Introduction
The case involves a 46-year-old Caucasian male employed as a welder at a steel manufacturing company. Stressful life events often precipitate specific behavioral and emotional effects (American Psychiatric Association, 2010a). The patient was brought to the emergency room for what he believed was a heart attack. He reported symptoms consistent with the condition, such as chest discomfort, shortness of breath, and an overwhelming sense of dread. During his visit, an electrocardiogram (EKG) was performed, which ruled out myocardial infarction (MI), and a physical examination revealed nothing unusual. The patient is also hypertensive and overweight, and controls his elevated blood pressure by monitoring his sodium consumption.
The patient did not provide any additional information regarding his medical history, nor did he mention any medications or herbs. He is a widower who pays for his elderly parents’ care out of pocket. He acknowledged drinking at least three to four beers a night to cope with the stresses of his profession. According to him, his boss was harsh, and he was concerned about his employment status at the company.
A mental status exam revealed that the client was alert and oriented to the place, person, time, and event. He was appropriately dressed, coherent, and expressed his ideas clearly. The client’s mood matched his affect, which was somewhat blunt, and he reported feeling nervous. There are no reported incidences of visual or auditory hallucinations, no paranoid thought processes, and no instances of suicidal ideation. The client’s judgment is grossly intact, and he has insight. A Hamilton Anxiety Rating Scale reveals a score of 26.
Decision 1
The choices for the first decision are to start with 10mg of oral Praxil daily, 25mg of oral Imipramine twice a day, or 10mg of oral Buspirone twice daily. I chose to start the patient on 10 mg of oral Praxil daily. The reasoning is that paroxetine, both in its quick-release and control-release formulations, has been shown in multiple major randomized controlled studies to be effective in the management of acute and long-term panic disorder (American Psychiatric Association, 2010b).
The drug’s oral bioavailability is excellent (Stahl, 2021). Patients on paroxetine also reported a significant decrease in self-reported interpersonal problems (Bendek et al., n.d.). It should be noted that saturation during the liver passes results in increased bioavailability. Praxil is the ideal treatment option given the patient’s presenting symptoms.
The other two options were not chosen for the following reasons. Firstly, Imipramine has an unfavorable side effect profile, with studies indicating that an estimated 20% of patients experienced severe adverse reactions (American Psychiatric Association, 2010b). Secondly, the available data demonstrate that Buspirone is ineffective in the management of anxiety disorders (American Psychiatric Association, 2010b).
The reason for choosing Praxil was to achieve adequate symptomatic relief, given that the medication’s regulation of vital serotonergic pathways significantly reduces generalized anxiety symptoms (American Psychiatric Association, 2010b). Therefore, the patient would experience less chest tightness and a reduced feeling of doom and would have a lower HAM-A score. Ethical considerations that must be taken into account include the patient’s autonomy. The patient will be allowed to make decisions regarding their treatment without undue influence from the medical staff.
Decision 2
The options include increasing the Praxilto dose to 20 mg, maintaining the current dose, or increasing it to 40 mg orally. I chose to increase the Praxil dose to 20mg orally. This is due to it being advised that patients who do not demonstrate an adequate response after treatment initiation have the drug dose increased gradually.
Even though the patient reports that some symptoms, such as chest tightness, shortness of breath, and work-related worries, have reduced, the HAM-A score of 18 indicates a partial response. There is, therefore, a need to increase the dosage to 20 mg orally. The decision to maintain the current dose is ill-advised, as the patient has shown partial symptom improvement. Increasing the treatment to 40mg is not appropriate, given that the patient is likely to suffer from heightened adverse effects when a high dose is introduced quickly.
The second decision aimed to facilitate the achievement of specific management goals. Firstly, it is vital to ensure continued improvement in the patient’s condition and a further decrease in the HAM-A score, provided the client can tolerate the treatment. It is also critical to ensure that the therapeutic dose of the drug, between 20 and 50 mg, is administered to achieve the objectives, starting with the lowest dose (Stahl, 2021). Another key principle to take note of is the prioritization of informed consent. For example, the patient must understand the potential benefits and side effects of Praxil in managing their condition.
Decision 3
The available options for the third choice are to maintain the current dose, increase the dose of the medicine to 30mg PO daily, or add an agent such as Buspar (Buspirone). I chose to keep the Praxil dose at 20 mg orally. The verdict was based on the American Psychiatric Association’s endorsement of a dose range of 20-40 mg per day, supported by comprehensive clinical trials (American Psychiatric Association, 2010b).
An extensive randomized controlled study demonstrated that 20mg of Paroxetine was associated with a 67% remission rate in symptoms, compared with 65% for patients on 40mg of the same drug (American Psychiatric Association, 2010b). The evidence indicates that there is no immediate benefit to increasing the dosage unless there is a lack of response to treatment. The client has experienced a significant reduction in the patient’s symptoms, with no associated adverse effects. It is vital to administer the treatment for at least 12 weeks to evaluate the drug’s effects fully.
Increasing the medication’s dose to 30mg orally is not recommended because there is a risk of amplified undesirable effects. Even though Buspirone is used in specific circumstances as an augmentation strategy in patients with anxiety disorders, there are no published studies except for case reports to support the practice (American Psychiatric Association, 2010b). In addition, the resolution of the patient’s symptoms suggests that he is responding adequately to the treatment. Polypharmacy should be avoided unless it is difficult to control the symptoms using a single drug. Therefore, there is no need for augmentation with additional medications.
The third decision aims to achieve symptom resolution without causing additional side effects. The ethical consideration that must be addressed is the patient’s right to accurate information. For example, it is vital to discuss the possible increase in side effects following an increase in the drug dosage with the patient. It is also essential to discuss the potential reduction in treatment duration with a higher medication dosage.
Conclusion
The vignette highlights a case in which a Caucasian male is diagnosed with generalized anxiety disorder (GAD). The ideal choice of treatment based on the provided options is 10 mg of Paxil taken orally. The drug is a selective serotonin reuptake inhibitor with a high degree of efficacy in the management of GAD. It is superior to Imipramine and Buspirone, as it is better tolerated, is almost completely absorbed orally, and is effective for both acute and chronic symptoms.
It is essential to increase the Praxil dose from 10mg to 20mg to ensure the patient experiences better symptom relief. The initial dose precipitated a partial response as demonstrated by the alleviation of chest discomfort, breathing difficulties, and feelings of worry. Therefore, it is essential to increase the dosage to facilitate symptom improvement, given that the medication’s therapeutic dose starts at 20mg.
Increasing the medication further would precipitate unwanted side effects, while maintaining it at 10 mg is not ideal for the resolution of the patient’s symptoms. Increasing the dosage to 30mg is unwise, given that it may precipitate unwanted side effects. The inclusion of Buspirone is not supported by credible evidence and should, therefore, be avoided. Praxil is an effective intervention for Generalized Anxiety Disorder.
Specific patient factors were considered when selecting and prescribing medication. Firstly, the patient’s autonomy was considered in all the decisions. All options were presented, and a choice was made based on the client’s wishes. Secondly, the client’s right to information, as well as the provision of informed consent, had bearing on decisions regarding dose increments or maintenance. The patient has since achieved a significant degree of normalcy and can carry out his daily activities without the interruption of cumbersome symptoms.
References
American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.
American Psychiatric Association. (2010b). Practice guideline for the treatment of patients with panic disorder (2nd ed.).
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.
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.