Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

Week 8 Discussion

Generalized anxiety disorder is characterized by excessive or unrealistic anxiety about two or more aspects of life such as work, social relationships, financial matters, etc., often accompanied by symptoms such as palpitations, shortness of breath, or dizziness. Consequently, generalized anxiety disorders (GAD) are usually accompanied by restlessness, feeling on edge, easily fatigued, difficulty concentrating,  mind going blank, irritability, muscle tension, and sleep disturbance.

Regarding inhibiting factors, people with GAD are prone to ambivalence about relinquishing their worries. On the one hand, they may be motivated to reduce the distress that worries cause, yet, on the other hand, they may experience fear as an adaptive mechanism of readiness and control. ( Muir, H. J. & Antony, M. M., 2021).

While on the cardiovascular unit, a 48-year-old male, Mr. F.T., visited his family who had just had surgery, and all of a sudden, he started having chest pain and could not keep his thought process, SOB,  and was restless. Therefore, the charge nurse took the patient to the ED ( Emergency Department), Where they did a cardiac workup which came back negative for MI (Myocardial Infarction). Consequently, Mr. F.T. had been referred for a psychological evaluation.

Upon psychological evaluation, the patient reports that he is currently taking care of his aging patients in his own home and has concerns about his job. Because of these issues, he drinks  a few beers a night to help calm himself. Upon mental exam, the patient admits feeling

anxious with an overall broad affect. Otherwise, the exam is relatively routine, with no thoughts of suicidal ideation. The Hamilton Rating Anxiety Scale, a 14-item scale used to measure the severity of anxiety symptoms, was administered,  yielding a score of 26, which is considered moderate to severe anxiety (Gang, Y. & Han, N., 2019).

First Decision

I chose  to start the patient on Buspirone 10mg PO BID, as Zoloft is not indicated for initial treatment in GAD, and Imipramine is used to treat clinical depression. Benzodiazepines are considered first-line treatment for anxiety disorders, but given none of those were an option, I chose buspirone as it is just as effective as benzos with no abuse potential (Rosenthal & Burchum, 2018). After four weeks of use, the client reports a slight decrease in symptoms but still feels very anxious. The HAM-A score decreased to 23, considered mild to moderate anxiety (Thompson, 2015). Even though Buspirone anxiolytic effects develop slowly (Rosenthal & Burchum, 2018), the patient should have seen some relief of anxiety within the first four weeks. Even though he did have a slight decrease in the HAM-A score, he still feels very anxious.

The second decision

I chose to discontinue buspirone and begin Lexapro 10mg orally daily. The patient needs to see relief, and although increasing the buspirone may improve his anxiety a little bit, it might take several more weeks to see improvement. At this point, I think it would be an excellent option to try a different medication, and Lexapro is one of the only SSRIs approved to treat GAD. Although the anxiolytic effects are slow, they can be seen in a week, are better at decreasing cognitive and psychic symptoms of anxiety and are effective even when depression is absent (Rosenthal & Burchum, 2018).

The third decision

I chose to continue the same dose of Lexapro but change the administration time to bedtime. The patient reports that he feels “great” and that his anxiety is “better,” with a decrease in his HAM-A score down to 13, which is now considered mild anxiety (Thompson, 2015). Since the patient states he feels a bit tired a few hours after taking the medication, and it would be good to change admin time to bedtime. That way, he is already sleeping during that “sleepy” and should feel refreshed when he wakes in the morning. Otherwise, if the patient is feeling good, there is no need to add any additional medications or increase the dose currently.

 Impact of Pharmacotherapeutics

Since Lexapro is a Selective Serotonin Reuptake Inhibitor (SSRI), its primary mechanism of action is to block the neuronal reuptake of serotonin, a monoamine neurotransmitter (Rosenthal & Burchum, 2018). SSRIs block serotonin leading to its accumulation in the neural junction, thus allowing appropriate transmission relating to emotions and stabilizing levels of serotonin leading to anxiety (Christensen et al., 2014). Lexapro is generally well tolerated and has no potential for abuse, therefore may be more appropriate for this patient since he drinks typically every night.

References

Batterham, P. J.& Hickie, I. (2019). The effectiveness of an online e-health application compared

to attention placebo or sertraline in the treatment of generalized anxiety disorder. Internet Interventions, 1(4), 169-174

Gang, Y. & Han, N. (2019). Chart review of patients receiving valsartan-amlodipine single-pill

combination versus valsartan and amlodipine combination for blood pressure goal achievement and effects on the Hamilton anxiety rating/Hamilton depression rating scales. Medicine, 98(51), 1–8. https://doi.org/10.1097/MD.0000000000018471

Muir, H. J. & Antony, M. M. (2021). Integrating Responsive Motivational Interviewing With

Cognitive-Behavioral Therapy (CBT) for Generalized Anxiety Disorder: Direct and Indirect Effects on Interpersonal Outcomes. Journal of Psychotherapy Integration, 31(1), 54–69.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice

providers. St. Louis, MO: Elsevier