Case Study

The client/patient is Caucasian male aged 46 years old and a welder at a local steel production plant. The client was referred to the psychiatric unit today after he arrived at the ER experiencing what seemed like a heart attack. As per his description, his chest was congested, he had breathing difficulties, and he constantly felt something was wrong. The patient suffers from mild hypertension and is overweight. Although he underwent a tonsillectomy at eight years old, his medical history is standard, and according to the EKG test performed, the patient is not likely to have a heart attack. Despite the outcome, the patient insisted that he suffers from bouts of “anxiety attacks characterized by chest congestion and shortness of breath. In addition, he is occasionally disturbed by a looming feeling of impending problems and the need to get away from his current physical and psychological state. During our interaction, the client stated that  has never taken any psychotropic medication but admitted to consuming three bottles of beer (ETOH) each night to suppress the negative feelings. The client does not have a partner, but he takes care of his elderly parents at his premises. The patient’s workplace environment is hostile, and he is constantly worried about losing his job.  

As per the mental examination, the patient is alert, fully oriented, has clear speech and his judgment and insight are intact. The client is neither delusional nor paranoid, denies experiencing any hallucinations, and has never thought of committing murder or suicide. Nonetheless, his effect is slightly blunted, and he felt moody and somehow nervous during our interaction. Based on his description and observations, I administered the Hamilton Anxiety Rating Scale(HAM-A) test. The client scored 26-indicating that he was suffering from Generalized Anxiety Disorder (GAD).

Introduction and therapy objective

As stated, the outcome of the metal examination established that the patient suffered from GAD. Since the condition adversely affected his physical and psychological wellness, it was necessary to implement a treatment plan to alleviate the symptoms within the shortest time possible, considering that the client was his elderly parent’s carer and risked losing his job. The treatment would last for 9-12 weeks, with symptoms expected to reduce by over 60% and the HAM-A score below 17. According to Thompson (2015), the HAM-A scale is among the widely used assessments to determine the incidence and severity of anxiety in people with a mental health condition. Primarily, the score consists of 14 sets of symptoms measured on scores ranging from 0-56. Scores above 25 indicate severe anxiety, 25-18 signify moderate, while less than 17 denotes mild anxiety (Matza et al., 2010). As per the case study, the patient scored 26; hence there was a need for medical intervention.

 In the context of this paper, the patient would embark on taking medication to improve his condition. However, it was critical to address several factors before the treatment commenced. Firstly, assessing his health records and medical history would clarify whether his family has a history of GAD. Secondly, the patient was it would be crucial to check whether he suffers from other psychological conditions that might interfere with the effectiveness of the treatment. Lastly, the health records and the diagnosis would provide adequate information to safeguard the patient from adverse side effects or reactions stemming from the prescribed medication (Loberg et al., 2019).

1. Decision 1

According to the diagnosis, the patient suffers from severe GAD. In the prescription, I recommended the patient begin with a daily dose of Zoloft 50mg to be taken orally. Zoloft contains Sertraline which is an SSRI and a first-line medication for anxiety disorders and other psychological illnesses According to Singh & Saadabadi (2020) the recommended starting dose for Sertraline medication for adults is 50mg.

• Reasons for making decision 1

Although other medications like Imipramine and Buspirone were available, there are several reasons why I prescribed the patient, to begin with, Zoloft. According to extensive studies, Imipramine and Zoloft are some of the primary interventions used in treating anxiety disorders like Panic Disorders (PD), Post-Traumatic-Stress-Disorder (PTSD), and Obsessive Compulsion Disorder (OCD), and Social Anxiety Disorder (Social Phobia). Regardless of that, research indicates that Zoloft is recommended more as a first choice intervention for anxiety disorders than Imipramine (Ressler, 2015). Besides, other studies show that Zoloft is more tolerable than Imipramine and more effective in alleviating other conditions like non-melancholic depression, which are linked to GAD (Kassin, 2020). On the other hand, Buspirone is FDA-approved and recommended first-choice treatment for anxiety disorders. According to Wilson & Tripp (2020), Buspirone is often recommended more than Sertraline because it does not trigger suicidal ideation. However, evidence shows that Buspirone takes a longer time than Sertraline to reduce anxiety symptoms, and hence it is not suitable for urgent interventions (Wilson& Tripp, 2020). Moreover, Buspirone causes dizziness and blurred vision, and thus, it is not ideal for anxiety patients who drive or operate machinery such as the client in this case.

• Achievement

The factors listed above informed my decision to choose Zoloft over Imipramine and Buspirone. In so doing, I aimed to achieve three objectives. Firstly, I wanted the client to begin treatment with a recommended intervention and the correct dosage. Secondly, I intended the patient to experience change as soon as possible given that his case was severe and he was at risk of losing his employment and thus become unable to care for his parents. Lastly, since the client is a casual worker at a steel plant, it would not be appropriate to prescribe medication that would render him vulnerable to accidents or even death at his workplace.

• Ethical considerations

As we commenced treatment, I informed the patient on critical aspects like possible side effects, appropriate time and way of taking medication, and the need to communicate on any emerging issue to increase the efficacy of the treatment process. As a health practitioner, I upheld confidentiality and adhered to all ethical principles are required. Nonetheless, I decided to prescribe the above-stated intervention because I the patient needed to recover within the shortest time possible.  Since the patient did not have profound knowledge about his condition, I relatively infringed on his autonomy and right to contribute to the decisions concerning treatment.

• Decision 2

After four weeks, the patient returned to the facility and reported that the tightness in his chest and shortness of breath had waned, and he was less worried about losing his job. I administered the HAM-A test, which yielded 18.  Such results indicated that the symptoms had reduced significantly, and the SSRI prescribed in the first quarter of the therapy was effective. In this case, I increased the Zoloft dose to 75mg.

• Reasons for making decision 2

As stated, the results attained within the first four weeks signified that the medication prescribed was effective against the GAD symptoms. Although I could have continued with the present dose or increased it to 100mg, I decided to expand. I settled on 75 mg due to several reasons. Firstly, according to Ressler (2015), 50mg is the optimum starting Sertraline dosage for adults. Since the symptoms had not wholly reduced, maintaining the current dose would not yield any further changes, and much worse, the condition would grow resistant to the medication (Ansara, 2020). On the other hand, increasing the 100mg would only harm the patient by increasing the severity of the side effects. Sertraline dosage should be increased gradually by 25mg up to a maximum of 200mg. If no changes are realized, the best option is to switch to another type of medication (Kassin, 2020).

• Achievement

Bearing in mind that the patient had started recovering, I made the decisions above to increase the efficacy of the therapy. Firstly, I wanted the patient’s progress not to stall as studies assert that GAD often becomes treatment-resistant to or after the initial treatment. On the other hand, I increased the dose slightly to safeguard the patient from any possible adversities if I increased it to 100mg.

• Ethical considerations

The patient’s response to treatment was positive, and it gave him hope to recover. As I took the next step, I communicated with the patient on possible positive and negative outcomes expected. Besides, and as my profession requires, I implored the patient on any issues he may have experienced in the previous period to safeguard his health. Although I remained as ethical as the situation warranted, the client’s autonomy to make decisions concerning the next step in therapy was limited because he did not have a profound understanding of the condition or the interventions applied.

• Decision 3

Four weeks after I increased the Zoloft dose to 75mg, the client returned and reported that he was feeling better and his symptoms had reduced further. After administering the HAM-A test, the patient recorded a significant change from 18-10. This reading signified that the previous intervention had worked because the symptoms had declined by 61%. In this case, I chose to maintain the current dose for another four weeks.

• Reasons for making decision 3

The outcome attained by making decision 2 showed that the patient responded well to treatment and was recovering. In these circumstances, I preferred to maintain the present dosage due to various reasons. Firstly, since we had attained the primary aim of the therapy (a HAM-A score below 17 and 61% symptom reduction), we could examine the efficacy of the current dosage for four more weeks because the patient was not experiencing any symptoms. Alternatively, although increasing the dosage would yield more impressive results, the patient would experience more severe side effects, which would take a toll on his physical and psychological wellness. Again changing to another type of medication (like Buspirone) would be unnecessary because studies suggest that such strategy is only feasible when the patient does not respond to the current therapy (Singh & Saadabadi, 2020). More importantly, switching to another medication would expose the patient to unnecessary withdrawal symptoms and reactions.

• Achievement

The decision above was crucial due to three reasons. Firstly, since the therapy had given the desired outcome, and the patient had recovered, it was essential to check whether the current dosage could yield more positive results. Secondly, I did not intend to exacerbate the side effects as I would increase the dose later if there were no further changes. Lastly, I planned to maintain the therapy constituency because Sertraline had already worked for the patient.

• Ethical considerations

The patient was glad to have recovered from the symptoms he was experiencing before he sought help. As a health provider, I was impressed that the interventions I selected worked. However, despite the outcome, it is critical to recognize that even though I acted in the client’s best interest throughout the therapy and informed him on the best possible options, he remained isolated from making any meaningful contributions in the treatment process.

Conclusion

This paper discusses therapy options for a 46-year-old white male diagnosed with GAD. The main aim of therapy was to reduce the symptoms and to have a score of less than 17 on the HAM-A scale. The therapy period lasted for 12 weeks with the patient’s progress monitored every four weeks and the appropriate measures applied. As discussed, Zoloft was recommended as a viable intervention over Imipramine and Busrpione because of its efficacy, shorter reaction period, and less likelihood of endangering the patient’s life. The results recorded after each interval showed progress and a positive response to treatment. After the first four weeks, the client experienced change, which gradually increased with treatment up to the 9^th week. Throughout the therapy, I desisted from prescribing high doses and changing to other types of medication for several reasons; Firstly, I examined the efficacy of Sertraline against GAD since it is a highly recommended intervention. Secondly, it was crucial to maintain therapy consistency and avoid unnecessary side effects, withdrawal symptoms, and drug reactions. Lastly, considering the severity of the patient’s condition and position, I recommended the most effective and urgent intervention-Zoloft.

Reference

Ansara E. D. (2020). Management of treatment-resistant generalized anxiety disorder. The mental health clinician, 10(6), 326–334. https://doi.org/10.9740/mhc.2020.11.326

Kassis, K. N. (2020). Is Sertraline Effective At Reducing The Symptoms Of Anxiety In Those Diagnosed With Generalized Anxiety Disorder (GAD)?.

Matza, L. S., Morlock, R., Sexton, C., Malley, K., & Feltner, D. (2010). Identifying HAM‐A cutoffs for mild, moderate, and severe generalized anxiety disorder. International Journal of Methods in Psychiatric Research, 19(4), 223-232.

Ressler, K. J., Pine, D. S., & Rothbaum, B. O. (Eds.). (2015). Anxiety disorders: Translational perspectives on diagnosis and treatment. Oxford University Press.

Singh, H. K., & Saadabadi, A. (2020). Sertraline. In StatPearls [Internet]. StatPearls Publishing.

Thompson, E. (2015). Hamilton rating scale for anxiety (HAM-A). Occupational Medicine, 65(7), 601.