Feb 23, 2024 NURS 6521 Comparing And Contrasting Pharmacologic Options For The Treatment Of Generalized Anxiety Disorder
NURS 6521 Comparing And Contrasting Pharmacologic Options For The Treatment Of Generalized Anxiety Disorder
A Sample Answer For the Assignment: NURS 6521 Comparing And Contrasting Pharmacologic Options For The Treatment Of Generalized Anxiety Disorder
Summary of Patient Case Study
A 71-year-old Asian man with a history of GAD, which was caused by diabetes and hypertension, was presented to our inpatient psychiatric clinic. He was mainly brought for stabilization and long-term medication. The information gathered from the family stated that the patient had refused oral food intake for about thirty hours, was isolative in his room, and had increased confusion.
The diagnosis also showed a history of GAD in the patient’s family, especially among aged people. After admitting him to our clinic, the clinical presentation of the patient depicted a transformed level of consciousness. I took three imperative decisions I thought could help him. They include: stabilizing him, performing psychotherapy, and administering relevant medication.
Evaluation of My Decisions
I believe the decisions I provided were supported by evidence-based literature. According to Watts et al. (2020), psychotherapy involves working with therapists to reduce the level of GAD. For example, in our case, I recommended the therapist to use behavioral therapy because it was the most effective psychotherapy for GAD. On the other hand, stabilizing the patient is imperative because it ensures the conditions of the patient are within the healthy range (Savioli et al., 2020).
For example, in our case, I recommended calming the patient to regain his level of consciousness. Lastly, I recommended the patient’s medication because it could ease symptoms and prevent or halt hypertension and diabetic conditions (Wilhelmsen & Eriksson, 2019). Medication was the heart of everything because the patient’s issues were beyond anxiety disorders.
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Objectives of My Decisions
First, I hoped behavioral therapy could help the patient manage various GAD-related symptoms, such as anxiety and stress. I also expected this treatment option could help the patient cope with negative emotions. Second, I hoped the medication decisions I recommended, such as Crestor 20mg daily, Lantus insulin 10 units daily, Metformin 70mg daily, Lithium 300mg daily, and hydrochlorothiazide 25mg daily, could help the patient improve his hypertension and diabetic conditions.
Lastly, I hoped the patient would be stable after recommending a stabilization program in the emergency room. I also expected his pressure to normalize after calming him by providing personal attention.
Differences between Expectations and Results
In psychotherapy, the expected results were attained. For example, the patient coped with adverse emotions and managed his anxiety and stress. He calmed down and started conversing with me. On the other hand, the prescribed medication also responded positively as planned. For example, in this decision, I aimed to improve the patient’s diabetic condition, which came down to manageable levels. Therefore, there was no difference between the anticipated and results. Lastly, the objectives of my decision to stabilize the patient aligned with the outcomes. For example, the patient’s hypertension was very high, but I managed to bring it to normal levels.
NURS 6521 Comparing And Contrasting Pharmacologic Options For The Treatment Of Generalized Anxiety Disorder
Pharmacokinetics and Pharmacodynamics Processes
In the pharmacokinetics process, the medication I recommended, especially oral medication, undergoes three stages. Absorption is the first stage, where the medicine is ingested and passed through the stomach into the intestine linings. The second stage is distribution, where the drugs pass through the liver and intestines into the bloodstream. The third stage is metabolism, where the drug undergoes glucuronidation and oxidation.
The last stage is the excretion of the medicine, mainly through the functioning of the kidney. The pharmacodynamics commences when the drug reaches the target organ or tissue. The drug may involve enzyme inhibition or cause presynaptic or postsynaptic effects on the patient. The final part of pharmacodynamics involves cellular response and signal transduction.
References
Savioli, G., Ceresa, I. F., Manzoni, F., Ricevuti, G., Bressan, M. A., & Oddone, E. (2020). Role of a brief intensive observation area with a dedicated team of doctors in the management of acute heart failure patients: a retrospective observational study. Medicina, 56(5), 251.
Watts, S., Marchand, A., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., & Dugas, M. J. (2020). Telepsychotherapy for generalized anxiety disorder: Impact on the working alliance. Journal of Psychotherapy Integration, 30(2), 208.
Wilhelmsen, N. C., & Eriksson, T. (2019). Medication adherence interventions and outcomes: an overview of systematic reviews. European Journal of Hospital Pharmacy, 26(4), 187-192.
Anxiety disorders are the most common mental condition among both children and adults with an increased risk of comorbid mood, significantly contributing to the world’s burden of disease. Epidemiological studies reveal that GAD affects approximately 5% of the entire population regardless of latitude, compromising their quality of life (Hurtado et al., 2020).
For this reason, different types of anxiety medications are available for the management of the various types of anxiety disorders outlined in the DSM-V. This discussion illustrates a comparison of the pharmacokinetics and pharmacodynamics relating to the different pharmacological options for the management of GAD.
Current clinical guidelines recommend the use of different classes of drugs for the management of anxiety disorders such as serotonin and noradrenaline reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOI), benzodiazepines and some antipsychotic and anticonvulsant in addition to miscellaneous agents, like 5-HT1A partial agonist, buspirone (Bandelow, 2020).
SSRIs (citalopram, paroxetine, sertraline) and SNRIs (levomilnacipran, duloxetine, desvenlafaxine) have been approved by the FDA as first-line for the management of anxiety disorders in adults. These drugs are recommended as the first-line mainly due to the great association of anxiety disorders with depression, in addition to the fact that they lack the potential for abuse and dependence.
TCAs (amitriptyline, dosulepin, clomipramine) and MAOI (phenelzine, isocarboxazid) are considered second-line for the management of anxiety disorder. However, unlike SSRIs and SNRIs, the use of TCAs and MAOIs are somehow limited in clinical practice due to less favorable safety profiles and side effects such as weight gain, and increased toxicity (Schanzer et al., 2019).
The third line includes drugs such as benzodiazepines, which are potent with rapid anxiolytic effects. However, they are considered controversial agents as a result of their inability to manage co-morbid depression and the associated risks of sedation, dependency, and memory problems.
Generally, several factors must be considered such as patient presenting symptoms, age, race, comorbidities, and overall health status among others, when deciding on what medication to prescribe for anxiety disorders. Consequently, evaluating the pharmacodynamics and pharmacokinetics of the available anxiolytics is crucial to promote the use of only safe and effective drugs for desirable treatment outcomes.
References
Bandelow, B. (2020). Current and novel psychopharmacological drugs for anxiety disorders. Anxiety Disorders, 347-365. https://doi.org/10.1007/978-981-32-9705-0_19
Hurtado, M. M., Villena, A., Vega, A., Amor, G., Gómez, C., & Morales‐Asencio, J. M. (2020). ‘I have anxiety, but I have values and preferences’ Experiences of users with generalized anxiety disorder: A qualitative study. International journal of mental health nursing, 29(3), 521-530. https://doi.org/10.1111/inm.12690
Schanzer, B., Rivas-Grajales, A. M., Khan, A., & Mathew, S. J. (2019). Novel investigational therapeutics for generalized anxiety disorder (GAD). Expert opinion on investigational drugs, 28(11), 1003-1012. https://doi.org/10.1080/13543784.2019.1680638
Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.
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Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA approved indications when referring to different medication classes used in the treatment of GAD.
To Prepare
Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
Think about a personalized plan of care based on these influencing factors and patient history with GAD.
By Day 3 of Week 8
Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.
Age as well as racial differences is important factors to be considered when planning a treatment regimen that is therapeutic and effective. Racial differences in the presentation of anxiety may contribute to under recognition and lack of treatment and hence there is always a difference exist with respect to treatment for anxiety disorders, with African-Americans being less likely than Whites to receive appropriate treatment.
Research states that older African American in the U.S despite of their vulnerability to diverse mental health conditions underuse mental health services and more likely seek help from Primary care providers instead of mental health professionals and less likely to prefer medication as a treatment option. They prefer to seek informal mental health care from spiritual leaders, social service organizations, and the family members as they have negative attitude towards seeking mental health treatment.
Also African- Americans have higher rates of substance use disorders, post-traumatic stress disorders, depression, which places them at increased risk for mental health conditions and suicidal ideation. African- Americans are less likely to seek care for anxiety disorders due to the factors such as negative stigma, racial discrimination in mental health care, lack of access to resources and mistrust of the medical establishment. As per research only about one-quarter of African Americans seek mental health care compared to 40 percent of whites.
It is very important to first figure out there treatment preference which is linked to patient s personal belief on the etiology of his or her disorder as it can help the provider to understand individuals belief behind the disorder for example if the patient prefer psychotherapy may believe their depression is related to psychological stress while those who chose medications as a form of treatment may believe that their mental health disorder is from chemical imbalance. Following their preferred method of treatment is important as it is effective in improving mental health service utilization, treatment outcomes with higher adherence rates.
Hence my first preferred way of treating GAD in older African-American is with cognitive-behavioral therapy especially with trained African- American therapists if possible to remove negative stigmas, mistrust, and barriers such as racial differences. Also I believe since the mental health therapist who has experience working with multicultural or one that share the same cultural beliefs will be better able to understand their concerns and address them effectively.
By Day 6 of Week 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder There are various pharmacotherapy approaches for the treatment of generalized anxiety disorder. (GAD). The main classes of FDA-approved drugs for the treatment of GAD are selective serotonin, selective norepinephrine reuptake inhibitors (SSRIs and SNRIs), azapirones, and benzodiazepines. An example of an SSRI approved for the treatment of GAD is Sertraline. Sertraline acts by increasing serotonin activity while blocking its reuptake (Garakani et al., 2020). Sertraline shows efficacy and well-tolerability in both adults and children. Additionally, the medication is safe and well-tolerated in the older adult population. While it has low chances of advanced events, the occurrences are higher in the pediatric population compared to adults (Strawn et al., 2018). Benzodiazepines class of drugs bind GABA to induce feelings of calmness. An example is diazepam. Benzodiazepines are effective for treating GAD with a faster response than SSRIs and SNRIs. Moreover, studies show they give better remission than SSRIs and SNRIs. However, they are not well-tolerated with the pediatric and older adult populations posing the risk of harm (Sartori & Singewald, 2019). Additionally, Benzodiazepines are not commonly prescribed because of the high risk of dependence, abuse, toxicity, and tolerance (Strawn et al., 2018). Due to this, the recommended pharmacotherapy using the medication is 3-6 months, yet this period is not enough for GAD treatment. Hence, people at high risk of abuse should not be given this class of medication. Azapirones is another class of drug for the treatment of GAD. The only FDA-approved drug from this class is buspirone, an anxiolytic and 5-HT1A receptor agonist (Strawn et al., 2018). The medication effectively treats GAD and is well-tolerated by both adults and the pediatric population. Similarly, the drug is well-tolerated in older adults with no requirement for dose adjustments (Sartori & Singewald, 2019). However, like SSRIs and SNRIs, Azapirones are safer but give lower efficacy than benzodiazepines. Finally, SNRIs like SSNIs act by causing changes in the brain that affect the functioning of neurotransmitters. An example approved for GAD is Effexor, which is well-tolerated and effective for treating GAD in adult and pediatric populations. However, it is associated with pain, weight loss, asthenia, and anorexia (Strawn et al., 2018). References Garakani, A., Murrough, J., Freire, R., Thom, R., Larkin, K., Buono, F., & Iosifescu, D. (2020). Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Front Psychiatry, 11:595584. https://doi.10.3389/fpsyt.2020.595584. PMID: 33424664; PMCID: PM. Sartori, S. B., & Singewald, N. (2019). Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders. Pharmacology & Therapeutics, 204, 107402. https://doi.org/10.1016/j.pharmthera.2019.107402. Strawn, J., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opin Pharmacother, 19(10),1057-1070. https://doi.10.1080/14656566.2018.1491966.
Generalized anxiety disorder (GAD), a chronic condition, frequently starts in adolescence or the early stages of adulthood and lasts the rest of one’s life (Strawn et al., 2018). The medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). These are Antianxiolytics, which typically affect the brain’s neurotransmitters inhabiting reuptakes in terms of their pharmacokinetics and pharmacodynamics.
Selective Serotonin Reuptake Inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered the first line of drugs to treat generalized anxiety disorder. The main mechanism of action of SSRIs is to prevent presynaptic serotonin reuptake at the serotonin transporter, which raises serotonin levels at the postsynaptic membrane in the serotonergic synapse (Edinoff et al., 2021). These medications include fluoxetine, Citalopram, escitalopram, paroxetine, sertraline, and fluvoxamine.
These medications treat generalized anxiety disorder using the same mechanism. However, each of them has unique pharmacokinetics and pharmacodynamics. The half-life of each drug varies, for instance, fluoxetine’s half-life is 1 to 4 days, whereas Citalopram’s half-life is 26 hours. SSRIs tend to be metabolized by cytochrome P450 in the liver. SSRIs tend to have better specificity than MAOIs and TCAs, which makes them the drug of choice for treating depression as well. The side effects of these medications include weight gain, sleepiness, and dry mouth.
Different Treatment Options:
Antihistamines, such as Hydroxyzine are one of the most common FDA-approved medications that could be used for anxiety as well. Antihistamines, such as hydroxyzine, are histamine-1 receptor (H1) blockers that are frequently used as an alternative to benzodiazepines for anxiety, panic attacks, and sleeplessness (Garakani et al., 2020).
Though antihistamines are used for allergy symptoms, Hydroxyzine and Diphenhydramine (Benadryl) may be safer for adolescents and in pregnancy for anxiety symptoms as well. Aside from side effects including dry mouth, constipation, and sedation, antihistamines are generally well tolerated.
Cannabis may have potential therapeutic effects in treating anxiety. Cannabis is known for its pleasurable and calming effects. Additionally, preclinical studies show that CBD has antidepressant effects after both acute and long-term dosing (Martin et al., 2021). The use of cannabis and other cannabinoids is accepted as a safe means of promoting relaxation and reducing anxiety, however there is not much literature or evidence that supports that.
Benzodiazepines are one the treatment for anxiety and remain one of the most commonly used classes of psychiatric drugs worldwide. Benzodiazepines, which function as GABA-A agonists, are very adaptable drugs that can be administered for a variety of disorders. They can be used for mania, insomnia, anxiety, agitation, and seizures. However, antidepressant effectiveness may be decreased by long-term usage of benzodiazepines to treat anxiety and co-morbid depression (Garakani et al., 2020).
Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., Kaye, A. D., Viswanath, O., Urits, I., Boyer, A. G., Cornett, E. M., & Kaye, A. M. (2021, August 5). Selective serotonin reuptake inhibitors and adverse effects: A narrative review. Neurology international. Retrieved January 14, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8395812/
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020, December 23). Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Frontiers in psychiatry. Retrieved January 15, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786299/#:~:text=in%20anxiety%20disorders.-,Antihistamines,approved%20for%20use%20in%20anxiety.
Martin, E. L., Strickland, J. C., Schlienz, N. J., Munson, J., Jackson, H., Bonn-Miller, M. O., & Vandrey, R. (2021, September 9). Antidepressant and anxiolytic effects of medicinal cannabis use in an observational trial. Frontiers in psychiatry. Retrieved January 15, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8458732/
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018, July). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert opinion on pharmacotherapy. Retrieved January 14, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340395
While cannabis can be a non-pharmacological route to help deal with anxiety, it can also cause it. The biphasic effect of cannabinoids on anxiety can be viewed as a consequence of cannabinoid regulation of GABA/glutamate balance. Acting on GABAergic terminals may increase anxiety and acting on glutamatergic terminals may decrease anxiety.
“The plant’s anxiety-modulating action has largely been attributed to a biphasic interaction with the CB1 receptor. Rey et al. (2012) found that the anxiolytic effects of low doses occur when they interact with the CB1 receptor on cortical glutamatergic terminals. Conversely, interaction with the CB1 receptor on the GABAergic terminals is responsible for anxiogenesis, something which takes place when higher doses are administered.”
Components of CBT include teaching patients to identify and label irrational thoughts and to replace them with positive self-statements. The cognitive modification approaches are combined with behavioral treatments such as exposure or relaxation training. In the article. it states that CBT significantly reduces anxiety symptoms post treatment in patients with generalized anxiety disorder.Compared with usual care, treatment with structured psychotherapy (CBT or interpersonal therapy) represents good value for money for adults with major depressive disorder and/or generalized anxiety disorder.”
References
(2018, November 13). Psychotherapy for major depressive disorder and generalized anxiety disorder: A Health Technology Assessment. Ontario health technology assessment series. Retrieved January 17, 2023, from https://pubmed.ncbi.nlm.nih.gov/29213344/
Sharpe, L., Sinclair, J., Kramer, A., de Manincor, M., & Sarris, J. (2020, October 2). Cannabis, a cause for anxiety? A critical appraisal of the anxiogenic and anxiolytic properties. Journal of translational medicine. Retrieved January 17, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7531079/
Thank you for the information regarding treatment for GAD during pregnancy. It is important to recognize treatment options that are safe to take during this time because GAD can be common perinatal and postpartum. Not treating GAD during pregnancy can have a negative impact on infants due to decrease responsiveness from mothers and increased stress (Misri et al., 2015).
It has been researched that SSRIs and SNRIs cross the placenta and can cause birth defects. Third-trimester exposure to SSRIs can cause withdrawal symptoms like jitteriness, irritability, tremors, difficulty feeding, sleeping, hypertonia, and seizures. Benzodiazepines can also cause cleft lips, withdrawal symptoms, and floppy infant syndrome.
Medications that are safe to take during pregnancy include sertraline, fluoxetine, mirtazapine, fluvoxamine, and paroxetine. Still, they should be discussed with the patient as they can cause various symptoms (Ballone et al., 2020). For example, fluoxetine and sertraline can promote inefficient weight gain during pregnancy and should be closely monitored.
Fluvoxamine can also cause nausea and vomiting and should not be used in those who are experiencing these symptoms during pregn
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