Treatment Goals
Treatment Goals
One might presume that the treatment goal for GAD is for the patient to have less anxiety. However, as Stein, et al. (2021) of BMC Psychiatry point out, the helpfulness of treatment for GAD is a subjective measure. Related issues include treatment adherence and whether psychotherapy is prescribed in addition to pharmacological treatment (Stein, et al., 2021). Ultimately, the helpfulness of treatment comes down to whether the patient feels less anxious in their day-to-day life. For healthcare providers, treatment goals should be helping the patient to achieve that.
Drug Therapy
Along with drug therapy for L.P., psychotherapy, specifically cognitive behavioral therapy (CBT), should be recommended as well. As for medications, it may take trial and error to figure out which of the many options that are available will work best for L.P. The first type of medications listed by Munir and Takov (2021) of Stat Pearls are antidepressants. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) are considered first-line pharmacotherapy for GAD with response rates between 30 and 50 percent. Several medications are included in these two drug classes including escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR), and paroxetine (Paxil). Munir and Takov (2021) also list antipsychotics as possible pharmacotherapy for L.P. (Munir & Takov, 2021).
Other classes of medication that might be considered include benzodiazepines and buspirone. Benzodiazepines, which include diazepam and clonazepam, is only for short-term relief of symptoms. Patients who understand that there symptoms have a psychological source and who are cooperative respond better to benzodiazepines. However, benzodiazepines can also be addictive, but L.P. does not have a history of addiction, so benzodiazepines could be considered for her treatment. Buspirone is a non-benzodiazepine and does not cause dependency, but it takes 2 to 3 weeks before the therapeutic benefits are realized (Munir & Takov, 2021). For L.P., the best choice of pharmacotherapy is to start with the first-line treatment of antidepressants and prescribe 10 mg. per day of Lexapro. If it does not result in some relief for L.P., other medications could be added or substituted.
Parameters for Monitoring
Patients being treated for GAD should be monitored. One reason for this may be the types of medications they are prescribed. Some of the medications used to treat GAD may be sedatives, which may not be helpful to patients who have jobs and must work such as L.P. Another reason for the monitoring is that about half of the patients who are treated for GAD will not respond to the first line treatment according to Ansara (2020) of Mental Health Clinician. This can lead to treatment resistant GAD (TR-GAD). TR-GAD occurs when a patient does not respond to at least one antidepressant at an adequate dose after trying it for an acceptable amount of time (Ansara, 2020). Depending upon what type of antidepressant (or other medication) was prescribed for L.P., she should be asked to check in at least once a week with her primary provider so it can be determined if the medication is taking effect or not.
Adverse Reactions
The main adverse reaction to Lexapro may be that it is not effective. Some of the side effects associated with Lexapro include a decreased interest in sex, the inability to have an orgasm or to get or keep an erection, and/or the loss of sex drive or desire. While these are disturbing side effects, they may only be temporary. If L.P. experiences them, she should notify her primary provider. Other rarer side effects that would require notification of the prescriber too include coma, confusion, decreased urine output, fast or irregular heartbeat, headache, increased thirst, muscle pain, nausea or vomiting, seizures, swelling of the face, ankles or hands, trouble breathing, and/or unusual tiredness or weakness (Mayo Clinic, 2021).
Second-Line Therapy
Rather than trying a benzodiazepine on L.P. as a second-line treatment, the primary provider should prescribe her a different antidepressant to see if it has more success in addressing the anxiety from which she suffers. Lexapro is an SSRI, so perhaps an SNRI would work better for L.P. She should also be seeing a psychotherapist for CBT.
References
Ansara, E. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician, 10(6), 326-34. Retrieved from https://watermark.silverchair.com/i2168-9709-10-6-326.pdf?
