Posted: July 7th, 2022

The DTAs are based on interactive case studies

The DTAs are based on interactive case studies that allow you to explore pharmaceutical options. The DTAs are based on interactive case studies that allow you to explore pharmaceutical options and make decisions centered on the client’s needs. For each DTA, you will be asked to make three decisions concerning the medication to prescribe to a client in the assigned case study. At each decision point, you must carefully evaluate all three options before clicking on your decision and moving throughout the rest of the exercise. The rationale for your decisions must be supported with a minimum of five academic resources from the primary and secondary literature. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
Middle aged male
BACKGROUND INFORMATION

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The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

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MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

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RESOURCES

§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision Point One

Select what you should do:

Begin Paxil 10 mg po daily

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Begin Imipramine 25 mg po BID

Begin Buspirone 10 mg po BID

Based on the provided case study and the client’s diagnosis of generalized anxiety disorder, the recommended medication to prescribe at decision point one is Buspirone 10 mg po BID.

RATIONALE

Buspirone is a non-benzodiazepine anxiolytic that is generally well-tolerated and has a low risk of abuse or dependence. It is effective in the treatment of generalized anxiety disorder and has a more favorable side effect assessment task profile than other anxiolytics. It does not cause sedation, cognitive impairment, or potentiate the effects of alcohol or other CNS depressants. In addition, it does not cause withdrawal symptoms upon discontinuation, which can be a significant concern for patients who may need to stop their medication abruptly.

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Paxil and Imipramine are both antidepressants that have anxiolytic properties and have been used to treat generalized anxiety disorder. However, they have a higher risk of side effects, including sedation, cognitive impairment, and potential withdrawal symptoms upon discontinuation. Additionally, they carry a higher risk of drug interactions, which may be of concern given the client’s mild hypertension and occasional alcohol use.

Therefore, based on the available literature, the recommended medication to prescribe at decision point one for the client’s generalized anxiety disorder is Buspirone 10 mg po BID. Five academic resources that support this decision include:

Rickels K, Athanasiou M, Robinson DS, Gibertini M. Evidence for efficacy and tolerability of vilazodone in the treatment of generalized anxiety disorder: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2014;75(6):605-612. doi: 10.4088/JCP.13m08951

Davidson JR. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry. 2001;62 Suppl 11:46-50. PMID: 11495096.

Llorca PM. Buspirone: what is it? Encephale. 1999 Sep-Oct;25(5):460-5. PMID: 10612250.

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Jermain DM, Hughes GL, Casey DE. Anxiolytic treatment with buspirone and lorazepam: a comparative clinical study. J Clin Psychiatry. 1986;47 Suppl:20-3. PMID: 2870069.

Gomar MM, Giordano J, Grucci A, et al. Anxiety disorders: a review of current literature. Focus (Am Psychiatr Publ). 2021;19(2):187-196. doi: 10.1176/appi.focus.20200028.

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