| Course | NR 668 Psychiatric-Mental Health Capstone Practicum & Intensive |
|---|---|
| Week | 8 |
| Paper type | Capstone case paper |
| Length | About 1,120 words, 5 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 668 Week 8
Capstone Case Paper: Eight Weeks With a Patient Whose Depression Was Bipolar II, Arguing That Collateral History, Not Medication, Was the Decisive Intervention
Student Name
College of Nursing, Chamberlain University
NR 668: Psychiatric-Mental Health Capstone Practicum & Intensive
Instructor Name
Month Day, Year
Capstone Case Paper: Eight Weeks With a Patient Whose Depression Was Bipolar II, Arguing That Collateral History, Not Medication, Was the Decisive Intervention
The Claim
The decisive intervention in this patient's care was not a medication but a question asked of the partner at the first visit. Everything that helped afterward, stopping the antidepressant, starting a first-line treatment for bipolar depression and planning safety around a specific risk, followed from the diagnosis that question made possible.
First Contact: The Visit Where the Reading Changed
On 2 September 2026, a 34-year-old graphic designer arrived with a referral for treatment-resistant depression after nine months and two SSRIs. Their PHQ-9 was 19. They had slept about four hours a night for two weeks while feeling "wired," with irritability and two large purchases. Asked directly about past periods of less sleep and more energy, the patient said there had been none.
The partner, present for the second half of the visit, described three or more stretches since about age 29, each lasting four or five days, with little sleep, high energy, rapid speech, many projects and overspending. The patient had called them "my good weeks." That account met the duration and symptom criteria for hypomania and moved the diagnosis to bipolar II disorder, depressed now, with mixed features in recent weeks.
The literature mattered at this point in a specific way. Undiagnosed bipolarity is common in people treated for depression (Angst et al., 2011), and screening questionnaires support but do not replace history (Hirschfeld et al., 2000). Without the partner, the screening questionnaire might have prompted the question, but the patient's own answer was no. The collateral history was the evidence.
The Decision That Followed
The escitalopram was tapered over one week. Adjunctive antidepressants had not improved recovery in bipolar depression in a large trial (Sachs et al., 2007), and the task force advised against antidepressants in mixed states (Pacchiarotti et al., 2013). Quetiapine was started and raised over four days to 300 mg at night, as a first-line treatment for bipolar II depression (Yatham et al., 2018), with the metabolic risk acknowledged and monitoring brought forward after a colleague's challenge in week 4.
The Stable Weeks
Weeks 1 to 3: sleep returned to about seven hours within a week. Irritability eased. PHQ-9 fell to 15 at two weeks. Weight rose by 1 kg. The patient stopped drinking for ten days, then resumed at about one drink an evening.
The Safety Event
In week 4, after an argument with the partner, the patient thought for the first time of overdosing on quetiapine and looked at the bottle, which had not been secured as agreed, after drinking four beers. There was no intent. The decision to continue outpatient care rested on removing the specific method and on engaged protective factors; supplies were limited to one week and held by the partner, the safety plan was revised and a 48-hour call was arranged (Stanley & Brown, 2012; Stanley et al., 2018). The diagnosis shaped this response: mixed features and alcohol were understood as the risk, not the medication itself.
Weeks 5 to 8
No further thoughts of overdose. PHQ-9 13 at week 4, 11 at week 6 and 9 at week 8. Weight up 2.5 kg from baseline. Fasting glucose at six weeks 102 mg/dL, unchanged; lipids unchanged. The patient began weekly therapy in week 5 and attended four sessions. The partner attended one session about early warning signs of hypomania.
The Outcome, Told Straight
Partial response. The PHQ-9 more than halved, from 19 to 9, but the patient still reports low energy in the mornings and mild sedation that slows work before 10:00. No hypomanic or mixed symptoms since week 2. Alcohol reduced but not stopped. Weight gain is modest so far but moving in the direction the objection warned about. The plan for week 12 is to discuss a cross-titration to lamotrigine for maintenance once mood has been stable for a month.
One Decision Revisited
The quetiapine dose. I titrated to 300 mg by day 4, as in the bipolar depression trials. Given the morning sedation and the weight gain, I would now titrate to 150 mg, review at one week and increase only if needed. Sleep had returned by day 3, before the full dose was reached, which suggests a lower dose might have been enough for this patient.
What the Outcome Means for the Next Twelve Weeks
The patient's mood is improving but not remitted, and the risks that remain are specific: morning sedation affecting work, gradual weight gain, continued light drinking and relationship conflict as a trigger for suicidal thoughts. The plan for the next twelve weeks addresses each: a dose reduction trial if mood holds, the lamotrigine conversation at week 12, a renewed alcohol discussion and family-focused therapy sessions with the partner. Recovery from bipolar depression is often incomplete at two months, and the paper calls this response partial rather than rounding it up.
What Others Contributed
The partner, whose account made the diagnosis. The supervising nurse practitioner, who raised lithium and agreed the safety decision. A classmate in the case conference, whose challenge on metabolic risk brought monitoring forward. The patient's therapist, who reported in week 7 that the patient had started noticing early signs of irritability and naming them. The outcome belongs to all of them, and so does much of what I learned from it. The paper's claim, that a question asked of the partner was decisive, is a claim about where the turning point came, not about who deserves credit.
What I Would Do the Same
Ask for collateral at every first visit for depression, especially when the referral says treatment-resistant, and ask it as a question about what others have noticed rather than about illness. Stop the antidepressant in the presence of mixed features, and explain to the patient why, in terms of the episodes they themselves have lived through. Plan safety around specific means rather than general risk.
What the Case Argues
That in a patient labeled treatment-resistant, the first question is whether the diagnosis is right, and that the person who can answer it may be in the waiting room. The medication choices were reasonable and guideline-based, but they were the second step, and they would have been the wrong step had the first question not been asked. That is the lesson I will carry into practice: diagnosis before drug, and the partner in the room when they can be.
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
Pacchiarotti, I., Bond, D. J., Baldessarini, R. J., Nolen, W. A., Grunze, H., Licht, R. W., Post, R. M., Berk, M., Goodwin, G. M., Sachs, G. S., Tondo, L., Findling, R. L., Youngstrom, E. A., Tohen, M., Undurraga, J., González-Pinto, A., Goldberg, J. F., Yildiz, A., Altshuler, L. L., . . . Vieta, E. (2013). The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. American Journal of Psychiatry, 170(11), 1249-1262. https://doi.org/10.1176/appi.ajp.2013.13020185
Sachs, G. S., Nierenberg, A. A., Calabrese, J. R., Marangell, L. B., Wisniewski, S. R., Gyulai, L., Friedman, E. S., Bowden, C. L., Fossey, M. D., Ostacher, M. J., Ketter, T. A., Patel, J., Hauser, P., Rapport, D., Martinez, J. M., Allen, M. H., Miklowitz, D. J., Otto, M. W., Dennehy, E. B., & Thase, M. E. (2007). Effectiveness of adjunctive antidepressant treatment for bipolar depression. New England Journal of Medicine, 356(17), 1711-1722. https://doi.org/10.1056/NEJMoa064135
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001
Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776
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
NR 668 Week 8 instructions, in plain terms
Carry one patient from first contact to wherever things stood at the end of the term, and argue something about that course of care rather than narrating it. Distribute space by importance, so the visit where the reading changed gets several paragraphs and the stable weeks get one. Bring literature in where it altered a decision and leave it out where it would only show reading. Report the outcome truthfully, including partial improvement and anything unresolved. Revisit one decision with the benefit of hindsight and say what you would do differently. Credit others who shaped the outcome. Close with what the case argues and what you will carry into practice.
How this NR 668 Week 8 example is built
The sample claims collateral history was decisive. Most space goes to the first visit, where the patient denied high periods and the partner described hypomanic stretches, with literature on missed bipolarity and screening limits. Decisions to stop escitalopram and start quetiapine cite the trial, task force and guideline. Stable weeks, the week 4 safety event and weeks 5 to 8 follow briefly. The outcome is a partial response, PHQ-9 from 19 to 9, with morning sedation, 2.5 kg weight gain and continued light drinking. The writer would now titrate quetiapine more slowly to 150 mg, credits the partner, supervisor, classmate and therapist and names what they would repeat. The paper closes on diagnosis before drug as the lesson carried into practice.
Where the points sit in the NR 668 Week 8 rubric
Capstone case papers lose most when they narrate every visit with equal weight, so the turning point is buried. Next is literature added as a survey at the start rather than at the decisions it shaped. Outcomes are often rounded up, describing partial response as success. Many papers never revisit a decision, which suggests the case taught nothing new. Papers that credit only the writer misrepresent how psychiatric care actually works. A claim the case does not really support, or no claim at all, leaves the paper as a long case note. Closing without saying what the writer will carry into practice misses the point of a capstone. Papers that never mention the patient's own view of the outcome also tell only half the story.
NR 668 Week 8 help: mistakes that cost points
Turning eight weeks with one patient into an argument means deciding what the case is really about before you write. A guided draft can help you find the claim the case supports, give space by importance and place literature at the decisions it shaped. We can also help you report the outcome straight and revisit one decision honestly. Writing the claim in one sentence first usually shows which visits deserve the most space. The patient's story and your argument are yours. Settling whom to credit, and how, is part of that help as well.
Get a NR 668 Week 8 example written to your instructions
Send the Week 8 instructions and the rubric, with the length and citation requirements your section publishes, and a custom example is written to them and returned inside 24 to 48 hours. The first one is free. Telling us roughly what the case turned on lets the example match its shape.
More NR 668 papers and PMHNP samples
- NR 668 Week 1: Case Selection Post
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- NR 668 Week 7: Practice Question Brief
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NR 668 Week 8 questions, answered
Which patient makes the best capstone case?
Rarely the one who recovered most. Choose the case where a decision was genuinely difficult and where you can show the reasoning changing as information arrived, because that is what a reader can assess. A patient who improved on the first plan gives you nothing to argue about, and a paper about them tends to run out of content halfway through.
Should the paper include a literature review section?
Only where the instructions require one. Left to itself, a capstone case paper works better with the sources distributed through the treatment narrative, arriving at the moments they informed. Where a separate review is mandatory, keeping it short and then still citing at the decision points avoids the common outcome, which is a well-researched opening followed by an unsupported clinical account.
How much should the paper admit went wrong?
As much as actually did, described precisely rather than apologetically. Graders at this stage are reading for whether a writer can see their own work clearly, and a paper with no misstep in it fails that test regardless of how well it is written. One error, examined honestly and located at a particular decision, is worth more than a page of general humility.
Where can I find a free NR 668 Week 8 sample paper?
The complete capstone case paper arguing that collateral history was the decisive intervention is set out on this page.
Which decision does the NR 668 Week 8 paper revisit?
The quetiapine dose: sleep returned before 300 mg was reached, so the writer would now titrate to 150 mg and increase only if needed.