Case Study: The Client Is A 46-Year-Old White Male

Examinecase Studythe Client Is A 46 Year Old White Male Who Works As

Examine Case Study: The client is a 46-year-old white male who works as a welder at a steel fabrication factory. He presents after a trip to the emergency room, feeling symptoms suggestive of a heart attack such as chest tightness, shortness of breath, and a sense of impending doom. Medical evaluation ruled out myocardial infarction, with normal EKG and physical exam findings. His medical history includes mild hypertension managed with a low sodium diet and being about 15 pounds overweight, with a history unremarkable since childhood aside from tonsil removal at age 8. He reports ongoing episodes of chest tightness and shortness of breath, which he now attributes to anxiety, along with occasional feelings of dread and urges to escape situations. He admits to occasional alcohol use (3-4 beers nightly) to cope with worries and reports stressors related to his job security and caring for aging parents. The HAM-A score is 26, indicating moderate to severe anxiety, with a diagnosis of Generalized Anxiety Disorder (GAD). The case highlights considerations such as the patient's age, weight, hypertension, alcohol consumption, occupational stress, and familial responsibilities, which affect pharmacokinetics and pharmacodynamics of potential medications and underpin personalized treatment planning.

Paper For Above instruction

The management of Generalized Anxiety Disorder (GAD) in a 46-year-old male with complex psychosocial factors necessitates a careful, individualized approach to pharmacotherapy. The patient's age, comorbid hypertension, weight, alcohol use, occupational stress, and family care responsibilities all influence medication selection, dosing, efficacy, and safety. Recognizing these factors enables clinicians to formulate a treatment plan that not only targets anxiety symptoms but also minimizes adverse effects and considers the patient's social context.

Decision 1: Initiating Buspirone 10 mg Twice Daily

The first decision to prescribe buspirone at 10 mg twice daily is grounded in its profile as a non-sedating, anxiolytic medication suitable for GAD, especially in patients like this who have comorbid hypertension and alcohol use issues. Buspirone's mechanism involves serotonergic modulation without significant sedative or dependency risks, making it advantageous for this patient (Lader & Taylor, 2019). Initial evidence supports its effectiveness in reducing generalized anxiety symptoms over 4-6 weeks, with a favorable side effect profile (Bandelow et al., 2015).

I opted for buspirone over other agents like SSRIs at this stage because of its minimal sedation and lower interaction risk with the patient's existing medications and alcohol use. Furthermore, this choice allows for gradual symptom improvement, aligning with the patient's initial moderate anxiety level and his need to avoid sedation or withdrawal complications (Rickels et al., 2019).

The alternatives considered included starting paroxetine (Paxil) at 10 mg daily or imipramine at 25 mg twice daily. Paroxetine, an SSRI, is effective but associated with sexual side effects, weight gain, and potential drug interactions with alcohol or other medications (Pollack & Rosenbaum, 2019). Imipramine, a tricyclic antidepressant, poses risks of anticholinergic effects, cardiotoxicity—a concern given his hypertension—and overdose risk (Birmaher et al., 2015). Given the patient's profile, buspirone's safety and tolerability favor its initial use.

The expected goal is to achieve at least a 20-30% reduction in anxiety symptoms over 4 weeks, paving the way for potential dose escalation or combination therapy if necessary. Ethical considerations include informed consent about the medication's benefits and limitations, respecting the patient's autonomy, and realistic expectations regarding symptomatic relief (Hoffman & Kleinman, 2018).

Decision 2: Adjusting Medication Timing to Bedtime

After four weeks, with a notable improvement (HAM-A score reduced from 26 to 13), adjusting the administration time of lexapro (escitalopram) to bedtime is chosen to mitigate morning sedation. The patient reports feeling sleepy post-dose but "perks up" during the day. This adjustment aims to enhance adherence, improve sleep quality, and further capitalize on the medication's anxiolytic benefits without exacerbating daytime drowsiness (Sanchez et al., 2020).

I did not increase the dosage to 15 mg daily because the current reduction in anxiety symptoms indicates sufficient response. Escitalopram doses below 20 mg are generally effective for GAD, and increasing doses may enhance efficacy but at the risk of side effects such as nausea, sexual dysfunction, or sleep disturbances (Reinecke et al., 2018). Similarly, reinitiating buspirone three times daily was avoided as the patient is already experiencing daytime sleepiness, and this could compound fatigue or impair functioning.

The goal with this decision is to maintain symptom control while minimizing adverse effects, addressing the patient's sleep concerns, and promoting medication adherence. Ethically, informing the patient about possible side effects, the rationale for dosing time adjustment, and monitoring for additional adverse effects reflect shared decision-making and respect for his autonomy (Hoffman & Kleinman, 2018).

Decision 3: Continuing Escitalopram at Bedtime without Dose Increase

Maintaining the current dose of 10 mg escitalopram at bedtime appears prudent because it has resulted in a significant symptomatic improvement, with the HAM-A score halved. Further dose escalation to 15 mg might enhance anxiety suppression but could increase side effects, notably morning sedation, which the patient already reports. Ensuring symptom stability and tolerability is paramount, particularly given his psychosocial stressors and alcohol use, which can alter pharmacodynamics (Reus et al., 2017).

I did not opt to reintroduce buspirone at 10 mg thrice daily because the current regimen effectively manages anxiety, and increasing medication complexity may reduce adherence. Additionally, combining SSRIs with buspirone can cause serotonin syndrome if not managed carefully (Bandelow et al., 2015).

The primary aim is to sustain symptom remission, enhance sleep quality, and prevent medication overload. Ethical considerations include the principle of non-maleficence—avoiding unnecessary side effects—and autonomy through ongoing patient education and involvement in treatment decisions (Hoffman & Kleinman, 2018).

Conclusion

In summary, initiating buspirone was appropriate considering the patient's comorbidities and medication safety profile, leading to initial symptom improvement. Transitioning to oral escitalopram with dose timing adjustment was effective in further reducing anxiety, enhancing sleep, and minimizing daytime sedation. Maintaining the current dose aligns with evidence supporting its efficacy and safety in GAD, especially in patients with psychosocial stressors and substance use concerns. Ongoing monitoring and patient education are essential to sustain remission, address side effects, and support adherence. Personalizing pharmacotherapy based on patient factors, therapeutic response, and safety considerations remains the cornerstone of effective GAD management.

References

• Bandelow, B., Zohar, J., Hollander, E., Kasper, S., Möller, H.-J., & Scharf, M. (2015). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive–compulsive and post-traumatic stress disorders—First edition. The World Journal of Biological Psychiatry, 16(3), 231–245.
• Birmaher, B., Brent, D., Chiappetta, L., Bridge, J., & Baugher, M. (2015). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 38(10 Suppl), 24S-54S.
• Hoffman, B., & Kleinman, M. (2018). Ethical considerations in prescribing pharmacotherapy for anxiety. Ethics & Behavior, 28(3), 204–219.
• Lader, D., & Taylor, D. (2019). Pharmacotherapy of generalized anxiety disorder. Psychopharmacology Bulletin, 49(2), 44–67.
• Pollack, M. H., & Rosenbaum, J. F. (2019). Selective serotonin reuptake inhibitors in the treatment of generalized anxiety disorder. Psychiatric Services, 70(4), 265–269.
• Reinecke, M. A., Bouchard, S., & Theisen, M. (2018). Pharmacotherapy for generalized anxiety disorder: Efficacy and tolerability. Current Psychiatry Reports, 20(9), 79.
• Reus, V. I., Lieberman, J., & First, M. B. (2017). The impact of alcohol on pharmacokinetics and pharmacodynamics of psychotropic medications. International Review of Psychiatry, 29(4), 384–394.
• Rickels, K., Zajecka, J., & Mahoney, E. (2019). Pharmacotherapy of anxiety disorders: An update. Current Psychiatry Reports, 21(5), 23.
• Sanchez, C., Chappell, P., & Malcolm, R. (2020). Optimizing SSRI therapy for anxiety: Dosing and administration considerations. Journal of Psychiatric Practice, 26(1), 44–50.