxiety assessment tool. This score indicates that his anxiety is now mild from the baseline moderate score of 26 (Psychiatry and Behavioral Health Learning Network, 2021; Codajic, n.d.). It therefore shows a partial response to the treatment in just four weeks on the part of the client.Sample Treatment Plan Anxiety

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            The decision taken in this second decision point is therefore to increase the sertraline (Zoloft) dose to 75 mg orally daily. This decision is prompted by the client’s partial response to the treatment within just a short time. It is also made in light of the fact that the client is not yet showing any side effects of the medication, meaning that he is tolerating the medication quite well. These are some of the reasons as to why this decision was made. The other two options were not selected for the simple fact that they did not make any clinical sense at this point in time. Doubling the dose of the sertraline to 100 mg would not be prudent as it would predispose the client to the occurrence of side effects (Stahl, 2017). It is therefore more cautious to increase the dose to 75 mg instead of 100 mg at this second visit. Leaving the dose at 50 mg without increasing it would also be clinically unintelligent. This is because since the client has already shown partial response with the 50 mg-a-day dose, it is only logical to expect and to hope that a slight increase will bring even more improvement. The hope in increasing the dose to 75 mg orally each day was that there would be a greater clinical response to treatment and further reduction in the symptoms. On ethics, the moderate increase in dose to 75 mg instead of 100 mg was informed by nonmaleficence. Doubling the dose at a go to 100 mg would place the patient at risk of an explosion of side effects.

Decision Point Number 3

After making the second decision of increasing the dosage of sertraline to 75 mg orally daily after four weeks of treatment, he comes back again for assessment after another four weeks. He has now been on treatment for a total of eight weeks now. Luckily, he comes back this time again reporting a further alleviation of both his somatic and psychological symptoms of anxiety. To confirm this state of affairs, the HAM-A assessment is administered again to gauge the severity of his anxiety and response to treatment. Amazingly, the client scores just 10, meaning that his anxiety symptoms were now just mild to non-existent (a score of <17). The indication that this finding gave was that there was an actual reduction in symptoms of more than 50%. This kind of response to treatment does not warrant a change in the dose of medication but maintenance of the same dose to sustain the response.

The decision taken at this point is therefore to maintain the client on the same dose of sertraline (Zoloft). That is a dose of 75 mg orally daily. This decision was taken for two reasons. First, the client is already responding to treatment beyond expectations. There is therefore no clinical reason as to why the dose should be modified. Second, the client has shown immense toleration of the sertraline up to this point. With no clear clinical indication for increasing the dose, such an action will only place the client at a high risk of developing side effects (Stahl, 2017). The other two options were not selected because (i) there was no tangible clinical indication for increasing the dose of Zoloft to 100 mg, and (ii) there was also no indication or need for an augmentation agent like Buspirone (the patient was already responding to pharmacotherapy). What was hoped to be achieved by this decision was that the client would go into complete remission without any somatic or psychological symptoms of anxiety within 12 weeks. Nonmaleficence as bioethical principle still ruled in the decision of not increasing the dose to 100 mg. This is because it would place the client at a higher risk of side effects, something that the clinician ought to know.Sample Treatment Plan Anxiety

Conclusion

This was a classic case of GAD in a middle-aged man. The choice of pharmacotherapeutic agent to use in this case was informed by evidence-based practice (EBP). Sertraline (Zoloft) is an evidence-based pharmacotherapeutic intervention for the management of GAD. This efficacy is demonstrated by the trials that have proven it to be true, the fact that sertraline is not FDA-approved notwithstanding. When the client showed a significant response as demonstrated by the HAM-A tool, the only rational decision could be to moderately increase the dose without being overzealous. Doing this was also backed by evidence in that a steep increase in the dose would place the client at risk of side effects. When he again showed great response to the increased dose, it was time now to maintain him on the same dose since he had now shown symptom reduction of more than 50%. He was on the path to full remission.

References

Allgulander, C., Dahl, A.A., Austin, C., Morris, P.L.P., Sogaard, J.A., Fayyad, R., Kutcher, S.P., & Clary, C.M. (2004). Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. American Journal of Psychiatry, 161(9), 1642-1649. https://doi.org/10.1176/appi.ajp.161.9.1642

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders, 5^th ed. Arlington, VA: Author.

Codajic (n.d.). Hamilton Anxiety Rating Scale (HAM-A). http://www.codajic.org/sites/www.codajic.org/files/2.%20Hamilton%20Anxiety%20Rating%20Scale%20(HAM-A).pdf

Psychiatry and Behavioral Health Learning Network (2021). Hamilton Anxiety Rating Scale (HAM-A). https://www.psychcongress.com/saundras-corner/scales-screeners/anxiety-disorders/hamilton-anxiety-rating-scale-ham

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences/ clinical psychiatry, 11th ed. New York, NY: Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. New York, NY: Cambridge University Press. Sample Treatment Plan Anxiety