L.P., age 23, is a white woman who graduated from college last year. She began working as an accountant 1 month after graduating. Approximately 2 months ago, she moved into a two-bedroom apartment with another woman who works at the same accounting firm. She states that her roommate recommended that she see a doctor to find out if she has anemia or “some sort of fatigue syndrome.” She states that she has felt “restless” and “on edge” for most of the past 9 months. She becomes easily fatigued and irritable and has difficulty concentrating and falling asleep. She states that sometimes her mind “just goes blank,” and she is worried that her work performance is no longer excellent. She reports that all her life she had good grades in school and was very successful in everything she attempted. Although she has been “a worrier from the day I was born,” now she worries more than she ever has and feels nervous “all the time.” L.P. reports that she has a good relationship with her boyfriend, but they do not get to see each other very often because he is attending graduate school 100 miles away. She reports having a satisfying sexual relationship with him. She denies having any problems with relationships with her parents, roommate, or peers. She denies having any financial worries unless she is fired from her job for poor work performance. She reports that she has always been healthy and has taken good care of herself. The only medication she takes is birth control pills, which she has taken for the past 4 years without any adverse effects. 1. List specific treatment goals for L.P. 2. What drug therapy would you prescribe? Why? 3. What are the parameters for monitoring the success of the therapy? 4. Describe specific patient monitoring based on the prescribed therapy. 5. List one or two adverse reactions for the selected agent that would cause you to change therapy. 6. What would be the choice for second-line therapy?

1. Treatment goals for L.P. would involve addressing her symptoms of restless feeling, fatigue, irritability, difficulty concentrating, and insomnia. Additionally, it would be important to alleviate her worry and nervousness, improve her work performance, and restore her overall sense of well-being. It would also be beneficial to assess her iron levels and rule out anemia or other medical causes for her symptoms.

2. Based on L.P.’s symptoms and presentation, a suitable drug therapy would be a selective serotonin reuptake inhibitor (SSRI) such as sertraline. SSRIs are commonly used to treat anxiety and depression, as they help to regulate serotonin levels in the brain. Sertraline is a widely prescribed SSRI and has been shown to effectively reduce symptoms of anxiety and improve overall function in individuals with generalized anxiety disorder.

Why sertraline? Sertraline has a well-established safety profile and is efficacious in reducing anxiety symptoms, making it a suitable first-line treatment option for L.P. Additionally, sertraline has a relatively low risk of adverse effects and is generally well-tolerated.

3. The success of therapy can be monitored by assessing changes in L.P.’s symptoms over time. This can involve regular follow-up visits to evaluate her levels of anxiety, fatigue, irritability, concentration, and sleep quality. It may be helpful to use standardized rating scales such as the Hamilton Anxiety Rating Scale (HARS) or the Panic and Agoraphobia Scale (PAS) to objectively measure changes in her symptoms. Improvement in work performance and overall well-being should also be considered as indicators of treatment success.

4. Patient monitoring should include regular check-ins to assess L.P.’s response to therapy and any potential side effects. Initially, close monitoring should be done to ensure proper dosing and titration of sertraline, as individual responses to medication can vary. It would be important to educate L.P. about potential side effects, such as gastrointestinal symptoms or changes in libido, and encourage her to report any adverse reactions promptly. Additionally, it would be beneficial to assess L.P.’s iron levels and rule out anemia as a contributing factor to her symptoms.

5. Possible adverse reactions of sertraline that may warrant a change in therapy include severe gastrointestinal side effects, such as persistent nausea or diarrhea, or the development of significant sexual dysfunction. If these adverse reactions occur and significantly impact L.P.’s quality of life, it may be necessary to discontinue sertraline and consider alternative treatment options.

6. If the initial therapy with sertraline is not effective, or if L.P. experiences intolerable side effects, a second-line therapy option could be a different class of antidepressants such as a serotonin-norepinephrine reuptake inhibitor (SNRI) or a benzodiazepine. SNRIs, such as venlafaxine, have shown efficacy in treating anxiety and can be considered as an alternative if sertraline is ineffective. However, it is important to weigh the potential risks and benefits of alternative therapies and to carefully consider L.P.’s individual circumstances and response to treatment.

In summary, treatment goals for L.P. would involve addressing her symptoms and restoring her overall well-being. Sertraline, an SSRI, would be a suitable first-line therapy due to its proven efficacy in treating anxiety symptoms. Monitoring the success of therapy would involve assessing changes in symptoms, work performance, and overall well-being. Patient monitoring should include regular check-ins to evaluate response to therapy and potential side effects. If adverse reactions occur or if sertraline is ineffective, alternative therapy options such as SNRIs or benzodiazepines can be considered.