Generalized Anxiety Disorder Case: Ivy, A 23-Year-Old White ✓ Solved

Generalized Anxiety Disorder case: Ivy, a 23-year-old white

Generalized Anxiety Disorder case: Ivy, a 23-year-old white woman, seeks management. Provide: 1) specific treatment goals for Ivy; 2) the drug therapy you would prescribe and why; 3) parameters for monitoring therapy success; 4) specific patient monitoring based on the prescribed therapy; 5) one or two adverse reactions for the selected agent that would prompt a change in therapy; 6) the choice for second-line therapy; 7) dietary and lifestyle changes to recommend; 8) one or two drug–drug or drug–food interactions for the selected agent.

Paper For Above Instructions

Case context and treatment goals: Ivy is a 23-year-old woman diagnosed with Generalized Anxiety Disorder (GAD) who has experienced nine months of pervasive anxiety, fatigue, irritability, difficulty concentrating, and sleep disturbance, with excessive worry about performance and daily functioning. The primary treatment goals are symptom reduction and functional improvement, restoration of work performance and sleep, reduction of excessive worry, and prevention of relapse or escalation of impairment (APA guidelines; NIMH, 2023). A combined approach emphasizing pharmacotherapy and evidence-based psychotherapy (notably cognitive-behavioral therapy) is recommended for initial management, with continuation to maintain gains and prevent relapse (Cuijpers et al., 2016; Hofmann et al., 2012).

1) Specific treatment goals for Ivy: The goals should be SMART: (a) achieve at least a 50% reduction in anxiety symptoms within 8–12 weeks, as measured by a validated scale such as the GAD-7 or Hamilton Anxiety Rating Scale (HAM-A); (b) return to prior level of occupational functioning within 2–3 months; (c) improve sleep latency and total sleep time, with fewer awakenings; (d) reduce excessive worry episodes to a manageable baseline; (e) maintain safe interpersonal and romantic relationships with stable mood; (f) minimize treatment-related adverse effects and ensure adherence; (g) prevent relapse during stressors or life changes; (h) avoid dependence on fast-acting benzodiazepines by favoring longer-term anxiolytic strategies (APA guidelines; NICE, 2011).

2) Drug therapy you would prescribe and why: The first-line pharmacologic option for GAD in a young adult is a selective serotonin reuptake inhibitor (SSRI) or an SNRI. Given Ivy’s profile—no history of bipolar spectrum symptoms, no substance use disorders, and a need for tolerable long-term therapy—escitalopram or sertraline (SSRI) or venlafaxine XR or duloxetine (SNRI) are appropriate. I would start escitalopram at 10 mg daily, with planned titration to 20 mg after 1–2 weeks if tolerated, based on robust efficacy in GAD and favorable tolerability in young adults (APA guidelines; Bandelow et al., 2017; NIMH, 2023). If tolerability is an issue, sertraline at 50 mg daily could be an alternative. SSRIs/SNRIs are preferred due to favorable efficacy-safety balance, low risk of misuse, and evidence supporting symptom reduction and functional improvement in GAD (Hofmann et al., 2012). Augmentation with buspirone could be considered if partial response occurs. If inadequate response after 6–8 weeks at an adequate dose, consider switching to another SSRI/SNRI or augmenting with a non-benzodiazepine anxiolytic; benzodiazepines would be avoided for long-term therapy due to dependence risk (APA guidelines; Bandelow et al., 2015).

3) Parameters for monitoring the success of therapy: Monitoring should include symptom scales (GAD-7 or HAM-A) at baseline and every 2–4 weeks during dose escalation, then every 6–8 weeks after achieving a stable dose, to assess response and guide dose adjustments (APA guidelines; NICE, 2011). Functional assessments (work performance, sleep quality, daytime functioning) and quality-of-life metrics should be tracked. Safety monitoring includes suicidality assessment at each visit, vital signs as clinically indicated, and monitoring for common SSRI/SNRI adverse effects (GI upset, sleep changes, sexual dysfunction, weight changes). Periodic reviews of adherence, concomitant medications (notably birth control pills and OTC/herbal supplements), and potential drug–drug interactions (e.g., NSAIDs or anticoagulants) are essential. In young adults, early treatment response tends to lag 2–4 weeks, with maximal effect often by 8–12 weeks (Hofmann et al., 2012; Bandelow et al., 2017).

4) Specific patient monitoring based on the prescribed therapy: If starting escitalopram 10 mg daily, monitor for initial worsening of anxiety, GI upset, sleep disturbance, or activation within the first 1–2 weeks and reassess at 4 weeks. Assess suicidality at each visit and ensure safety planning. If symptoms improve, continue for at least 6–12 months before gradual tapering to minimize relapse risk (APA guidelines; NIMH, 2023). Monitor sexual function and energy levels, as SSRIs can cause sexual dysfunction in some patients. Consider periodic metabolic monitoring only if indicated by weight changes or comorbid conditions. If Ivy experiences interactions with birth control medications or OTC supplements (e.g., St. John’s wort), adjust the regimen accordingly (Mayo Clinic; Katzung, 2020).

5) One or two adverse reactions for the selected agent that would cause you to change therapy: Common SSRI/SNRI adverse effects include sexual dysfunction (decreased libido, anorgasmia), GI upset (nausea), sleep disturbance (insomnia or somnolence), and weight changes. If sexual side effects are intolerable or significant suicidality emerges, or if hyponatremia develops (especially in older patients but possible in any age), consider changing therapy or switching to another agent with a different side-effect profile (Katzung, 2020). If there is a poor initial response after 6–8 weeks at an adequate dose, switch to another SSRI/SNRI or add augmentation rather than persisting with ineffective therapy (APA guidelines; Bandelow et al., 2017).

6) What would be the choice for second-line therapy: If there is incomplete response or intolerance to an SSRI/SNRI, options include switching to another SSRI or SNRI, or augmenting the SSRI with buspirone (5–10 mg twice daily, titrating as tolerated to 20–30 mg/day total) or adding structured psychotherapy (CBT) as adjunctive treatment (Hofmann et al., 2012; Cuijpers et al., 2016). A SNRI such as venlafaxine XR (once-daily 75 mg, titrating to 150–225 mg) or duloxetine (60 mg daily) can be considered as second-line monotherapy, particularly if somatic symptoms are prominent or there is partial response to an SSRI (Bandelow et al., 2017).

7) Dietary and lifestyle changes to recommend for this patient: Recommend a comprehensive lifestyle plan to support pharmacotherapy and improve outcomes: reduce caffeine and alcohol intake; maintain a regular sleep schedule and sleep hygiene; engage in regular aerobic exercise (e.g., 150 minutes per week); practice stress-management techniques such as mindfulness-based interventions or brief CBT-based strategies; ensure adequate nutrition and hydration; maintain social connections and structured daily activities; minimize exposure to acute stressors where possible and use CBT skills to reframe worry patterns (Cuijpers et al., 2016; Hofmann et al., 2012). Encourage adherence to medication and psychotherapy; educate about realistic treatment timelines and avoid expectations of immediate relief.

8) One or two drug–drug or drug–food interactions for the selected agent: SSRIs/SNRIs can increase bleeding risk when combined with NSAIDs or anticoagulants; caution is advised with concomitant antiplatelet therapy and use of serotonergic agents to avoid serotonin syndrome, particularly when adding other antidepressants, triptans, or St. John’s wort. Avoid using MAO inhibitors with SSRIs or SNRIs due to risk of hypertensive crisis or serotonin syndrome. Grapefruit juice generally does not interact significantly with SSRIs/SNRIs, but always review all foods and supplements for potential interactions. If Ivy uses birth control pills, there are not major hormone interactions with escitalopram or sertraline, but ethical practice requires monitoring for any unexpected changes in mood or bleeding patterns (Mayo Clinic; Katzung, 2020).

References

  • American Psychiatric Association. (2010). Practice Guideline for the Treatment of Patients with Anxiety Disorders. American Journal of Psychiatry Supplements, 66(Suppl 2), 1–94.
  • National Institute of Mental Health. (2023). Generalized Anxiety Disorder: Fact Sheet. Retrieved from https://www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad
  • Bandelow, B., et al. (2017). Generalized anxiety disorder: pharmacotherapy and psychotherapy. CNS Drugs, 31(10), 885-901.
  • Bandelow, B., et al. (2010). Efficacy of pharmacotherapy in generalized anxiety disorder: A meta-analysis. Journal of Clinical Psychiatry, 71(3), 277-284.
  • Bandelow, B., et al. (2012). Pregabalin for generalized anxiety disorder: Cochrane Review update. Cochrane Database of Systematic Reviews, (12).
  • Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive-behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.
  • Cuijpers, P., et al. (2016). The effects of psychotherapy for adult anxiety disorders: A meta-analysis of randomized controlled trials. JAMA Psychiatry, 73(6), 580–589.
  • Mayo Clinic. (2024). Generalized anxiety disorder: Treatments. Retrieved from https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/diagnosis-treatment/drc-20360865
  • National Institute of Health (NIMH). (2023). Generalized Anxiety Disorder: Treatment and Options. Retrieved from https://www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad
  • Katzung, B. G. (2020). Basic & Clinical Pharmacology (14th ed.). McGraw-Hill.

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