Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Asian girl

 

Decision Point One


Begin Zoloft 50 mg orally daily

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what you should do next:


Increase dose to 75 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports an even further reduction in his symptoms
  • HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)
Decision Point Three
Select what you should do next:


Maintain current dose
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Increase current dose of medication to 100 mg orally daily
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Add augmentation agent such as BuSpar (buspirone)
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Increase dose to 100 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client is a bit evasive about his symptoms. Eventually he admits that he stopped taking the medication about a week ago because he was experiencing difficulty acquiring an erection.
Decision Point Three
Select what you should do next:


Start Paxil (paroxetine) at 50 mg orally daily
Guidance to Student
You should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. You should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
Add agent to treat side effects
Guidance to Student
You should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. You should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
Begin Lexapro (escitalopram) 5 mg orally daily
Guidance to Student
You should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. You should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, you could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
No change in drug/dose at this time

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports no further decreases in anxiety and is wondering if this means that the medication will not be effective for him
Decision Point Three
Select what you should do next:


Increase drug to 75 mg po daily
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.
Consider addition of augmentation agent such as BuSpar (buspirone)
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.
Switch to a serotonin norepinephrine reuptake inhibitor (SNRI) such as Effexor (venlafaxine)
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.