| Course | NR 606 Diagnosis & Management in Psychiatric-Mental Health II Practicum |
|---|---|
| Week | 8 |
| Paper type | Complex case paper |
| 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 8
Complex Case Paper: D.L., 46, in Remission After a Partial Response, Sleep Apnea and Bupropion Augmentation, and the Maintenance Decision Now Due
Student Name
College of Nursing, Chamberlain University
NR 606: Diagnosis & Management in Psychiatric-Mental Health II Practicum
Instructor Name
Month Day, Year
Complex Case Paper: D.L., 46, in Remission After a Partial Response, Sleep Apnea and Bupropion Augmentation, and the Maintenance Decision Now Due
The Decision That Is Due
D.L. has been well for two months on the combination reached last term. The decision now is how long to continue both medicines, and whether either should be reduced first.
History That Constrains the Decision
Episodes: this is D.L.'s third major depressive episode. The first, at 31, resolved with therapy alone. The second, at 39, was treated with sertraline for eight months, then stopped; it recurred within a year. The current episode began 14 months ago.
Treatment course this episode: partial response to sertraline 150 mg, explained partly by weekend missed doses and partly by untreated sleep apnea; then sertraline 200 mg for residual anhedonia; then bupropion augmentation, bringing remission.
Comorbidity: obstructive sleep apnea, moderate, treated with airway pressure, used well; depressive symptoms improved after airway treatment, as published work has shown in other patients (Edwards et al., 2015).
Other: blood pressure in the low 130s; weight down 3 kilograms; alcohol limited.
Only these facts constrain the decision; the rest of D.L.'s history is in earlier notes.
Organized by Decision
Decision 1, made: treat the sleep apnea before changing the antidepressant. The airway treatment removed fatigue, poor sleep and poor concentration from the picture and showed that anhedonia was the true residual.
Decision 2, made: increase sertraline before adding a second agent. The dose was raised once the trial had become adequate.
Decision 3, made: add bupropion rather than switch or hold. Remission followed in eight weeks.
Decision 4, now due: maintenance duration and order of any reduction.
The Shortfall Explained
The original partial response had three causes, ranked: the antidepressant had not been taken every day, sleep apnea was producing half the residual symptoms, and the depression needed more treatment than sertraline alone. Each was addressed in turn, and the order allowed each to be judged.
What D.L. Wants Now
D.L. has been offered a promotion at work and wants to stay well for it. D.L. would like eventually to take fewer pills but says, "I never want to feel like that again." D.L. does not want to stop anything before the busy tax season, January to April.
The Evidence on Maintenance
Continuing antidepressant treatment after recovery roughly halves the risk of relapse compared with stopping, according to a systematic review of relapse prevention trials (Geddes et al., 2003). Patients with three or more episodes have a high risk of recurrence, and guidance generally supports longer maintenance, often of two years or more, and in some cases indefinitely.
The Decision
Continue both sertraline 200 mg and bupropion 150 mg for at least 12 months from remission, that is until at least the autumn after next, and certainly through the tax season.
At that point, if D.L. remains well, consider reducing bupropion first, slowly over four weeks, because it was the last added and D.L.'s main benefit from it, interest and energy, can be tracked. If symptoms return, restart it. Sertraline would be reviewed separately, given three episodes; long-term continuation is likely to be recommended.
Alternatives considered: stopping both now, rejected given three episodes and Geddes et al. (2003); reducing sertraline first, rejected because sertraline carried the main response and its withdrawal can cause discontinuation symptoms; continuing indefinitely without review, rejected because D.L. wants the option of fewer medicines and deserves a planned review.
Monitoring the Risk Named
The risk is relapse. Monitoring: PHQ-9 every three months, and at any time D.L. or the partner notices early warning signs, which D.L. has listed as stopping cycling, sleeping badly despite the machine and withdrawing from friends. A written relapse plan names those signs and what to do: call the clinic within a week.
Sleep apnea adherence: machine data reviewed every six months, since stopping airway pressure could bring back fatigue that looks like relapse.
Blood pressure: every three months, given bupropion.
Sexual side effects: asked at each visit.
Why the Remission Matters for the Plan
Patients who reached full remission in STAR*D had lower relapse rates over the following year than those who only responded (Rush et al., 2006). D.L. reached remission, which is the best position from which to start maintenance, but a third episode still carries a high chance of a fourth. The plan therefore protects the remission rather than testing it.
What Psychotherapy Could Add
D.L. has not had psychotherapy this episode. Cognitive behavioral therapy or mindfulness-based approaches during maintenance can reduce relapse risk for people with several episodes. D.L. was offered a referral and chose to wait until after tax season, when there will be time to attend. A reminder is set for May.
What Would Change the Decision
A relapse while on both medicines would lead to reassessment, including psychotherapy, which D.L. has not had this episode and which could add protection. Intolerable side effects would lead to a planned change. A major life event, such as the promotion going badly, would bring forward the next review.
Who Was Involved in the Decision
D.L. made the decision with me at a visit where the options were set out on one page. The partner attended and asked about relapse signs, which are now in the written relapse plan. Primary care received a copy, since they manage blood pressure. The sleep clinic received a copy, since stopping airway pressure would change the picture.
What the Patient Gives Up
Continuing two medicines for at least a year means daily tablets, the remaining sexual side effect and blood pressure checks. D.L. accepted these in exchange for protection through the promotion and tax season. The plan records that this was D.L.'s choice, made with the evidence in front of D.L., so that a future clinician understands why both medicines were continued.
The Next Review
Three months from now, after tax season: PHQ-9, blood pressure, machine data, side effects and a check on the psychotherapy referral. The date for discussing any reduction is set for twelve months from remission.
Closing
Each decision in this paper was made with the information available at the time and recorded with its reason.
The case was complex because three things looked like one: incomplete dosing, a breathing disorder and depression. Separating them, one decision at a time, led to remission. The maintenance plan now protects that result.
References
Edwards, C., Mukherjee, S., Simpson, L., Palmer, L. J., Almeida, O. P., & Hillman, D. R. (2015). Depressive symptoms before and after treatment of obstructive sleep apnea in men and women. Journal of Clinical Sleep Medicine, 11(9), 1029-1038. https://doi.org/10.5664/jcsm.5020
Geddes, J. R., Carney, S. M., Davies, C., Furukawa, T. A., Kupfer, D. J., Frank, E., & Goodwin, G. M. (2003). Relapse prevention with antidepressant drug treatment in depressive disorders: A systematic review. The Lancet, 361(9358), 653-661. https://doi.org/10.1016/S0140-6736(03)12599-8
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
NR 606 Week 8 instructions, in plain terms
The Week 8 paper is long, and length is where these come apart. Make every earlier section serve the final decision. Keep the history selective, carrying only what constrains the choice ahead. Report partial responses as findings with consequences. Where a second condition is present, argue its interaction and the order chosen. Record what the patient wants now. Explain the shortfall, rank its causes and then make the decision that is due, with monitoring for the risk you name. Most rubrics mark down the chronicle, complexity by accumulation and an unranked shortfall. State the decision that is due at the start. Rank the causes of any earlier shortfall.
Inside the NR 606 Week 8 example
The sample opens with the maintenance decision. History is limited to three episodes, the course this episode, the sleep apnea and blood pressure. Earlier work is organized as four decisions. The original shortfall is explained with three ranked causes. What the patient wants, staying well through a promotion and tax season while eventually taking fewer pills, is recorded. Relapse prevention evidence is cited. The decision continues both drugs for twelve months, then considers tapering bupropion first, with three alternatives rejected. Sections cover remission, psychotherapy, monitoring, what the patient gives up, who was involved, what would change the decision and the next review. Margin notes show how each section serves the final decision. The decision is stated before the history.
Where the points sit in the NR 606 Week 8 rubric
The dominant loss is the chronicle, an accurate account with a decision that could have been made without it; this paper's history is chosen for what constrains the decision. Complexity by accumulation costs the next share, while every condition here is tied to the choice. An unranked shortfall loses a row, and three causes are ranked. Ignoring what the patient wants loses marks, and the promotion and tax season shape the timing. Monitoring the named risk, relapse, with written warning signs earns the final criterion. Offering psychotherapy during maintenance shows the plan looks beyond medication. Recording what the patient gives up shows the decision was shared.
Common NR 606 Week 8 mistakes, and how to avoid them
Weak NR 606 Week 8 papers retell everything that happened before reaching a decision. Others add diagnoses and social details without saying how they affect the choice. Many describe several explanations for the earlier shortfall without ranking them. Patient goals are often missing. Monitoring is frequently general. Keep only the history that constrains the decision, organize earlier work as decisions, rank the causes of any shortfall, record what the patient wants and monitor the risk you name. If your case differs, share the decision that is due, and a paper built around it can be drafted. Say what the patient gives up under your plan. Organize the earlier work as decisions, not dates.
Get a NR 606 Week 8 example written to your instructions
Send the Week 8 instructions, the rubric and the case your classroom assigned, and a custom example is written to that material and returned inside 24 to 48 hours. The first one is free. If you already know which decision you want to defend, say so, and the sample will build the paper so that decision is the one it earns.
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 6: Augmentation Rationale
- NR 606 Week 7: Progress Note Series
- NR 605 Week 8: Management Case Paper
- NR 548 Week 8: Assessment Reflection
- NR 546 Week 8: Psychopharmacology Case Paper
- NR 547 Week 8: Diagnostic Case Paper
NR 606 Week 8 questions, answered
What makes a case complex enough for this assignment?
Difficulty in the decision rather than volume in the history. A patient with one condition, a partial response and a genuine argument on both sides of changing treatment is complex in the sense that counts. Stacking additional diagnoses onto a case without letting any of them affect the reasoning produces a longer paper that demonstrates less than a tight one would.
How much of the earlier weeks should appear?
The methods, not the material. Partial response reasoning, the ranking of explanations, sequencing when two conditions interact and comparative costing of options all belong here, applied to one case at full length. Reusing an earlier submission is a separate matter and is governed by your section's policy on prior work, which is worth checking before you build on anything.
Does the paper need a decision at the end?
Yes, and hedging it is the most common way a well written paper loses points. Instructors are marking judgment, so a clear recommendation with acknowledged uncertainty scores above balanced options left standing. State what you would do, name the evidence that would change it, and say when the decision gets reviewed.
Where can I find a free NR 606 Week 8 sample paper?
The full complex case paper on maintenance after remission with augmentation and sleep apnea is published on this page.
What maintenance decision is made in the NR 606 Week 8 paper?
Continue both medicines for at least 12 months from remission, through tax season, then consider tapering bupropion first.