Depression is a major health concern, which is relatively prevalent in the modern world. Indeed, in the US, 6.7 % of adults experienced an episode of the Major Depressive Disorder in 2015 (Center for Behavioral Health Statistics and Quality, 2016). However, the treatment of depression is currently viewed as not particularly effective; issues like misdiagnosing, undertreatment, and excessive treatment are cited (Petrosyan et al., 2017; Straten, Hill, Richards, & Cuijpers, 2015). One of the problems that might explain the situation is the fact that some of the types of depression and related treatments remain understudied. Mild depression is one of the underresearched topics nowadays.
Some of the approaches to the treatment of mild depression include psychotherapy and pharmacotherapy. Psychotherapy is currently recommended for the condition, even though the evidence supporting its effectiveness for this specific depression type has been characterized as inconclusive (Olfson, Blanco, & Marcus, 2016). For example, Reid, Cameron, and MacGillivray (2014) highlight the fact that more studies focusing on the comparison of psychotherapy with placebo are needed and that some methodological flaws (in particular, with respect to outcomes measurement) may limit the contribution of the existing literature. Still, this approach is supported and viewed as appropriate in current guidelines meant for mild depression (Cleare et al., 2015; Guidi, Tomba, & Fava, 2016; National Institute for Health and Care Excellence, 2016; Reid et al., 2014). Thus, the modern scientific community views psychotherapy as a more appropriate treatment than antidepressants when milder forms of depression are concerned.
Regarding pharmacotherapy, there are more concerns surrounding its use for the condition. There is some evidence to pharmacotherapy having only minor success and exhibiting little difference from placebo effects in treating mild depression (Olfson et al., 2016). However, this evidence is not very conclusive and indicates uncertainty, which, among other things, is connected to the methodological flaws of existing studies (Reid et al., 2014). Mosca, Zhang, Prieto, and Boucher (2017) and Reid et al. (2014) also report that, in general, few high-quality studies have addressed the topic while adequately assessing depression severity. In practice guidelines, antidepressants are not recommended for mild depression, but they are an option (depending on the preferences and resources of patients) (Cleare et al., 2015; Guidi et al., 2016; Reid et al., 2014). They also need to be considered in particular cases (for example, persistent or chronic depression) (National Institute for Health and Care Excellence, 2016). Still, as can be seen from the presented information, the guidelines are based upon inconclusive evidence, and more research is necessary for definitive statements.
In practice (in the US), both methods are used, but pharmacotherapy is more typical for mild depression than for its more severe forms (Olfson et al., 2016). Technically, this fact demonstrates that for some reason, practicing providers may not directly follow the above-described recommendations. Apart from that, this tendency indicates that both pharmacotherapy and psychotherapy are used, but their application would be expected to have limited effectiveness because it is based on non-conclusive evidence. In summary, practice is currently under-supported by research, which is why it is necessary to contribute more information to this discussion, which the proposed project intends to do.
Purpose
In order to address the problem introduced above, a project with the following PICO question is proposed: in psychiatric patients with mild depression, what is the effect of psychotherapy on health compared with pharmacotherapy? The purpose of the described project predominantly consists of contributing some more data to the investigation of the discussed problem. It is also noteworthy that the project will help to attract some attention to the fact that modern practice is understudied and requires more evidence to become actually informed. Consequently, the study can assist in providing healthcare professionals with high-quality and evidence-based guidelines on mild depression management. Eventually, it will make a step towards improving the quality of care for patients with mild depression, and the latter outcome is the overarching aim of the project. While it is obvious that the contribution of more data cannot resolve the problem, it would still move the scientific community towards an improved understanding of the issue, which is the result that is hoped to be achieved. Thus, the purpose of the project is appropriate for a nursing project.
Background
As it was mentioned, there are very few recent original studies that consider the comparative effectiveness of pharmacotherapy and psychotherapy for mild depression. Similarly, the works that would review either of the approaches while specifically focusing on mild depression do not appear to be numerous. There is a number of recent systematic reviews and meta-analyses that consider both treatments or one of them, but they predominantly review the studies that are older than five years. Still, some information on the topic can be gleaned from a few recent works.
A preliminary investigation has found only one study that would consider the severity of depression (including its milder forms) in its review of both pharmacotherapy and psychotherapy. In particular, Vittengl et al. (2016) requested the results of 16 clinical trials to acquire the total sample of 1700 adults with mild to extreme depression treated with either pharmacotherapy or psychotherapy in the form of Cognitive Behavioral Therapy. The authors use the data for their original analysis and demonstrate that in the mildly depressed group of the sample, the possibility of deterioration and non-response to both treatments was higher than in the patients with more severe conditions. The chance of superior improvement (reduction of the initial screening scores by 95%) was greater for antidepressants (based on clinician assessment). However, the authors do not specify the correlations of the severity of depression with this outcome. The rest of the results (deterioration, lack of response) were not statistically different for the two treatments. Also, it is important that the authors only considered one type of psychotherapy. Thus, this study contributes some evidence pertinent to the topic but does not allow making conclusive statements about mild depression specifically.
Some studies that review the effectiveness of the individual types of psychotherapy have been found. For example, Fonagy et al. (2015) conduct a randomized controlled trial to test the effectiveness of long-term psychoanalytic psychotherapy, demonstrating that it is indeed associated with improved long-term outcomes in treatment-resistant depression. The authors determine the severity of depression pre-treatment, indicating that about 18% of their patients were mildly depressed (with the total sample of 129 patients in both intervention and control groups). However, the authors do not attempt to compare the effects in the groups with different depression severity, and given the size of the sample, such comparisons would probably not be very conclusive. Thus, the study cannot be used to prove or disprove the hypothesis that long-term psychoanalytic psychotherapy is helpful specifically for resistant mild depression.
There are also studies that focus on specific antidepressants, but they rarely consider mild depression. For example, Mosca et al. (2017) collect the individual patient data from nine short-term studies that compare desvenlafaxine to placebo and use them for their original analysis. The results demonstrate that the antidepressant can be effective for moderate and severe depression treatment, but the authors highlight the fact that there is not enough data to make definite conclusions about mild depression. Fann et al. (2017) conduct an individual randomized controlled trial in the population with a recent traumatic brain injury and show that sertraline is not effective in this group of patients regardless of the severity of their depression. However, the study has a very specific population, which limits the applicability of its results. Mostly, such studies focus on depressions that are moderate to severe (Mosca et al., 2017), which demonstrates the lack of attention to the problem considered by the proposed project.
The fact that the topic requires attention can be demonstrated through the analysis of another study. Olfson et al. (2016) examine the “2012 and 2013 Medical Expenditure Panel Surveys (MEPS) conducted by the Agency for Healthcare Research and Quality” (p. 2). MEPS include a valid screening tool and a tool for determining the treatments received by the respondent. The authors analyze the total of 46,417 responses and make conclusions about the treatments that are employed in the US to treat depression. The results demonstrate that patients with mild depression in the US are more likely to receive pharmacotherapy than those with more severe forms of the condition. The authors state that the reasons for this fact cannot be interpreted conclusively, but still, the article demonstrates that the use of recommended treatments in practice seems to differ in its general patterns from the typical depression treatment guidelines. Thus, the problem of choice between pharmacotherapy and psychotherapy for patients with mild depression is acute nowadays.
In summary, little is known about the stated research problem. Most recent studies either do not mention patients with mild depression or do not sufficiently represent the group in their samples despite the fact that both treatments are evidenced to be used with the population. The issue is true both for general studies and those focusing on specific antidepressants or approaches to psychotherapy. Given the fact that this conclusion coincides with those forwarded by the authors of the meta-analyses described above, it can be stated that the use of pharmacotherapy and psychotherapy with mild depression is drastically understudied. Since the use of both is present in modern practice, the issue needs to be addressed.
Significance
Nursing
The described project is significant from multiple viewpoints. From the perspective of nursing, a major positive consequence of generating evidence is its potential for the improvement of clinical outcomes, as well as the quality of care and safety of patients (White, 2016; Wiener, 2016). As it has been shown, the quality of the treatment of mild depression is currently questionable because relevant guidelines are based on inconclusive evidence (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014). Therefore, from the perspective of nursing, the primary significance of the project consists of producing the evidence that can potentially improve the quality of care for people with mild depression. Naturally, the outcomes are unlikely to have drastic consequences, and the problem will not be resolved as a result of the project, but the process requires collaborative efforts of multiple researchers. The project will become one of these efforts, which makes it significant for nursing.
Healthcare
The inefficient treatment of depression is an apparent issue, and while its causes and manifestations are multifaceted (Petrosyan et al., 2017; Straten et al., 2015), the lack of conclusive evidence regarding the treatments for mild depression is one of the related problems (Reid et al., 2014). Given the fact that both psychotherapy and pharmacotherapy are currently employed to treat mild depression (Olfson et al. 2016), an improved understanding of their expected efficiency and recommended use would be beneficial from the point of view of modern healthcare. The described project cannot resolve the problem completely, but it can contribute to its resolution by offering more evidence that will be directly devoted to the treatment of mild depression, which, as it was shown, is not emphasized very often in modern studies. In general, the coverage of an understudied element of contemporary healthcare science is significant.
Moreover, the project will also highlight the issue, which can be a beneficial factor for future research. While multiple systematic reviews and meta-analyses report or mention the fact that mild depression treatment may need additional research (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014), they do not typically focus on the problem. The described project will disseminate the findings, as well as communicate the concern for the issue, within a limited but interested audience (the researcher’s peers and instructors), which may prompt future research. Thus, the described project is indeed significant for healthcare.
Advanced Practice Nursing
In Florida (Florida Board of Nursing, 2016), as well as the majority of other states of the US (Stokowski, 2018), the prescriptive authority of advanced practice nurses has been experiencing expansion. In Florida, there are some limitations (specifically those related to the field of nurses’ expertise and age of patients) (Stokowski, 2018), but in general, the advanced practice nurses of Florida can prescribe antidepressants. Similarly, psychiatric advanced practice nurses can treat depression without supervision, diagnosing and tailoring the treatment to the needs of their patients. Thus, the investigation of mild depression management is relevant for advanced practice nursing.
Indeed, as decision-makers, advanced practice nurses need relevant evidence-based tools, but at this point of time, their guidelines are based on the evidence that is not very conclusive or complete (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014). Therefore, advanced practice nurses can benefit from a study that contributes data to the ongoing discussion of the suitability of different treatments that are currently used to manage mild depression (Olfson et al. 2016). Indeed, this contribution would make another step towards providing advanced practice nurses with improved guidelines that would result in better patient outcomes and quality of care. Thus, the described project is significant for advanced practice nursing.
Practice Support for Project
The project will be supported by the settings of my practice to a noticeable extent. It will be carried out at my workplace (New Horizons Community Mental Health Center in Miami, FL). Thus, the location (place) will be used to set the project and carry out the procedures related to it. Similarly, the people of the Center will also make a major contribution since the collaboration of my colleagues will be required to monitor the anticipated number of patients. In general, the assistance of the care providers of the New Horizons Community Mental Health Center, who are not going to be compensated, is most significant to the project and needs to be ensured. A preliminary investigation shows that the professionals employed by the Center acknowledge the problem of treating mild depression, which illustrates their motivation. Regarding the processes of the settings, the procedures of the project, which mostly consist of depression assessment, intervention choice, and its application, are in line with the current activities of the care providers and can be easily integrated into their everyday work. Due to the smooth functioning of the New Horizons Community Mental Health Center, the project is likely to progress smoothly as well while employing the usual tools used by the care providers of the Center. In summary, the settings and their support are very important to the project’s success.
Benefit of Project to Practice
The benefit of the project to practice stems from the discussed significance of the project. The New Horizons Community Mental Health Center currently employs the methods of mild depression treatment that are not based on conclusive evidence because the latter does not exist. With the help of the discussed project, more evidence will be contributed on the topic, and it will be popularized among the professionals of the New Horizons Community Mental Health Center. The former aspect will be beneficial due to the increased awareness of the potential shortcomings of the existing treatments and the possibility of prompting future research. Thus, while the described study cannot resolve the issues that the New Horizons Community Mental Health Center currently faces, it can contribute to their removal while also promoting the awareness of them. In summary, the project is beneficial to the settings.
Conclusion
As a significant condition, depression requires adequate management, but the lack of appropriately conclusive evidence concerning some of its aspects may decrease the quality of care for the depressed populations. In particular, the treatment of mild depression is an understudied topic, which means that the relevant guidelines tend to be based on less than appropriate evidence. A preliminary investigation indicates that modern studies rarely consider the problem of mild depression treatment, focusing on other forms of the condition. The works that do review it tend to underrepresent the mildly depressed population or do not offer conclusions regarding the interrelationships between the severity of depression and the observed outcomes. Consequently, the proposed project intends to contribute some evidence regarding the topic of the effectiveness of pharmacotherapy and psychotherapy in mildly depressed adults.
The settings of the project would provide major support to it, especially the people who will become the primary contributors. In turn, the project will offer some support to the improvement of the quality of care in the settings. Indeed, from the perspective of nursing, it will provide some evidence that can potentially promote evidence-based practice and, consequently, improve the quality of care for the depressed. From the perspective of advanced practice nursing, the project will offer some support to the development of decision-making tools for mild depression management. From the perspective of healthcare, the project will contribute the data to an underresearched topic and attract attention to it. Thus, the proposed project can be viewed as significant.
References
Center for Behavioral Health Statistics and Quality. (2016). Results from the 2015 national survey on drug use and health: Detailed tables.
Cleare, A., Pariante, C. M., Young, A. H., Anderson, I. M., Christmas, D., Cowen, P. J.,… Haddad, P. M. (2015). Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology, 29(5), 459-525.
Fann, J., Bombardier, C., Temkin, N., Esselman, P., Warms, C., Barber, J., & Dikmen, S. (2017). Sertraline for Major depression during the year following traumatic brain injury. Journal of Head Trauma Rehabilitation, 32(5), 332-342.
Florida Board of Nursing. (2016). Important Legislative Update regarding HB 423.
Fonagy, P., Rost, F., Carlyle, J. A., McPherson, S., Thomas, R., Pasco Fearon, R. M.,… Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock Adult Depression Study (TADS). World Psychiatry, 14(3), 312-321.
Guidi, J., Tomba, E., & Fava, G. (2016). The sequential integration of pharmacotherapy and psychotherapy in the treatment of major depressive disorder: A meta-analysis of the sequential model and a critical review of the literature. American Journal of Psychiatry, 173(2), 128-137.
Mosca, D., Zhang, M., Prieto, R., & Boucher, M. (2017). Efficacy of desvenlafaxine compared with placebo in major depressive disorder patients by age group and severity of depression at baseline. Journal of Clinical Psychopharmacology, 37(2), 182-192.
National Institute for Health and Care Excellence. (2016). Depression in adults: Recognition and management.
Olfson, M., Blanco, C., & Marcus, S. (2016). Treatment of adult depression in the United States. JAMA Internal Medicine, 176(10), 1482.
Petrosyan, Y., Sahakyan, Y., Barnsley, J., Kuluski, K., Liu, B., & Wodchis, W. (2017). Quality indicators for care of depression in primary care settings: A systematic review. Systematic Reviews, 6(1), 1-14.
Reid, I., Cameron, I., & MacGillivray, S. (2014). Depression: Current approaches to assessment and treatment. Prescriber, 25(12), 16-20.
Stokowski, L. (2018). H APRN Prescribing Law: A state-by-state summary. Medscape.
Straten, A., Hill, J., Richards, D. A., & Cuijpers, P. (2015). Stepped care treatment delivery for depression: A systematic review and meta-analysis. Psychological Medicine, 45(2), 231-246.
Vittengl, J. R., Jarrett, R. B., Weitz, E., Hollon, S. D., Twisk, J., Cristea, I.,… Faramarzi, M. (2016). Divergent outcomes in cognitive-behavioral therapy and pharmacotherapy for adult depression. American Journal of Psychiatry, 173(5), 481-490.
White, K. (2016). Translation of evidence for improving safety and quality. In K. White, S. Dudley-Brown & M. Terhaar (Eds.), Translation of evidence into nursing and health care (pp. 95-114). New York, NY: Springer Publishing Company.
Wiener, P. (2016). Translation of evidence to improve clinical outcomes. In K. White, S. Dudley-Brown & M. Terhaar (Eds.), Translation of evidence into nursing and health care (pp. 73-94). New York, NY: Springer Publishing Company.