NR 605 Week 8 Management Case Paper Example

Management Case Paper: T.N. From Evaluation to Twelve Weeks, a Chain From Findings to Diagnosis to a Plan Whose Every Element Carries the Option It Displaced and the Point It Was Judged

Student Name

College of Nursing, Chamberlain University

NR 605: Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum

Instructor Name

Month Day, Year

Management Case Paper: T.N. From Evaluation to Twelve Weeks, a Chain From Findings to Diagnosis to a Plan Whose Every Element Carries the Option It Displaced and the Point It Was Judged

The Chain, Link by Link

Findings: three months of low mood, loss of interest, broken daytime sleep, weight loss, poor concentration and panic attacks beginning on a loading dock; a prior depressive episode; PHQ-9 17, GAD-7 13; hazardous drinking; passive death wish without plan; firearm at home.

Diagnosis: a second episode of major depression, moderate in severity, with anxious distress; panic attacks; drinking at a hazardous level.

Plan: a sedating antidepressant timed to daytime sleep, therapy aimed first at panic, a drinking limit, a written safety plan with the rifle locked away, and review against measures.

Each link depends on the one before. The prior sertraline trial and its side effects, recorded in the history, removed the SSRIs. The broken daytime sleep removed activating options. The panic and avoidance made therapy aimed at panic the first therapy target. The drinking shaped both the medicine choice and the alcohol element.

Room to Argue the Alternatives

Escitalopram, properly argued. On average, escitalopram is among the better-tolerated and effective antidepressants in comparative analyses (Cipriani et al., 2018), and it treats anxiety well. Had T.N. never taken an SSRI, it would have been my first choice. It was set aside because sexual side effects ended T.N.'s last SSRI trial, and T.N. said plainly that another "pill like that" would be stopped. A different SSRI might have been tolerated, since individual responses vary, and it could have been tried with a plan for the side effect. I judged that starting with an agent T.N. distrusted risked losing T.N. from treatment altogether, which is the larger harm.

Bupropion, properly argued. Sexual side effects are uncommon with it and does not cause weight gain, which mirtazapine does. Those two advantages are real, and the weight gain T.N. has had shows the cost of passing them over. It lost out because activation could deepen the sleeplessness and worry T.N. most wanted gone, and because seizure risk rises with it, a concern in someone drinking ten to twelve drinks a week at the start. With drinking now reduced and sleep restored, bupropion would be a reasonable option to add or switch to if weight gain becomes a problem.

A benzodiazepine for panic. It would have stopped attacks quickly. It was set aside because of the drinking, the risk of dependence and evidence that it can interfere with the learning that exposure therapy depends on.

Trazodone added for sleep. Considered at evaluation. Not needed, because mirtazapine at 08:00 restored daytime sleep inside a fortnight.

The Middle Third: Management Over Twelve Weeks

Weeks 0 to 2: mirtazapine 15 mg; daytime sleep rose from 4.5 to 6 hours; PHQ-9 17 to 15; no change in panic. Dose increased to 30 mg.

Weeks 2 to 4: PHQ-9 to 11; panic attacks to 1 a week; first two days back on the dock; drinks down to 4 a week; weight up 2.1 kilograms.

Weeks 4 to 8: therapy sessions on bringing on bodily sensations and the graded dock list; panic attacks to 1 every two weeks; PHQ-9 to 8, meeting the definition of response, a halving from baseline; weight up 3.4 kilograms, 4.3% of baseline, below the 5% threshold set for discussing a switch.

Weeks 8 to 12: PHQ-9 to 5; GAD-7 to 5; no panic attacks in three weeks; walking the dock floor every shift; AUDIT-C 3; Columbia screen negative throughout; blood pressure treated by primary care.

Cognitive behavioral therapy for panic has been shown in trials to produce gains that last after treatment ends (Barlow et al., 2000), which is one reason the therapy was kept going through week 12 even as the medicine was working.

Where the Plan Was Judged and What Was Decided

Week 2: sleep improved, mood barely changed; increased dose.

Week 4: partial response; continued without change, as argued in the follow-up note.

Week 8: response achieved; weight gain below threshold; continued.

Week 12: PHQ-9 of 5, at the edge of remission; continued.

What the Evaluation Got Right and Wrong

The evaluation correctly predicted that sleep would respond first and mood more slowly. It underestimated the weight gain: the plan anticipated it but expected less. It also underestimated how much the alcohol goal would help; drinking fell faster than expected once sleep improved, suggesting that much of the drinking had been self-treatment for insomnia.

What the Partner Reported

At week 12, the partner joined the visit and described T.N. as "back to about 80 percent," sleeping well and playing with the child again, but still quick to anger when tired. That observation fits the residual PHQ-9 score and is a reason not to call the episode finished.

What Was Not Achieved

T.N. is not yet in full remission, defined as a PHQ-9 below 5. Weight has risen by 3.6 kilograms. The partner reports T.N. is still more irritable than before the episode.

How the Plan Would Have Differed for Another Patient

For a day worker with no prior SSRI trial and no drinking, escitalopram at bedtime with general cognitive behavioral therapy would likely have been the first plan. For a patient with bipolar features, no antidepressant would have been started alone. The chain from findings to plan is specific to T.N., which is the point the course asks the paper to show.

The Conclusion, Committed

The chain holds: each element of the conclusion follows from a finding recorded at evaluation.

Continue mirtazapine 30 mg for at least six months after remission, given that this is T.N.'s second episode, then review whether to taper or continue longer. Complete the 12 therapy sessions and move to monthly booster sessions for three months. If weight gain exceeds 5% from baseline, switch to or add bupropion, now that sleep has recovered and drinking has fallen. Reassess at week 16 for full remission.

A second depressive episode raises the chance of a third, and the safety plan and firearm agreement remain in place throughout maintenance. Stanley and Brown (2012) describe the safety plan as something to revisit over time, and it will be reviewed at every quarterly visit.

Published Requirements

The paper addresses the course's required elements: diagnosis with supporting criteria, differential, pharmacological and nonpharmacological management with evidence, monitoring, safety and follow-up.

References

Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA, 283(19), 2529-2536. https://doi.org/10.1001/jama.283.19.2529

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001