Advanced Psychopharmacology.

Introduction: This case study involves a 46-year-old male who presented for assessment after experiencing fears of an impending heart attack. The client reported symptoms such as chest tightness, a feeling of impending doom, and shortness of breath. The client further said anxiety, and especially regarding his fears about losing his job. He admitted to using ETOH to reduce stress. The EKG and ER findings were within the normal range, and thus a heart attack was ruled out. His HAM-A score was 26, confirming the diagnosis of a generalized anxiety disorder (GAD). Advanced Psychopharmacology.

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This paper will discuss decisions about the treatment choices for this client and conclude by discussing the ethical considerations that might affect the client’s treatment plan. Decision Point One: The first decision is for the client to start Zoloft 50 mg. This decision was chosen because the medication is an SSRI that prevents the reuptake of serotonin and thus increases the amount of serotonin within the brain (Rosenthal & Burchum, 2018). Serotonin is a neurotransmitter that regulates moods, and therefore it’s efficacy in treating symptoms of GAD. Additionally, Zoloft has an excellent safety profile and hence has minimal side effects, and it is well tolerated (Stahl, 2014). Advanced Psychopharmacology. Selection of this decision hoped that the client would manifest symptom improvement. This is due to the efficacy of Zoloft in improving anxiety and other symptoms associated with GAD. Moreover, it is hoped that the client would tolerate the medication and report no or minimal side effects. Evidence shows that Zoloft is well tolerated in people with GAD (Stahl, 2014). As anticipated, the client reported symptom improvement as he did not experience symptoms like breath shortness and tightness of the chest. The client further said that he had stopped worrying about his job. Moreover, the HAM-A scale indicated that he was partially responding to the treatment. Advanced Psychopharmacology. Symptom improvement is attributable to the efficacy of Zoloft medication in treating symptoms of GAD (Stahl, 2014). The client did not report any side effect, and this indicates the excellent safety profile and tolerability of Zoloft. Decision Point Two: The second decision is to increase the Zoloft dose to 75 mg. The rationale for this decision is to facilitate a higher treatment response for the client. According to Carvalho et al. (2016), a higher Zoloft dose is likely to increase the level of serotonin in the brain, and this ensures a more significant symptom improvement. The selection of the decision to increase Zoloft dose to 75 mg hoped that the client would manifest complete symptom remission due to the increased response. This is because higher doses of Zoloft lead to increased serotonin levels in the brain and thus increased symptom improvement (Steven et al., 2018). Advanced Psychopharmacology. Secondly, it is hoped the client will tolerate the increased dose, and therefore he will not report any significant side effects. As expected, the client reported significant symptom improvement with the increased dose. The HAM-A score further reduced. This increased symptom improvement is attributable to the increase Zoloft dose availing more serotonin in the brain and thus increasing response to treatment (Crocco et al., 2017). Moreover, the client was able to tolerate the increased dose as he did not report any side effects. Decision Point Three: The third decision is maintaining the current dose of Zoloft (75 mg). Advanced Psychopharmacology. The reason for choosing this decision is because the client is responding very well to treatment and, at the same time, tolerating the dose. Increased doses are associated with increased probability of side effects, and therefore it is safe and logical to maintain the Zoloft dose at 75 mg (Steven et al., 2018). They are maintaining the current dose expected that the client will continue responding to treatment and eventually achieve complete symptom remission. It is also likely that he will not experience significant side effects since Zoloft is well tolerated in people with GAD (Carvalho et al., 2016). Ethical Considerations:  Advanced Psychopharmacology. The PMHNP should seek informed consent from the client before starting any treatment. This includes giving the client all information regarding the medications, including the dependency associated with SSRIs. This will enable the client to make an informed choice concerning his treatment. The PMHNP needs to educate the client regarding the dependence associated with Zoloft and implement the appropriate strategies to prevent misuse or abuse of the medication by the client (Cartwright et al., 2016). It is also essential to ensure that confidentiality of all the information the client discloses during treatment. Conclusion: The first treatment choice was Zoloft 50 mg because of the efficacy of Zoloft in reducing symptoms of GAD. The client manifested partial response to treatment, and thus the second decision was to increase the Zoloft dose to 75 mg. Advanced Psychopharmacology. With the increased dose, the client showed a further response and did not report any side effects, and thus the third decision was maintaining the current dose. Before starting treatment, the PMHNP should obtain informed consent from the client and ensure that the client’s confidentiality is maintained throughout the treatment period. References Cartwright C, Gibson K, read J, Cowan O & Dehar T. (2016). Long-term antidepressant use: patient perspectives of benefits and adverse effects. Patient Prefer Adherence, 1(10), 1401–1407. Carvalho A, Sharma M, Brunoni A, Vieta E & Fava G. (2016). Advanced Psychopharmacology. The Safety, Tolerability, and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychiatry, 85(5). Crocco E, Aramillo S, Ortiz C & Camfield K. (2017). Pharmacological Management of Anxiety Disorders in the Elderly. Curr Treat Options Psychiatry, 4(1): 33–46. Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0. Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier. Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press. Steven S, Devvrat M, Dang J, Vanle B & IsHak W. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacol, 8(1), 49–58. Based on the above discussion answer questions 1-4; Use a minimal of 5 References Week 8 Assignment 1. Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. 2. Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Advanced Psychopharmacology. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. 3. What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. 4. Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. Advanced Psychopharmacology.

Question 1

GAD is the commonest mental disorder that is often under-diagnosed and undermanaged in primary care settings that results in persistent feelings of worry and fear in everyday life. This paper analyzes the decisions made in the psychopharmacological management of a 46-year-old who presented in the ER with complaints of impending doom, chest tightness, and shortness of breath. The patient also complained of anxiety feelings with an immense fear of losing his job and admitted to using ETOH to combat work-related worries. Despite ruling out myocardial infarction in the ER with an EKG, he still experienced these symptoms. His Hamilton Anxiety score was 26 that prompted the diagnosis of GAD.  In the initial visit (decision one), the patient was managed with Zoloft 50mg that was increased to 75 mg during the second visit (decision two) and maintained at 75 mg in the third and subsequent visits (decision tree). Advanced Psychopharmacology.

Question 2

The decision to manage the patient with Zoloft 50mg PO daily was influenced by the finding that Zoloft, an SSRI, also known as sertraline, is the first-line therapy for the management of GAD that has proven to be well-tolerated and highly efficacious. Zoloft is an SSRI that restores the balance of serotonin in the brain, which is often unbalanced in patients with anxiety (Bandelow, Michaelis & Wedekind, 2017). When balanced, it restores interest in daily life, improves mood, and reduces fear and anxiety.  The initial therapeutic dose of Zoloft is 25mg-50mg per day and PMHNP can increase the dosage with 25-50mg per day in case a patient responds inadequately to treatment to a maximum dose of 200mg per day (Locke, Kirst & Shultz, 2015). It is for this reason that in the second visit, the dosage was increased to 75mg PO daily and after attaining the desired therapeutic outcome; the dose was maintained at 75mg PO daily. Advanced Psychopharmacology.

Question 3

GAD is a common mental disorder that impacts negatively on a patient’s QoL and disrupts the ADL. The patient admitted to using ETOH to combat work-related worries revealing that his symptoms affected his ability to perform ADL efficiently and reduced his QoL. In such a case, only pharmacologic treatment will benefit the patient and provide symptom relief (Stahl, 2014). Therefore, the primary goal of acute therapy for GAD in this patient was to reduce the severity of the symptoms of SOB, chest tightness, feelings of anxiety and fear, to improve the patient’s functional status, achieve remission and minimize adverse drug reactions. As the first-line drug of choice for managing GAD, Zoloft relieves the symptoms of fear and anxiety that accompany GAD   by inhibiting the neuronal uptake of serotonin (Locke, Kirst & Shultz, 2015). In the long term, it was expected that adequate pharmacologic treatment would help to prevent relapse of symptoms, improve the patient’s QoL, and minimize adverse drug reactions. Advanced Psychopharmacology.

Question 4

At every decision point of treatment, there was no significant difference between the expected and actual outcomes of treatment.  For instance, after starting the patient on Zoloft 50mg PO daily at the first decision point, it was expected that the patient will have some relief of the symptoms of anxiety and fear after two weeks but long-term results may be achieved after four weeks or longer (Khushboo & Sharma, 2017). Similarly, after four weeks, the patient returned to the clinic and reported some improvement with partial response of 18 HAM-A scores. Since Zoloft produces better treatment outcomes with higher doses, this outcome prompted the decision to increase the dosage from 50mg PO daily to 75mg PO daily (decision two) where he reported even further reduction in symptoms (61%) and a HAM-A score of 10 as expected. Advanced Psychopharmacology.