Pharmacologic Treatment for General Anxiety Disorder (GAD)
According to the results of the evaluation, the patient has been diagnosed with general anxiety disorder (GAD). There is a limited improvement following administration of the Hamilton Anxiety Rating Scale (HAM-A) after each therapy, indicating that pharmacotherapeutic treatments such as the use of Buspirone resulted in failure treatment. To provide long-term treatment, it is recommended that Buspirone be discontinued and SSRI medication with an agent such as Zoloft 50 mg orally daily be initiated. It has also been said that lorazepam 0.5 mg orally TID and benzodiazepine augmentation are not acceptable. In fact, benzodiazepine should be strongly avoided unless extremely necessary or in situations involving treatment-resistant chronic GAD (Bystritsky, Khalsa, Cameron, & Schiffman, 2013).
Effectiveness of Benzodiazepines in GAD Treatment
According to Locke, Kirst, and Schultz (2015), benzodiazepines are effective in the treatment of symptoms associated with GAD, but their use is limited due to adverse effect profiles and risk of abuse. It is, therefore, important to choose a pharmacologic therapy which is not only safe but also has a high potential to improve the client's condition in the long-term.
Selective Serotonin Reuptake Inhibitors (SSRIs) as First-line Therapies for GAD
The most suitable pharmacologic therapy for the patient is selective serotonin reuptake inhibitors (SSRIs). According to Kavan Elsasser, and Barone (2009), SSRIs are among the first-line therapies for the management of patients diagnosed with GAD. Although the mechanism of action of the SSRI agents has not been well-defined, it is believed to involve deregulation of noradrenergic receptors. It has been found out that the use of SSRIs is more advantageous than benzodiazepines or other drugs such as buspirone.
Advantages of SSRIs for Long-term GAD Treatment
The main reason why I decide to use SSRI is their low potential for negative side effects. Kavan, Elsasser, and Barone (2009) pointed out that unlike benzodiazepines, SSRIs can be used for long-term treatment of GAD without fear of abuse or tolerance. Further, the authors pointed out that clinical trials have shown that SSRIs can be used for effective management of GAD. Bystritsky, Khalsa, Cameron, and Schiffman (2013) and University of Michigan (2016) suggested that the best strategy is to start the dosage slowly and continue by going slow such as by starting with almost half the dose that is usually used for depression and gradually titrating the dose higher with a weekly change in dosage that does not go beyond one. However, SSRIs have been associated with adverse events such as agitation, weight gain, nausea, weight gain, sexual dysfunction, and insomnia. Kavan Elsasser and Barone (2009) warned that although the side effects tend to be mild, the patient might mistake by thinking that the anxiety is getting worse and may lead to failure to adhere to drug dosage. This implies the patient needs to be advised accordingly. In case the patient develops adverse effects, benzodiazepines might need to be administered for the first few weeks of treatment to counteract the likely adverse effects. However, Kavan Elsasser and Barone (2009) pointed warned that such a practice might delay the effectiveness of SSRI, which is usually approximately four weeks. The authors also noted that there are fewer incidences of adverse events when escitalopram is administered as compared with paroxetine. In case Zoloft is not available, and if there is a need to minimize the side effects that are likely to occur when an SSRI is used, the other best alternative is an initial dosage of Lexapro 10mg daily which can be later increased to a range between 10 to 20mg daily. Withdrawal syndrome is common with abrupt with the use of SSRIs (Bystritsky, Khalsa, Cameron, & Schiffman, 2013) and can lead to symptoms such as nausea uneasiness, dizziness, and fatigue (WebMD, 2017). To avoid incidences of withdrawal symptoms, Kavan Elsasser, and Barone (2009) recommend a slower taper of dosage that runs several weeks.
The Choice of Zoloft and Expectations
By making the decision to use Zoloft, I hope to achieve a better outcome in the treatment of the patient. I would like to achieve positive changes within the first four to six weeks of treatment. Zoloft is one of the many SSRIs which have been proven to be effective in the treatment of GAD. I hope that Zoloft will produce the same treatment as any other SSRI because Bystritsky, Khalsa, Cameron, and Schiffman (2013) argued that none of the available SSRIs has been proven to be superior to another. According to them, the choice of a particular SSRI to administer depends on factors such as side-effect profile, pharmacodynamics and pharmacokinetics, and also their potential interactions with other co-administered medications. By choosing to administer Zoloft, I hope to minimize the side-effects that are associated with benzodiazepines (Brooks, 2014; Ritchie & Neslon, 2015).
Experience with Zoloft Treatment
The decision to administer Zoloft to the patient did not meet some of my expectations. Initially, I had targeted to notice positive changes between the 4th and the 6th week. However, the first positive changes were noticed in the 7th week. I had also expected that the tapering of the drug dosage would not result in a withdrawal syndrome. As soon as the patient stopped taking Zoloft, there was mild withdrawal syndrome, and I had to administer a little dosage for two more weeks. Fortunately, Zoloft treated the patient of GAD after two and a half months of taking Zoloft.
References
Brooks, B. W. (2014). Fish on Prozac (and Zoloft): ten years later. Aquatic Toxicology, 151, 61-67.
Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety disorders. PT, 38(1), 30-57.
Kavan, M. G., Elsasser, G. N., & Barone, E. J. (2009). Generalized anxiety disorder: practical assessment and management. American family physician, 79(9).
Locke, A.L., Kirst, N., & Schultz, C.G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician, 91(9), 617-624.
Ritchie, E. C., & Nelson, C. S. (2015). Updates in Psychopharmacology for PTSD and Related Conditions: Focus on the Active Duty Service Member. In Posttraumatic Stress Disorder and Related Diseases in Combat Veterans (pp. 47-54). Springer International Publishing.
The University of Michigan. (2016). Treatment for Anxiety Disorders. Retrieved from: http://www.psych.med.umich.edu/anxiety/treatment-for-anxiety.asp
WebMD. (2017). What Are SSRIs? Retrieved from: http://www.webmd.com/depression/ssris-myths-and-facts-about-antidepressants#1
