NR 668 Week 5 Panel Review Example

Panel Review Write-Up: Five Patients Started on a New Mood Medication This Term, Compared for What Repeated Across Them and What It Says About My Prescribing

Student Name

College of Nursing, Chamberlain University

NR 668: Psychiatric-Mental Health Capstone Practicum & Intensive

Instructor Name

Month Day, Year

Panel Review Write-Up: Five Patients Started on a New Mood Medication This Term, Compared for What Repeated Across Them and What It Says About My Prescribing

What the Set Has in Common

Five adults I started on a new medication for a mood or anxiety disorder in the first four weeks of the practicum, each followed for at least four weeks, at an outpatient psychiatric clinic. They were chosen because they were all the new starts I made in that period, not because their outcomes were tidy. Each was measured with the same scales at the start and at four weeks.

Profiles, Built to One Shape

Each profile gives presentation, what was started and the dose at four weeks, the measure at start and four weeks, and where the patient stood.

Patient A: the 34-year-old with bipolar II depression and mixed features from the case conference. Quetiapine to 300 mg, escitalopram tapered. PHQ-9 19 to 13. Sleep restored to seven hours; weight up 1.5 kg; a safety concern in week 4, described separately.

Patient B: a 52-year-old with a first episode of major depression and no prior treatment. Sertraline 50 mg, increased to 100 mg at two weeks. PHQ-9 17 to 8. Improved faster than expected.

Patient C: a 27-year-old with generalized anxiety disorder and prior intolerance to an SSRI. Escitalopram 5 mg, increased to 10 mg at three weeks. GAD-7 15 to 12. Partial improvement, slower than hoped.

Patient D: a 41-year-old with recurrent major depression and chronic back pain. Duloxetine 30 mg, increased to 60 mg at two weeks. PHQ-9 16 to 15. No meaningful improvement.

Patient E: a 63-year-old with late-life depression and mild cognitive complaints. Sertraline 25 mg, increased to 50 mg at two weeks. PHQ-9 14 to 9. Improved, though the patient's daughter also moved in during week 2, so the reason is uncertain.

The One Who Did Not Improve

Patient D's PHQ-9 moved by one point in four weeks. Looking back at the notes, three things stand out. I did not ask about alcohol at the first visit; at week 4 the patient described drinking four to five beers most nights to manage pain and sleep. I increased duloxetine on schedule without checking whether the patient was taking it daily; they were missing about two doses a week because of nausea. And I did not involve the patient's primary care clinician, who was prescribing tramadol, a combination with duloxetine that needs watching for serotonin toxicity. Each of these is a prescriber pattern, not a patient failing.

Patterns in the Prescriber

Across the five, three patterns repeat. First, I asked about alcohol in a structured way only for patient A, where the referral raised it. Second, I recorded adherence as "taking as prescribed" without asking how many doses were missed. Third, I titrated on a fixed schedule rather than on the measure: patient B might have stayed at 50 mg, and patient C might have gone up sooner.

What did not repeat: I used the same scales at the same points for all five, which is the only reason this comparison is possible. Measurement with the PHQ-9 at baseline and follow-up gave a common yardstick (Kroenke et al., 2001; Löwe et al., 2004).

The Patient Who Improved for Uncertain Reasons

Patient E improved, but the daughter's arrival brought company, meals and help with appointments. Sertraline may have helped, the social change may have helped or both. I will not count this as a medication response in my own learning.

What Repeated Across the Patients Who Improved

Three of the five improved meaningfully: A, B and E. All three had a family member involved in at least one visit. The two who improved least, C and D, came alone every time. Five patients cannot show that family involvement causes improvement, and patient E's improvement may owe as much to the daughter's arrival as to sertraline. But the pattern is worth noticing, and it matches the role collateral played in patient A's diagnosis. From week 6, I will ask every new patient whether there is someone they would like to bring to a visit, and record the answer. Whether that changes outcomes is something a panel of five cannot show, but it costs nothing to ask and it found the diagnosis for patient A.

One Change, Named Specifically

From the start of week 6, every new medication start will include the AUDIT-C alcohol questions at the first visit and a count of missed doses in the past week at every follow-up, recorded in the note. I will check both at the next five new starts and report whether the pattern has changed, with the supervising nurse practitioner reviewing the notes.

Why Patient A Is in the Set

Patient A's treatment followed the guideline's first-line recommendation for bipolar II depression (Yatham et al., 2018), and the profile shows improvement with a safety event and early weight gain. Including the case in the panel matters because it is the one where diagnosis, not medication choice, made the difference, and it would be easy to remember it as a medication success.

What the Patterns Cost

The missed alcohol question for patient D meant four weeks of a medication that could not work well while the patient drank nightly. The missed adherence count meant a dose increase that was really a dose of nausea. The fixed titration schedule may have exposed patient B to a higher dose than needed. None of these harmed a patient seriously, but each cost time, and in depression time is the cost that matters most to the patient.

What the Set Cannot Show

Five patients over four weeks cannot show which medication works best, and comparing their outcomes as though it could would be misleading, since each had a different diagnosis and starting point. They can show habits in the person prescribing, which is what this review is for.

Supervision

The supervising nurse practitioner reviewed the five profiles on 7 October and agreed with the three patterns, adding a fourth I had missed: I rarely asked about side effects by name, such as nausea, sleep, sexual function or weight, relying on "any side effects?" which patient D answered "no" despite nausea. From the next visit I will ask about the four common side effects of each medication by name.

References

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Löwe, B., Unützer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Medical Care, 42(12), 1194-1201. https://doi.org/10.1097/00005650-200412000-00006

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