| Course | NR 606 Diagnosis & Management in Psychiatric-Mental Health II Practicum |
|---|---|
| Week | 6 |
| Paper type | Augmentation rationale |
| Length | About 1,100 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 6
Augmentation Rationale: Adding Bupropion to Sertraline 200 mg for D.L.'s Persisting Anhedonia, Set Against Switching and Holding, With the Runner-Up Named
Student Name
College of Nursing, Chamberlain University
NR 606: Diagnosis & Management in Psychiatric-Mental Health II Practicum
Instructor Name
Month Day, Year
Augmentation Rationale: Adding Bupropion to Sertraline 200 mg for D.L.'s Persisting Anhedonia, Set Against Switching and Holding, With the Runner-Up Named
Where the Treatment Stands
D.L., 46, major depressive disorder, recurrent. Sertraline 200 mg daily for eight weeks after eight weeks at 150 mg; daily adherence confirmed; obstructive sleep apnea treated with airway pressure, used well. PHQ-9 now 7: mood 1, sleep 1, tiredness 1, concentration 1, interest 2, others 0 or 1. The interest item has not moved through two dose levels and airway treatment. Delayed orgasm has increased at 200 mg. D.L. wants to feel "like doing things again."
Three Roads, Named Together
Add a second agent to sertraline. Switch from sertraline to another antidepressant. Hold the current plan for another interval.
The Price of Adding
Keeps the real gain from sertraline: mood, suicidal thinking and guilt have improved and D.L. values that. Pays for it in a second medicine, possible interactions, more side effects and, afterward, uncertainty about which agent is doing the work.
Options considered for adding:
Bupropion. Acts on dopamine and noradrenaline, which may help low interest and energy, and often reduces sexual side effects from SSRIs. Costs: can cause insomnia, anxiety and raised blood pressure; lowers seizure threshold; at sertraline 200 mg, there is a modest interaction because bupropion inhibits the enzyme that breaks down some medicines, though sertraline levels are affected less than many others. In STAR*D, adding bupropion and adding buspirone produced similar remission rates, with bupropion better tolerated (Trivedi et al., 2006).
Aripiprazole. In the VAST-D trial, adding aripiprazole produced modestly higher remission than switching to bupropion (Mohamed et al., 2017). Costs: restlessness, plus weight and blood sugar effects that would push against D.L.'s weight loss and sleep apnea care.
The Price of Switching
Abandons the partial benefit. A cross-taper to a different antidepressant, for example vortioxetine or venlafaxine, accepts a period of weeks during which mood could slip. Gains a simpler, one-drug plan and a cleaner answer about whether the new drug works. For D.L., whose mood and suicidal thinking responded to sertraline, losing that response is a real risk.
The Price of Holding
Costs time. D.L. has had residual anhedonia for four months. Holding another eight weeks might see interest return on its own, but residual symptoms are linked to relapse, and D.L.'s third episode would be more likely. Holding gains certainty and no new side effects.
The Choice and the Runner-Up
Choice: bupropion XL, 150 mg on waking, with a step to 300 mg at four weeks if interest has not returned and side effects allow.
Reasons: it targets the residual symptom most directly, it may reduce the sexual side effect that has worsened at 200 mg and it does not cause weight gain, which matters for the sleep apnea.
Runner-up: holding for one more interval. It lost because four months of persistent anhedonia, through two dose levels, is enough evidence that sertraline alone will not resolve it.
Aripiprazole lost on weight and metabolic grounds. Switching lost because it risks the response D.L. has.
Attribution Plan
Only bupropion changes; sertraline stays at 200 mg. The target symptom, interest, is tracked with the PHQ-9 item and a weekly count of activities D.L. chose to do, such as rides or meals cooked. If interest returns within six to eight weeks, bupropion gets the credit. If D.L. remits and later wishes to reduce medicines, the plan would be to reduce one at a time, watching which change brings symptoms back.
How This Fits the Step Sequence
STAR*D found that each further treatment step brought lower remission rates than the one before, and higher relapse among those who reached remission only at later steps (Rush et al., 2006). D.L. is effectively at a second step. Choosing an option that is likely to be tolerated, and that preserves the response already gained, makes the most of this step rather than spending it on a switch that might need to be undone.
What D.L. Thought
D.L. was relieved not to stop sertraline: "It's the first thing that's helped." D.L. asked whether bupropion would help with the sexual side effect and was told it often does but is not guaranteed. D.L. was wary of anything that would make sleep worse, so the morning dosing and the airway data check were agreed together.
Interaction Check
Bupropion inhibits a liver enzyme that breaks down several medicines. Sertraline is affected only modestly. D.L. takes no other medicines affected by it. The pharmacy system flagged no interaction requiring a dose change, and the pharmacist confirmed this by phone before the first dose was dispensed.
What Would End the Augmentation
If bupropion causes insomnia that reduces airway pressure use below four hours a night, blood pressure above 140/90 on two readings, or anxiety that D.L. rates above 5 of 10, it will be reduced or stopped. Should interest still be flat after eight weeks on 300 mg, the augmentation will be judged ineffective and the next decision will be between aripiprazole, with its weight cost, and a switch.
Safety Checks
Blood pressure at baseline (132/84) and at each visit, since bupropion can raise it.
Sleep: bupropion taken in the morning only; airway pressure data checked, since insomnia from bupropion could reduce machine use.
Anxiety and agitation: asked at each visit.
Seizure risk: no history of seizures, no eating disorder, alcohol limited to two glasses of wine on weekend days.
What Holding Would Have Required
If D.L. had preferred to hold, the plan would have kept sertraline at 200 mg for eight more weeks with the same measures, and set a firm point at which augmentation would follow if interest had not returned. D.L. did not want to wait, and the evidence of four months without change made waiting harder to justify.
What Switching Would Have Required
A switch to vortioxetine, for example, would have meant reducing sertraline over two weeks while starting the new medicine, with weekly calls to watch for a dip in mood and for discontinuation symptoms. It would also have meant losing the delayed-orgasm side effect, which is the main argument in its favor, but bupropion is expected to reduce that too.
Review Point
Four weeks: PHQ-9 interest item, activity count, sexual side effects, blood pressure, sleep. Eight weeks: decide whether to continue, increase or stop bupropion.
References
Mohamed, S., Johnson, G. R., Chen, P., Hicks, P. B., Davis, L. L., Yoon, J., Gleason, T. C., Vertrees, J. E., Weingart, K., Tal, I., Scrymgeour, A., Lawrence, D. D., Planeta, B., Thase, M. E., Huang, G. D., & Zisook, S. (2017). Effect of antidepressant switching vs augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment: The VAST-D randomized clinical trial. JAMA, 318(2), 132-145. https://doi.org/10.1001/jama.2017.8036
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905
Trivedi, M. H., Fava, M., Wisniewski, S. R., Thase, M. E., Quitkin, F., Warden, D., Ritz, L., Nierenberg, A. A., Lebowitz, B. D., Biggs, M. M., Luther, J. F., Shores-Wilson, K., & Rush, A. J. (2006). Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 354(12), 1243-1252. https://doi.org/10.1056/NEJMoa052964
What the NR 606 Week 6 assignment asks for
The Week 6 rationale is comparative all the way through. Adding keeps a real but modest gain and pays for it in burden, interactions and never knowing afterward which agent worked. Switching abandons the partial benefit and accepts a gap during the change, in exchange for a simpler plan and a cleaner answer. Holding costs time, which may be the most expensive thing for this patient. Price all three, choose one and name the runner-up. Plan how you will tell which agent did the work. Most rubrics mark down a one-sided rationale, a straw alternative and an addition with no attribution plan. Name the runner-up and why it came second.
How the NR 606 Week 6 example is put together
The sample states the position: sertraline 200 mg for eight weeks, PHQ-9 of 7 with interest unchanged and sleep apnea treated. Three roads are named together. Adding is priced for bupropion, with STAR*D evidence and its blood pressure and insomnia costs, and for aripiprazole, with VAST-D evidence and its weight cost. Switching and holding are priced for this patient. Bupropion is chosen and holding named runner-up. Sections place the choice in the step sequence, record the patient's view, give an attribution plan, an interaction check, exit conditions, safety checks and a review point. Margin notes mark where each road is priced. The runner-up is named with its reason.
Where the points sit in the NR 606 Week 6 rubric
The heaviest loss is a one-sided rationale with the other options mentioned and never costed; each road here gets its price. A straw alternative tells the reader the comparison was decorative, while switching and holding are described as reasonable choices. An addition with no attribution plan loses a row, and this rationale changes only one drug and tracks one target. Missing exit conditions lose marks, and four are listed. Naming the runner-up with its reason earns the comparison criterion, and the patient's view shows the choice was shared. Placing the choice in the STAR*D step sequence explains why preserving the existing response matters. An interaction check shows the addition was screened.
Common NR 606 Week 6 mistakes, and how to avoid them
Weak NR 606 Week 6 rationales argue for one augmenting agent and mention the others in a line. Others describe switching or holding in a form nobody would choose. Many add a second drug with no plan to learn which one helped. Exit conditions are rarely stated. Few name the option that came second. Price adding, switching and holding for this patient, choose one, name the runner-up and plan how you will attribute any change. If your patient's position differs, share it, and a three-road comparison can be built for them. Plan exactly which symptom will show whether the added drug worked. Price the option you did not choose as carefully as the one you did.
Get a NR 606 Week 6 example written to your instructions
Send the Week 6 instructions and the case from your classroom, with your section's rubric if one is posted, and a custom example is written to that material and returned inside 24 to 48 hours. The first one is free. Name the option you are leaning toward and the sample will cost all three against it.
More NR 606 papers and PMHNP samples
- NR 606 Week 1: Inherited Patient Post
- NR 606 Week 2: Partial Response Analysis
- NR 606 Week 3: Comorbidity Case Write-Up
- NR 606 Week 4: Plan Revision Note
- NR 606 Week 5: Stalled Case Analysis
- NR 606 Week 7: Progress Note Series
- NR 606 Week 8: Complex Case Paper
- NR 605 Week 6: Follow-Up Note
- NR 548 Week 6: Psychiatric Evaluation Note
- NR 546 Week 6: Adverse Effect Brief
- NR 547 Week 6: Lifespan Variation Write-Up
NR 606 Week 6 questions, answered
Does the paper have to recommend augmenting?
No. The genre names one of the three options and the assignment usually asks for a defended decision rather than a predetermined one. Switching and holding both win on the right facts, and a paper that argues for either against a fair comparison scores as well as one that adds. What loses marks is arriving at any of the three without having priced the others.
How do I handle the attribution problem?
Name it and plan around it. Once two agents are running, later improvement cannot be assigned cleanly, which matters when something has to be simplified or stopped. Strong papers say how they will limit the damage: changing one thing at a time, holding other variables steady across the interval, and setting a point where the added agent gets reassessed rather than left in place indefinitely.
Where does non-medication treatment fit?
Usually as one of the additions being priced, and it belongs in the same comparison rather than in a paragraph of its own at the end. Access, cost, scheduling and the patient's willingness are legitimate costs to weigh openly. A rationale that recommends therapy without addressing whether this particular patient can actually get to it is incomplete in a way instructors notice.
Where can I find a free NR 606 Week 6 sample paper?
The full augmentation rationale comparing adding bupropion with switching and holding is published on this page.
Why does aripiprazole lose in the NR 606 Week 6 rationale?
It can help, but its weight and metabolic effects would work against the patient's weight loss and sleep apnea treatment.