Reply #1

Case Study Questions

Based on the case study, answer the following questions.

Treatment Goals

1. List 2 treatment goals for this case. State goals in SMART format (Specific, Measurable, Achievable, Relevant, and have a Timeline for completion)

Julie reported feelings of anxiety on a somewhat daily basis, which limits her ability to interact with others or leave the home. Julie’s symptoms of anxiety will significantly reduce to no longer interfere with her daily functioning. She will develop strategies to reduce feelings of anxiety as evidenced by less reported symptoms of chest pain and anxiety to her NP. The nurse practitioner will provide psychoeducation on anxiety and will identify and practice implementing effective coping skills to manage anxiety. The nurse practitioner will also aid Julie in identifying feelings, thought distortions, and/or events that could lead to anxious symptoms. This will be achieved within 90 days.

Julie has struggled with maintaining her full time job and as a result, called out sick numerous times over the past 6 months. She will connect with resources for additional support in re-establishing the ability to work on a full-time basis. Julie will create a list of friends, family, or coworkers that she can talk to about job related stressors and provide encouragement to return to work. The NP will aid Julie in practicing to reframe cognitions and implement positive self-talk in order to increase his/her confidence in the ability to work. Her attendance will improve within 90 days.

Identification of target symptoms/problems

2. What information, if any, would you like to know that was not included in the case?

I would like to know more about Julie’s medical history and psychiatric history. Has she ever been treated for anxiety in the past? Has she been given any psychiatric diagnoses in the past? What medications is she currently taking? What does she like to do for fun? Does she have any hobbies or interests?

3. Which psychiatric symptoms are a treatment priority for this case?

Julie’s excessive worrying about having a heart attack, her withdrawal from her job, difficulty concentrating on anything else other than the effects of her anxiety, and the avoidance of certain social situations which appears to be causing isolation.

4. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?

Issues that can not be addressed with medications include her reports of rapid heart rate and cardiac symptoms, her attendance at work and her thoughts of having a heart attack or dying.

Medication Choice 1

5. List 1 medication that would be appropriate for this case. Include name, starting dose.

I would start the patient on fluoxetine 20mg daily.

6. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

Fluoxetine, an SSRI, has a rapid onset of action (approximately 1–2 weeks) and has proven to be effective in maintenance treatment. Fluoxetine is generally well-tolerated with the most common side effect of dry month and nausea. SSRIs can be helpful for depression, panic disorder, social anxiety, obsessive compulsive disorder, generalized anxiety and PTSD. They are well tolerated medications that are safe for medically ill or frail patients and safe in overdose. There are no withdrawal effects unless the patient stops them abruptly, and no dependency develops. They generally do not promote weight gain. These drugs offer a different chemical structure than the cyclic antidepressants and therefore produce different effects on the brain. Primarily they assist the brain in maintaining enough supply of the neurotransmitter serotonin. It works by blocking the absorption of the neurotransmitter serotonin in the brain. It also results in more neurons being present in a region of the brain called the "dentate gyrus," part of the hippocampal formation.

7. What laboratory testing/monitoring is needed for safely prescribing this medication?

When starting a patient on antidepressant drug therapy, I would obtain a set of baseline laboratory tests to rule out underlying medical conditions that may be contributing to the patient’s depression or that may preclude the use of a given drug. Tests would include a complete blood cell count, complete metabolic panel and a thyroid-stimulating hormone level. Electrocardiography may also be useful in this case to provide reassurance to Julie about her cardiac status and ensure there is no history of QT prolongation. If all labs were normal, I would follow up with labs yearly.

8. Are there any contraindications or safety issues associated with this medication?

The following conditions are contraindicated with this drug:

· diabetes

· a disorder with excess antidiuretic hormone called syndrome of inappropriate antidiuretic hormone

· low amount of sodium in the blood

· an increased risk of bleeding

· manic behavior

· a form of mania that has a lower severity of symptoms

· Manic-Depression

· suicidal thoughts

· serotonin syndrome

· a type of disorder with high serotonin levels

· closed angle glaucoma

· heart attack within the last 30 days

· torsades de pointes

· a type of abnormal heart rhythm

· prolonged QT interval on EKG

· suddenly serious symptoms of heart failure

· abnormal EKG with QT changes from birth

· hardening of the liver

· liver problems

· bleeding from stomach

· esophagus or duodenum

· seizures

· decreased appetite

· CYP2D6 poor metabolizer

· risk of angle-closure glaucoma due to narrow angle of anterior chamber of eye

Side effects include:

· sleep problems (insomnia), strange dreams;

· headache, dizziness, vision changes;

· tremors or shaking, feeling anxious or nervous;

· pain, weakness, yawning, tired feeling;

· upset stomach, loss of appetite, nausea, vomiting, diarrhea;

· dry mouth, sweating, hot flashes;

· changes in weight or appetite;

· stuffy nose, sinus pain, sore throat, flu symptoms; or

· decreased sex drive, impotence, or difficulty having an orgasm.

Medication Choice 2

9. What is your second choice of medication for this case? Include name and starting dose. Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

Paroxetine 20mg daily would be my second choice for this patient. Paroxetine is the most potent and one of the most specific selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (SSRIs). It also binds to the allosteric site of the serotonin transporter, similarly, but less potently, than other meds. Paroxetine also inhibits the reuptake of norepinephrine to a lesser extent. Paroxetine targets the neurotransmitters in the brain.

10. Describe your clinical decision making. What is your rationale for choosing this medication?

Paroxetine is an effective antidepressant which also has proven effective in treating generalized anxiety, panic, posttraumatic stress, social phobia, premenstrual dysphoric disorder, and obsessive-compulsive spectrum disorders. It also is being used to treat peri-menopausal or menopausal hot flashes. Currently, it has received FDA indications for major depressive disorder, social phobia, generalized anxiety disorder and hot flashes. SSRI medications are first line treatment for general anxiety disorders.

11. What laboratory testing/monitoring is needed for safely prescribing this medication?

There are no specific labs needed for this medication however I would draw a complete blood count as a baseline as well as obtaining an EKG.

12. Are there any contraindications or safety issues associated with this medication?

Contraindications associated with this medication include those identical to all SSRIs

· a disorder with excess antidiuretic hormone called syndrome of inappropriate antidiuretic hormone

· low amount of sodium in the blood

· an increased risk of bleeding

· manic behavior

· Manic-Depression

· suicidal thoughts

· serotonin syndrome

· a type of disorder with high serotonin levels

· closed angle glaucoma

· liver problems

· bleeding from stomach

· esophagus or duodenum

· severe renal impairment

· seizures

· a feeling of restlessness with inability to sit still

· pregnancy

· Broken Bone due to Disease or Illness

· risk of angle-closure glaucoma due to narrow angle of anterior chamber of eye

Common side effects of paroxetine are nervousness, sleep difficulties (either too much or too little), restlessness, fatigue, dry mouth, nausea, headache, sweating, diarrhea, and sexual problems. Typically, these side effects will go away within a couple of weeks of taking the medication. Rare side effects include bleeding, teeth grinding, and low sodium blood levels. Serious side effects are seizure and serotonin syndrome

Non pharmacologic Interventions

13. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies?

In addition to psychotherapy, at least once a week, I would encourage Julie to consider biofeedback, yoga and other mind-body approaches, acupuncture, massage, music, and relaxation techniques to help reduce symptoms of generalized anxiety. Exercising 20 to 30 minutes daily can significantly lower anxiety level in individuals who have generalized anxiety, this would be suggested to Julie as well.

Safety Risk Assessment

14. What are the safety concerns, if any, associated with this case? How will you address safety?

I do not think that there are any safety concerns for this patient.

15. When would you follow up with this patient?

Weekly

References

16. List your references.

Mayo Clinic. (2019, September 1). paroxetine (Oral route). Retrieved from https://www.mayoclinic.org/drugs-supplements/paroxetine-oral-route/proper-use/drg-20064603

Post R. M. (2018). The new news about general anxiety disorders: An underutilized treatment in the United States. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 43(5), 1174–1179. doi:10.1038/npp.2017.238

Shafti, S.S. (2018). Aripiprazole versus lithium in management of acute mania: A randomized clinical trial. East Asian Archives of Psychiatry, 28(3), 80-84. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30146495

Stahl, S. (2013). Essentials of psychopharmacology, (4th edition). United Kingdom: Cambridge University Press.

Thompson, D. (2016, May 12). Lithium beats newer meds for bipolar disorder. Retrieved from https://www.webmd.com/bipolar-disorder/news/20160512/lithium-beats-newer-meds-for-bipolar-disorder-study-finds#1

Corey, G. (2017). Theory and practice of counseling and psychotherapy. Australia: Cengage Learning.

Next steps: 1. Post your responses to questions 5-8 and 13 to the discussion board. 2