What are the parameters for monitoring the success of the therapy?
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Irmaylin Duran Parra
1. List specific treatment goals for L.P.
The key treatment goals for L.P is to reduce the general frequency, duration and intensity of her anxiety to allow her to continue with daily functioning and work. The client should also learn to implement different coping skills that would reduce her worry and level of anxiety. Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence (Gautam et al., 2017).
2. What drug therapy would you prescribe? Why?
Selective serotonin reuptake inhibitors are the drug of choice for the management of generalized anxiety. The medications recommended for the condition include escitalopram, fluoxetine and paroxetine (Gautam et al., 2017). These have central activity and will have a faster onset of action compared to other drug choices. They also have lesser side effects. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others.
3. What are the parameters for monitoring the success of the therapy?
The frequency of the worry periods and feelings of uneasiness will be recorded through the course of the treatment. Further, her ability to sleep and perform at work will also be included in the parameters to monitory therapy effectiveness. Patients should receive “psychoeducation” about their diagnosis, the possible etiology, and the mechanisms of action of the available treatment approaches. Before considering a patient to be treatment unresponsive, it should be ascertained that the diagnosis was correct, adherence to the treatment plan was sufficient, the dose prescribed had covered the full range, and there had been a trial period of adequate duration (Driot et al., 2017).
4. Describe specific patient monitoring based on the prescribed therapy.
At the baseline level, and the weekly for the first four weeks of therapy, the patient will have to be monitored for suicidal behavior and thoughts. SSRIs are associated with the potential for increased depression and suicidal tendencies (Driot et al., 2017). L.P will also have to be monitored for serotonin syndrome dystonia and increased predisposition to bleeding. SSRIs are associated with side effects such as indigestion, diarrhea and dizziness. These lead to weight loss and feelings of nausea.
5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
Extreme side effects that might necessitate medication change include excessive weight loss that does not resolve with the continued use of the medication. Further, the induction of suicidal thoughts is a premise for medication discontinuation. Although there may be concern about tachyphylaxis, there is limited evidence of adverse outcomes with the chronic use of SSRIs or SNRIs. These medications also tend to be well-tolerated, with usually manageable or short-lived adverse effects such as nausea, headache, dry mouth, diarrhea, or constipation. Sexual dysfunction tends to be a more durable and problematic adverse effect of SSRIs and SNRIs but can be managed with adjunctive treatments. There is the possibility of patients developing antidepressant-induced jitteriness or anxiety, potentially due to initial surge of serotonin, although this anxiety can be mitigated by slower titration or adjunctive use of benzodiazepines (Bandelow, 2017).
6. What would be the choice for second-line therapy?
Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have reasonable efficacy data in anxiety disorders but are usually reserved for second-line treatment due to safety and tolerability issues. The benzodiazepines play an important role in the treatment of some anxiety disorders; however, these agents too are usually reserved for second-line or adjunctive use due to tolerability and abuse liability issues. Buspirone is considered second-line medication for the management of the anxiety. The medication can be used on an ongoing basis. Buspirone, a 5-hydroxytryptamine receptor 1A (5HT1A) agonist, has been shown in some controlled studies to be effective in the treatment of GAD. However, not all studies have shown superiority to placebo and/or equivalence to standard drugs. Also, the medication may take up to several weeks for its effect to be felt (Bandelow, 2017).
1-Driot, D., Bismuth, M., Maurel, A., Soulie-Albouy, J., Birebent, J., Oustric, S., & Dupouy, J. (2017). Management of first depression or generalized anxiety disorder episode in adults in primary care: a systematic metareview. La Presse Médicale, 46(12), 1124-1138.
2-Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Gautam, A. (2017). Clinical practice guidelines for the management of generalised anxiety disorder (GAD) and panic disorder (PD). Indian Journal of Psychiatry, 59(Suppl 1), S67.
3-Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107. doi:10.31887/DCNS.2017.19.2.
Tatiana Davalos Sarria
One might presume that the treatment goal for GAD is for the patient to have less anxiety. However, as Stein, et al. (2021) of BMC Psychiatry point out, the helpfulness of treatment for GAD is a subjective measure. Related issues include treatment adherence and whether psychotherapy is prescribed in addition to pharmacological treatment (Stein, et al., 2021). Ultimately, the helpfulness of treatment comes down to whether the patient feels less anxious in their day-to-day life. For healthcare providers, treatment goals should be helping the patient to achieve that.
Along with drug therapy for L.P., psychotherapy, specifically cognitive behavioral therapy (CBT), should be recommended as well. As for medications, it may take trial and error to figure out which of the many options that are available will work best for L.P. The first type of medications listed by Munir and Takov (2021) of Stat Pearls are antidepressants. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) are considered first-line pharmacotherapy for GAD with response rates between 30 and 50 percent. Several medications are included in these two drug classes including escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR), and paroxetine (Paxil). Munir and Takov (2021) also list antipsychotics as possible pharmacotherapy for L.P. (Munir & Takov, 2021).
Other classes of medication that might be considered include benzodiazepines and buspirone. Benzodiazepines, which include diazepam and clonazepam, is only for short-term relief of symptoms. Patients who understand that there symptoms have a psychological source and who are cooperative respond better to benzodiazepines. However, benzodiazepines can also be addictive, but L.P. does not have a history of addiction, so benzodiazepines could be considered for her treatment. Buspirone is a non-benzodiazepine and does not cause dependency, but it takes 2 to 3 weeks before the therapeutic benefits are realized (Munir & Takov, 2021). For L.P., the best choice of pharmacotherapy is to start with the first-line treatment of antidepressants and prescribe 10 mg. per day of Lexapro. If it does not result in some relief for L.P., other medications could be added or substituted.
Parameters for Monitoring
Patients being treated for GAD should be monitored. One reason for this may be the types of medications they are prescribed. Some of the medications used to treat GAD may be sedatives, which may not be helpful to patients who have jobs and must work such as L.P. Another reason for the monitoring is that about half of the patients who are treated for GAD will not respond to the first line treatment according to Ansara (2020) of Mental Health Clinician. This can lead to treatment resistant GAD (TR-GAD). TR-GAD occurs when a patient does not respond to at least one antidepressant at an adequate dose after trying it for an acceptable amount of time (Ansara, 2020). Depending upon what type of antidepressant (or other medication) was prescribed for L.P., she should be asked to check in at least once a week with her primary provider so it can be determined if the medication is taking effect or not.
The main adverse reaction to Lexapro may be that it is not effective. Some of the side effects associated with Lexapro include a decreased interest in sex, the inability to have an orgasm or to get or keep an erection, and/or the loss of sex drive or desire. While these are disturbing side effects, they may only be temporary. If L.P. experiences them, she should notify her primary provider. Other rarer side effects that would require notification of the prescriber too include coma, confusion, decreased urine output, fast or irregular heartbeat, headache, increased thirst, muscle pain, nausea or vomiting, seizures, swelling of the face, ankles or hands, trouble breathing, and/or unusual tiredness or weakness (Mayo Clinic, 2021).
Rather than trying a benzodiazepine on L.P. as a second-line treatment, the primary provider should prescribe her a different antidepressant to see if it has more success in addressing the anxiety from which she suffers. Lexapro is an SSRI, so perhaps an SNRI would work better for L.P. She should also be seeing a psychotherapist for CBT.
Ansara, E. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician, 10(6), 326-34. Retrieved from https://watermark.silverchair.com/i2168-9709-10-6-326.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAtwwggLYBgkqhkiG9w0BBwagggLJMIICxQIBADCCAr4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMaKdibtPUnM3EMMoEAgEQgIICj6ki8jmB74uzk57-YZdZhCo-DdzA_ywftNb
Mayo Clinic. (2021, November 1). Escitalopram (Oral Route). Retrieved from Mayo Clinic: https://www.mayoclinic.org/drugs-supplements/escitalopram-oral-route/proper-use/drg-20063707?p=1
Munir, S., & Takov, V. (2021). Generalized Anxiety Disorder. Stat Pearls. Retrieved from https://www.statpearls.com/ArticleLibrary/viewarticle/22130
Stein, D., Kazdin, A., Ruscio, A., Chiu, W., Sampson, N., Ziobrowski, H., & Aguilar-Gaxiola, S. (2021). Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report. BMC Psychiatry, 21(392), 1-14. Retrieved from https://bmcpsychiatry.biomedcentral.com/track/pdf/10.1186/s12888-021-03363-3.pdf