One of the most common anxiety disorders, generalized anxiety disorder (GAD), is marked by ongoing, excessive, and uncontrolled anxiety and concern over ordinary daily occurrences. The primary indicator of GAD, worry, is a component of the majority of anxiety disorders (Altunoz, 2018). Adults with GAD frequently experience extreme anxiety over everyday events, such as their career progression or performance, health, income, and the health and general well-being of their parents or children.
The 46-year-old white male with an anxiety disorder will be assessed and treated in this case study. The client is a welder at a local steel manufacturing company. He went to the emergency department and felt like he had a heart attack, so his PCP referred him today. He claimed to experience shortness of breath, a tightening of the chest, and a sense of impending doom. The patient describes the tightness and chest pain as anxiety episodes. Patients claim that he occasionally feels as though he wants to run and escape from wherever he is. The patient acknowledges using alcohol on occasion to ease his work-related anxiety. The patient, who is single, looks after his ailing parents at home.
He is well-oriented to people, time, and place, according to the assessment of his mental status. He speaks with clarity, coherence, and purpose. The client describes his own mood as “bleh” and admits to feeling “nervous.” He said that he experienced neither auditory nor visual hallucinations nor thoughts of homicide or suicide. Throughout the clinical interview, the effect is somehow blunted but does occasionally brighten. The patient said that his employer was strict at work and that he was afraid for his job. A diagnosis of anxiety disorder was obtained when the patient scored a 26 on the Hamilton Anxiety Rating Scale (HAM-A). One of the earliest rating tools to assess the intensity of experienced anxiety symptoms was the Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959). When prescribing drugs, it is important to consider the patient’s history of substance use and current level of regular drinking. For psychopharmacological therapies, there will be a step-by-step approach to treating the patient. The goal of this paper is to demonstrate how to assess and treat patients who need anxiolytic therapy dependent on the choice of the drug to be prescribed and the ethical considerations that could affect the treatment plan and client communication.
I would decide to start the patient on Paxil 10 mg once a day as the mental health nurse. The best drug with the least adverse effects should always be chosen when determining what to administer to a patient with an anxiety illness. The pharmacology of the drug and all the dangers and advantages must be understood by the health care providers. My initial choice was to recommend Paxil 10 mg PO once a day. Paxil is classified as a selective serotonin reuptake inhibitor (SSRI) antidepressant. The initial drugs attempted to treat GAD are often SSRIs like Paxil. Contrary to benzodiazepines, antidepressants like Paxil primarily treat psychological discomfort and anxiety symptoms, such as fear, worry, restlessness, and difficulty concentrating. Research demonstrates that Paxil, regardless of gender or ethnicity, effectively lowers anxiety in people who have GAD (Mochcovitch et al., 2017). According to several studies, taking GAD drugs like Paxil for at least six months following remission may help prevent symptom relapse (Mochcovitch et al., 2017). Paxil should be used with caution, as with any medicine taken, and this is achieved through patient education.
Since the patient had never used any psychiatric drug, I made the decision to start him on a low dosage of Paxil. One may experience suicidal thoughts at the start of treatment or when the dose is changed. It is ethically right to inform the patient of any potential side effects of this drug. Additionally, it is advised to enhance patient-nurse contact when this therapy is first started to reduce suicidal thoughts. Although it would be wise to inform the client about the value of abstaining from alcohol during treatment, it is unethical telling them to quit totally. Paxil’s advantages may be diminished by alcohol; therefore, encouraging the client to limit their consumption will be helpful. At four weeks, I was anticipating at least a 50% reduction in symptoms. In four weeks, the client comes to the clinic and says he no longer has chest tightness or shortness of breath. He claims that during the last four or five days, his concerns regarding his job have lessened. A repeat of the HAM-A score is now 18 (partial response).
The decision is to raise the dosage to 20 mg po daily at this point. Since this client has been taking Paxil without experiencing any negative side effects, I decided to double the dose. Maintaining the same dosage would not have altered any of its effects, in my opinion. I decided against raising it to 40 mg PO once a day since I did not want the patient to encounter any severe negative side effects, such as suicidal thoughts. In addition, there was not much improvement in his HAM-A tool. Paxil dosage adjustments should be made in 10-mg increments for individuals who do not demonstrate an appropriate therapeutic response between 1 to 4 weeks of starting treatment (Osuch, 2017). Paxil should not be taken in excess of 60 mg per day.
A greater reduction in anxiety symptoms and a lower score on the HAM-A assessment were the desired outcomes at this decision point. Side effects and patient tolerability is also regarded as the main objective. In four weeks, the patient returns to the clinic and says that his symptoms have further subsided, and his HAM-A score is now 10. At this point, continuing the current dose is critical (61% reduction in symptoms of anxiety).
My third choice was to keep taking the Paxil at the same dosage. This patient is responding well (as seen by a greater than 50% reduction in symptoms). Since the patient reports no adverse or side effects, the present dose can be kept up for another 12 weeks to assess the full impact of the medication. Early treatment termination due to common, treatment-emergent adverse effects, such as nausea, restlessness, and somnolence, may subvert the effectiveness of antidepressants (Hengartner, 2020). Paxil was created to increase gastrointestinal and overall tolerability so that it may be used for lengthy periods of time, up to 12 weeks (Hengartner, 2020). At this point, increasing the dosage may result in a further reduction in symptoms, but it may also raise the chance of adverse effects. It is, therefore, important to talk to the client about this choice. Nothing in the client’s condition suggests that, given how well the client is responding to the medication, we should now think about adding an augmentation agent. Providers must recognize that they should avoid polypharmacy unless their patients’ symptoms can not be treated with a single medication.
The objective at this time was to maintain the patient alive and stop a recurrence of symptoms. For the majority of people with major depressive disorder (MDD), recurrent anxiety is an issue over the course of their lives (Saris et al., 2017). Remission and essentially no longer having any symptoms are hence the best therapy objectives. There would be no justification for changing the dosage or drug if the patient can function at their highest level in life and tolerates this dose without experiencing any side effects.
It might be challenging to get through the day if one suffers from an anxiety disorder. Sweating is one of the symptoms, along with feelings of anxiety, panic, and fear. Anxiety does not easily disappear for those who have an anxiety condition, and it may even worsen with time. Daily tasks, including job performance, academic progress, and interpersonal interactions, might be hampered by the symptoms. A continuous sense of dread or worry that interferes with daily living is typically a symptom of a generalized anxiety disorder (GAD).
It is vital to consider a variety of factors before beginning and discontinuing new drugs in light of the case study’s many varied aspects. When providing care, it’s crucial to take into account all the many client-related variables that could affect the client’s treatment strategy. Paxil, in particular, is the medication that is most usually suggested to help with anxiety disorders since it is well tolerated for extended periods of time. Accordingly, the patient found that Paxil worked best for him. This is a safe drug to use and has a serotonin-related effect that may help with his anxiety. The patient would still require substantial education regarding the medication and its side effects. He should limit his alcohol intake if he does not stop. His anxiety was his main issue when he first arrived at the facility, and after starting therapy, his HAM-A scores decreased positively from 26 to 10.
Altunoz, U., Kokurcan, A., Kirici, S., Bastug, G., & Ozel-Kizil, E. T. (2018). Clinical characteristics of generalized anxiety disorder: Older vs. young adults. Nordic Journal of Psychiatry, 72(2), 97-102.
Hamilton, M. A. X. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology 32, 50–55. Web.
Hengartner, M P. (2020). How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding. Therapeutic Advances in Psychopharmacology, 10.
Mochcovitch, M. D., da Rocha Freire, R. C., Garcia, R. F., & Nardi, A. E. (2017). Can long-term pharmacotherapy prevent relapses in generalized anxiety disorder? A systematic review. Clinical Drug Investigation, 37(8), 737–743.
Osuch, E., & Marais, A. (2017). The pharmacological management of depression–update. South African Family Practice, 59(1), 6-16.
Saris, I. M. J., Aghajani, M., Van Der Werff, S. J. A., Van Der Wee, N. J. A., & Penninx, B. W. J. H. (2017). Social functioning in patients with depressive and anxiety disorders. Acta Psychiatrica Scandinavica, 136(4), 352-361.