| Course | NR 668 Psychiatric-Mental Health Capstone Practicum & Intensive |
|---|---|
| Week | 1 |
| Paper type | Discussion post with two replies |
| Length | About 510 words |
| Format | Discussion post with APA 7 citations |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 668 Week 1
Week 1 Discussion: Initial Post
A Referral for Treatment-Resistant Depression That Turned Out Not to Be Depression Alone, and the Question I Still Have About the Medication Plan
Initial Post
This patient is worth ten minutes because the obvious reading, treatment-resistant depression, was wrong, and the referral letter would have led any of us to a third antidepressant.
The history, cut to fit. A 34-year-old graphic designer was referred by their primary care clinician after nine months of depression that had not responded to sertraline or to escitalopram at full dose. Their PHQ-9 at referral was 19. Over the two weeks before the visit they had been sleeping four hours a night but felt "wired," had made two large purchases and had argued at work. Their partner came to the visit.
The moment it turned. When I asked whether there had ever been a stretch of days when they needed much less sleep and felt unusually productive, the patient said no. Their partner said yes: at least three times in the past five years, for four or five days each, "they barely slept, redid half the apartment and talked nonstop." No hospitalization, no psychosis. With the partner's account, the picture fit bipolar II disorder, current episode depressed, with recent mixed features that may have been pushed along by the antidepressant. A screening questionnaire for bipolar spectrum was then positive (Hirschfeld et al., 2000), and undiagnosed bipolarity is common among people treated for major depression (Angst et al., 2011).
What is still open. Whether to taper the escitalopram now or hold it while starting a mood stabilizer, and which first-line agent fits someone whose body mass index is 31 and a parent with type 2 diabetes. The guideline puts quetiapine first for bipolar II depression and places lithium and lamotrigine lower (Yatham et al., 2018), yet for someone with these metabolic risks that choice has a real price.
What I would ask the room. Has anyone found a reliable way to ask about hypomania that works when the patient does not see it as illness? "Have you ever felt too good?" got me nothing. "Has anyone ever told you that you seemed unusually wound up for days at a time?" might have. And how do you weigh one informant's account when the patient disagrees?
What I took from it. A referral letter frames the visit before it starts. This one said "treatment-resistant depression," and I had a third antidepressant in mind before the patient sat down. The partner's account was the only thing that stopped me, and the partner was only in the room because the patient had asked them to drive.
Reply to Danielle
Danielle, your patient's anxiety improved on buspirone after two SSRIs failed. What made you choose buspirone over a third SSRI? Was it the side effects, or something in the history?
Reply to Tomás
Tomás, you said the adolescent "clearly had ADHD." What would have made you consider anxiety or a mood disorder first? Did anyone besides the parent describe the symptoms?
References
Angst, J., Azorin, J.-M., Bowden, C. L., Perugi, G., Vieta, E., Gamma, A., & Young, A. H. (2011). Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE study. Archives of General Psychiatry, 68(8), 791-798. https://doi.org/10.1001/archgenpsychiatry.2011.87
Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873
Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O'Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., . . . Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170. https://doi.org/10.1111/bdi.12609
The Chamberlain NR 668 Week 1 instructions
Say in your first line why a room of prescribers should spend ten minutes on this patient: usually because the obvious reading was wrong, two clinicians disagreed or the plan had to change for an instructive reason. Rarity and severity are not the test. Give a compressed history of three or four sentences, enough for a reader to picture the person without the history swallowing the post. Name the moment the case turned and who supplied the information that turned it. State what is still open, so classmates have something to answer. Keep the patient unidentifiable. In replies, ask something specific about a classmate's case rather than agreeing, such as what drove a choice or who supplied the history.
How this NR 668 Week 1 example is built
The sample's first line says the referral's reading was wrong. A 34-year-old designer had nine months of depression unresponsive to sertraline and escitalopram, a PHQ-9 of 19 and two weeks of four-hour nights, purchases and arguments. The patient denied past high periods; the partner described three or more four- to five-day stretches of little sleep, high energy and overspending. A screening questionnaire was positive and undiagnosed bipolarity in depression is common. Still open: tapering the antidepressant and whether quetiapine suits someone with a body mass index of 31. The post asks the room how to ask about hypomania, and replies ask what drove a buspirone choice and who described a teenager's symptoms. The post also notes how the referral letter framed the visit before it began.
Where the points sit in the NR 668 Week 1 rubric
Case selection posts lose most when a rare diagnosis decides which patient is brought rather than for what the case teaches. Next is a history so long that the turning point disappears. Many posts never say who supplied the information that changed the reading, which is often the most useful part. Posts that present the case as settled leave classmates nothing to answer. Details that could identify the patient or site raise confidentiality problems. Replies that praise a classmate's case without asking what drove a decision earn little, since the discussion is meant to test reasoning rather than share stories. A post with no stated question for the room wastes the format.
NR 668 Week 1 help from the desk
Choosing which patient to bring, and cutting the history to a few sentences, is harder than writing the full story. Working from a short draft, you can write a first line that justifies the room's time, compress the history and name the turning point and who supplied it. We can also help you frame what is still open as a question classmates can answer and write replies that ask rather than agree. A quick conversation about two or three candidate patients usually shows which one teaches most. The patient, the case and your questions are yours.
Get a NR 668 Week 1 example written to your instructions
Send the Week 1 prompt exactly as your classroom shows it, with any word limit or reply requirement, and a custom example is written to it and returned inside 24 to 48 hours. The first one is free. Which of your own patients is worth presenting stays a judgment only you can make.
More NR 668 papers and PMHNP samples
- NR 668 Week 2: Case Conference Write-up
- NR 668 Week 3: Comprehensive Evaluation Note
- NR 668 Week 4: Case Defense Write-up
- NR 668 Week 5: Panel Review Write-up
- NR 668 Week 6: Safety Decision Write-up
- NR 668 Week 7: Practice Question Brief
- NR 668 Week 8: Capstone Case Paper
- NR 546 Week 1: Antidepressant Timing Discussion
- NR 607 Week 1: Missing Fact in the Record Post
- NR 547 Week 1: Diagnostic Position Discussion
- NR 606 Week 1: Inherited Patient Post
NR 668 Week 1 questions, answered
How much of the patient's history belongs in a post this short?
Less than most writers include. Carry only the detail that supports the claim you opened with, which is usually the presenting problem, the treatment course and the point where something changed. Everything else can be answered if a classmate asks. A post that spends its word count on background arrives at its argument too late for anybody to engage with it.
Does the case have to be unusual to be worth posting?
No, and reaching for rarity is a common way to lose marks here. What makes a case worth a colleague's attention is that a decision in it was difficult, contested or wrong the first time. A straightforward diagnosis handled badly for two months teaches a class more than an exotic presentation that resolved on the first attempt.
How do I write about a real patient without identifying them?
Shift anything that could pin the person down, and say in a line that you have. Give an age band, say what type of setting it was without naming it, and leave out dates. Psychiatry needs more care here than most specialties, because the detail that makes a presentation worth discussing is often the same detail that makes somebody recognizable locally.
Where can I find a free NR 668 Week 1 sample paper?
The complete post on a depression referral that turned out to be bipolar II disorder, with replies to Danielle and Tomás, is on this page.
What changed the diagnosis in the NR 668 Week 1 case?
The partner described past four- to five-day periods of little sleep, high energy and overspending that the patient had not seen as illness.