| Course | NR 606 Diagnosis & Management in Psychiatric-Mental Health II Practicum |
|---|---|
| Week | 5 |
| Paper type | Case analysis |
| Length | About 1,110 words, 4 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 606 Week 5
Case Analysis: A 29-Year-Old Whose Generalized Anxiety Has Stalled on Escitalopram 20 mg for Twelve Weeks, Five Candidate Explanations Tested Against the History and Ranked
Student Name
College of Nursing, Chamberlain University
NR 606: Diagnosis & Management in Psychiatric-Mental Health II Practicum
Instructor Name
Month Day, Year
Case Analysis: A 29-Year-Old Whose Generalized Anxiety Has Stalled on Escitalopram 20 mg for Twelve Weeks, Five Candidate Explanations Tested Against the History and Ranked
The Case
A 29-year-old graphic designer with generalized anxiety disorder started escitalopram 10 mg three months ago, increased to 20 mg at week 4. GAD-7: 16 at start, 15 at week 4, 14 at week 12. The patient describes constant worry about deadlines, money and health, restlessness, poor sleep and trouble finishing tasks. "I don't think this medicine does anything." The referring clinician asks whether to switch.
Stalled, Not Mysterious
A case like this is rarely mysterious. Several explanations usually fit the facts, and the task is to put them in order before deciding anything.
The Candidate Set
1. The medicine is not being taken as prescribed.
2. Something the patient is taking is driving anxiety: caffeine, cannabis, stimulants or another substance.
3. The diagnosis is incomplete: another condition is producing the worry or the restlessness, such as attention-deficit/hyperactivity disorder, a mood disorder or a medical cause.
4. The dose or duration has not been adequate.
5. The medicine truly does not work for this patient.
Testing Against This Patient
Adherence. Pharmacy records show escitalopram 20 mg filled twice in twelve weeks, enough for about 60 days, so roughly two thirds of doses. Asked how it is taken, the patient said, "When I'm having a bad day, I take it. On good days I skip it so I don't get used to it." The patient believed the medicine worked like a sedative. Confirmed: inconsistent, symptom-driven dosing.
Substances. Three cups of coffee and one energy drink a day; cannabis on weekends; no stimulants. Caffeine at this level can worsen anxiety and sleep, but it has been stable for years, before the anxiety worsened. A contributor, not a driver.
Incomplete diagnosis. Asked about childhood: difficulty sitting still and finishing homework, frequent lost items and teachers' comments about "not living up to potential." Adult ADHD Self-Report Scale screener: 5 of 6 items in the positive range (Kessler et al., 2005). Much of the worry is about missed deadlines and unfinished work. Attention-deficit/hyperactivity disorder is plausible and would explain worry that tracks with disorganization. Not confirmed; screening is not diagnosis.
Mood disorder: no periods of elevated mood, no family history of bipolar disorder. Thyroid-stimulating hormone normal.
Dose and duration. Twenty milligrams is the usual maximum; twelve weeks is long enough. But the dose has not been taken consistently, so the trial has not qualified.
True non-response. Cannot be judged until the drug has been taken daily.
Elimination With Reasons
Inadequate dose: eliminated as a separate explanation, because the prescribed dose was adequate; the problem is that it was not taken.
True non-response: set aside for now, because a fair trial has not occurred.
Mood disorder and medical cause: unlikely on history and tests.
Substances: kept as a contributor.
The Verdict
The leading explanation is symptom-driven, inconsistent dosing, based on a misunderstanding of how the medicine works. Escitalopram needs daily use to work; taken only on bad days, it cannot. The second explanation, possibly contributing, is undiagnosed attention-deficit/hyperactivity disorder. Escitalopram and several other antidepressants are effective for generalized anxiety when taken as prescribed (Slee et al., 2019), so switching now would discard a medicine that has not yet been tried properly.
Ranking, Stated Plainly
First: inconsistent, symptom-driven dosing, confirmed by records and the patient's own account. Second: possible attention-deficit/hyperactivity disorder, supported by a positive screen and a history that fits, to be confirmed or excluded. Third: caffeine, a contributor. Unlikely: mood disorder, medical cause. Untestable until the first is fixed: true non-response.
Plan
Explain that escitalopram works only with daily dosing, reaching its effect over weeks. Agree on daily morning dosing at 20 mg with a phone reminder and a weekly pill box.
Reduce caffeine to two cups of coffee and stop the energy drink.
Arrange a structured evaluation for attention-deficit/hyperactivity disorder, which takes several weeks to complete.
Review in six weeks: GAD-7, a daily dosing count and the evaluation result.
What Would Overturn the Verdict
Should six weeks of confirmed daily dosing bring the GAD-7 down by fewer than 4 points, true non-response becomes likely, and a switch to another first-line agent such as sertraline or duloxetine would follow, as guidance recommends after an adequate failed trial (Baldwin et al., 2014). If the evaluation confirms attention-deficit/hyperactivity disorder, treatment of that condition may reduce the worry more than any change in anxiety medicine.
Why Not Switch Now
Switching would be the expected move after twelve weeks at the maximum dose with no change. It would also repeat the same problem with a new drug: the patient would take the new medicine on bad days only, and in another twelve weeks it would also seem to fail. The explanation for the stall lies in how the medicine is taken, so changing the medicine would not address it.
Why Not Add a Benzodiazepine for Bad Days
The patient's own belief, that the medicine should work like a sedative on bad days, describes a benzodiazepine. Adding one would confirm that belief, reduce the incentive to take escitalopram daily and introduce dependence risk in someone who already uses cannabis. It was not offered.
Who Does What
The patient takes the medicine daily and keeps a simple tick chart. The pharmacy sets up a monthly refill reminder. The clinic arranges the attention evaluation. The patient's partner, who suggested the visit, agreed to ask once a week how the chart is going, without nagging, and to say nothing about doses on good days, so that the medicine does not become a source of tension at home.
What Would Count as Progress at Six Weeks
Daily dosing confirmed on at least 38 of 42 days; GAD-7 down by 4 points or more; caffeine down to two cups; evaluation for attention-deficit/hyperactivity disorder under way. Any of these missing tells the clinician where to look next.
What the Patient Was Told
That the medicine had never had a fair chance, that taking it every day was the test and that the questions about concentration might point to a second condition worth evaluating. The patient said, "So I've been doing it wrong this whole time?" I said that the instructions had not explained how this kind of medicine works, which was a gap in the teaching, not a failing of the patient.
References
Baldwin, D. S., Anderson, I. M., Nutt, D. J., Allgulander, C., Bandelow, B., den Boer, J. A., Christmas, D. M., Davies, S., Fineberg, N., Lidbetter, N., Malizia, A., McCrone, P., Nabarro, D., O'Neill, C., Scott, J., van der Wee, N., & Wittchen, H.-U. (2014). Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. Journal of Psychopharmacology, 28(5), 403-439. https://doi.org/10.1177/0269881114525674
Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes, M. J., Jin, R., Secnik, K., Spencer, T., Ustun, T. B., & Walters, E. E. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245-256. https://doi.org/10.1017/S0033291704002892
Slee, A., Nazareth, I., Bondaronek, P., Liu, Y., Cheng, Z., & Freemantle, N. (2019). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, 393(10173), 768-777. https://doi.org/10.1016/S0140-6736(18)31793-8
The Chamberlain NR 606 Week 5 instructions
The Week 5 analysis treats a stalled case as over-explained rather than mysterious. Several candidate reasons usually fit: the diagnosis may be incomplete, the dose may never have reached a working level, the patient may not be taking it as written, a second condition may be driving things or the drug may not work. Lay them out, test each against this patient's history and records, eliminate with reasons and commit to a verdict. Say what would overturn it. Most rubrics mark down an inventory with no ranking, a favorite asserted without testing and an explanation dropped silently, especially adherence.
Inside the NR 606 Week 5 example
The sample describes twelve weeks on escitalopram with GAD-7 moving from 16 to 14 and a referrer asking about switching. Five candidates are listed. Pharmacy fills show two thirds of doses, and the patient explains taking it only on bad days. Caffeine and weekend cannabis are weighed as contributors. A childhood history and a positive adult screen raise attention-deficit/hyperactivity disorder. Dose is adequate but untested in practice; true non-response cannot yet be judged. The verdict is symptom-driven dosing with possible ADHD. Sections explain why switching and a benzodiazepine are not chosen, give the ranking, plan, progress criteria and what would overturn the verdict. Margin notes show where testing and elimination meet the rubric. A ranking section states the order plainly.
Where the points sit in the NR 606 Week 5 rubric
The most expensive loss is the inventory, every explanation described and none ranked; this analysis commits to a verdict. Naming a favorite without testing it is the second loss; this analysis checks every candidate against records and history. Silent elimination loses a row, especially of adherence, and here adherence is tested first and confirmed. Ignoring what would overturn the verdict loses marks, and two conditions are stated. Explaining why the expected moves, switching and a sedative, were not made earns the reasoning criterion. Explaining to the patient that the gap was in the teaching, not the patient, keeps the relationship intact. Naming who does what makes the daily dosing likely to happen.
Common NR 606 Week 5 mistakes, and how to avoid them
Weak NR 606 Week 5 analyses list possible reasons for a stalled case without choosing one. Others pick a favorite and never test it. Many skip adherence or assume it. Few check pharmacy records or ask how the medicine is actually taken. Verdicts rarely say what would prove them wrong. Lay out the candidates, test each against this patient, explain each elimination and commit to the most likely cause with a condition that would overturn it. If your stalled case differs, share the history and records, and a ranked sample can be written. Check pharmacy fills and ask how the medicine is actually taken. Say what result would make you switch.
Get a NR 606 Week 5 example written to your instructions
Send the Week 5 case and the instructions your classroom published, along with any rubric, and a custom example is written to that material and returned inside 24 to 48 hours. The first one is free. Say which explanation you lean toward and the sample will argue a ranking you can push back against.
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NR 606 Week 5 questions, answered
Is it acceptable to rank adherence first?
Yes, and it is often correct, but the paper has to work for it. Adherence as a first-line explanation needs evidence in the case: refills, a side effect the patient stopped mentioning, a schedule that never fitted their week. Named without support it reads as blaming the patient, and that reading costs more marks than a wrong ranking argued from the record would.
How many explanations should the paper carry?
Enough to show the field and few enough to rank convincingly. Most strong versions carry four or five, examine each briefly, and spend their length on the top two. A paper listing every possibility in the literature loses the thread, while one carrying a single explanation has skipped the sorting work the assignment is actually asking for.
What if the assigned case leaves out something I need?
Say so and treat the gap as a finding. Cases are written with holes in them and noticing which piece of information would change your ranking is itself analysis. State what you would want, what you would do with it, and how you are proceeding meanwhile. That is stronger than quietly inventing the missing detail to make a conclusion tidy.
Where can I find a free NR 606 Week 5 sample paper?
The full stalled case analysis of generalized anxiety on escitalopram, with five ranked explanations, is on this page.
What is the verdict in the NR 606 Week 5 analysis?
The patient was taking escitalopram only on bad days, so the trial never happened; possible ADHD is a second explanation to evaluate.