Introduction
The PICO that is being discussed can be phrased as follows: in psychiatric patients with mild depression, what is the effect of psychotherapy on health compared with pharmacotherapy? To respond to it, it is necessary to consider the information available on the topic, as well as the conceptual underpinnings of the project. The present section will critically analyze the theories pertinent to depression treatment, summarize the relevant evidence, define the key concepts of the project, and explain the framework chosen for it.
Critical Analysis of Conceptual and Theoretical Literature
The examination of theoretical literature and evidence is crucial for the development of a study (Moran, 2017), and the present review will demonstrate the way the proposed research is capable of contributing data to a gap in depression research. The proposed project is predominantly connected to the efficacy of treatments, which requires the investigation of pertinent evidence. However, the study of depression is currently incomplete, and its mechanisms are indeed theorized based on available evidence. Consequently, the present section will consider the literature that is reviewing the process of developing depression in search of the information that can support the choice of one of the two studied treatments.
Nowadays, it is relatively well-established that depression is associated with multiple risks and can be the result of the interaction of numerous factors. In particular, biological, psychological, and environmental factors are typically named (Botha & Dozois, 2015; Miller & Hen, 2015; Pulcu & Browning, 2017; Slavich & Irwin, 2014). However, due to the complexity of this phenomenon, as well as the intricacy of the biological mechanisms that are believed to have an impact on depression, the present perspectives on the specific causes of depression are mostly theoretical.
Biomedical theories consider the possible biological causes of depression, which is a viable field of examination. For example, one of the theories that are currently studied suggests that impaired adult neurogenesis may be the cause of the condition; this issue can be rectified with the help of antidepressants. The theory is supported by the studies of animal models and some indirect evidence gained from neuroimaging and postmortem investigation of humans (Miller & Hen, 2015). However, Miller and Hen (2015) admit that more direct evidence is required to support this theory.
Another biomedical theory that is supported by some indirect evidence suggests that the cause of depression may be connected to impairments in the reward system of the brain, which is particularly difficult to study. According to Pulcu and Browning (2017), its response cannot be observed (can only be inferred from behaviors and neuroimaging), and the system itself is very complex and changeable. However, the authors report the results of a series of recent studies that used both possible routes of inferring for better results. The studies produced some consistent evidence that no abnormalities are present in the reward systems of patients with depression, which implies that future research might debunk this theory.
The example of the reward system theory highlights the importance of acknowledging the fact that the causes of depression are still understudied, and new evidence might debunk some of the modern ideas on the topic. Apart from that, this theory exemplifies the fact that while biological factors are theorized to cause depression, they are still not sufficiently evidenced to do so (Deacon, 2013). However, the investigation of biomedical theories does not presuppose the lack of attention to other ones.
Indeed, environmental and cognitive theories emphasize respective environmental and cognitive factors. For example, research is being conducted to determine the possible effects of environmental influences (including phenomena like social rejection) and distorted thinking (for instance, minimization of personal accomplishments) on depression development (Botha & Dozois, 2015). Such theories introduce another dimension into the discussion, allowing researchers to take into account the non-biological factors of depression development.
Moreover, some theories attempt to reconcile the three mentioned dimensions. Slavich and Irwin (2014) study the models that suggest a cause-and-effect relationship between stress and depression. They point out the fact that stress is currently evidenced to be a major risk factor for depression development and describe the theories that suggest the existence of cognitive processes that can result from stress and cause depression. They also state that there is little evidence to imply that there is a biological mediator in the relationship. However, they review several hundreds of studies on the topic and present their theory: according to it, stress affects the immune system, which results in behavioral changes that are symptomatic of depression.
The model is supported by indirect evidence that demonstrates the effects of stress on the immune system and the impact of the response of specific immune components on behavior. More research is needed to make conclusive statements about this theory. However, it expressly demonstrates the way multiple factors (social stresses, cognitive processes related to stress, and biological processes related to immunity) might interact in the process of developing depression.
In summary, the causes of depression are still being studied, which is why they are predominantly connected to theories that might yet be debunked. It is believed that biological, environmental, and psychological causes of depression can exist. Consequently, both pharmacotherapy and psychotherapy seem to be justified since they target specific factors that are currently theorized to be the possible causes of depression. Thus, the theoretical literature on the topic supports both approaches, but it cannot prove their effectiveness, which is why the existing evidence should also be reviewed.
Synthesis of Evidence
The evidence on the treatment of mild depression is not very extensive or sufficiently conclusive to make statements about the effectiveness of psychotherapy and pharmacotherapy. There is a limited number of recent original research on the topic of the efficacy of antidepressants for depression management, especially when mild depression is concerned. This issue may be connected to the fact that some not very recent evidence indicates that antidepressants have the same effect as placebo in the case of mild depression (Olfson, Blanco, & Marcus, 2016). In other words, it is assumed that pharmacotherapy is not the best choice for the treatment of mild depression.
However, systematic reviews and meta-analyses indicate that more research is required on the matter. In particular, new studies need to rectify the issue of the methodological shortcomings of prior investigations (the discrepancies in depression severity assessment) and offer more data (Cameron, Reid, & MacGillivray, 2014; Mosca, Zhang, Prieto, & Boucher, 2017; Reid, Cameron, & MacGillivray, 2014). Currently, antidepressants are not recommended for mild depression except specific cases (Guidi, Tomba, & Fava, 2016; National Institute for Health and Care Excellence, 2016), but this decision is based on outdated and inconclusive evidence, which is problematic for guidelines (Terhaar, 2016). This fact suggests that more attention should be paid to the topic.
Psychotherapy has been evidenced to have small to moderate effects on mild depression, but this research is also characterized as inconclusive, particularly because of the need for a unified approach to outcomes measurement (Olfson et al., 2016; Reid et al., 2014). Few recent studies of psychotherapy’s effect on mild depression exist, but a review of the less recent evidence indicates that the quality of the majority of studies was not very high (Cuijpers et al., 2014; Olfson et al., 2016; Reid et al., 2014). Despite this fact, psychotherapy is currently viewed as the appropriate method of treating mild depression (National Institute for Health and Care Excellence, 2016; Reid et al., 2014). Therefore, to inform future guidelines, more recent and high-quality evidence is required for both types of treatment.
Concepts and Definitions
As can be seen from the PICO question, the key concepts that are used by the project include the terms “health,” “depression,” “psychotherapy,” and “pharmacotherapy.” The word “depression” refers to the continuum of depressive disorders that are characterized by specific “changes in effect, cognition, and neurovegetative functions” (American Psychiatric Association, 2013, p. 155). The definition is significant because the diagnosis of depression is the key inclusion criterion for future participants. The recruiting healthcare providers are familiar with the definition, as well as the diagnosing process.
Within this project, “psychotherapy” and “pharmacotherapy” refer to the interventions that are used to treat depression. In particular, “pharmacotherapy” describes the variety of drugs that are employed to treat depression, and “psychotherapy” is the umbrella term for the possible psychological interventions that can be used to treat depression (Reid et al., 2014). The determination of the specific drug or psychological treatment will depend on the needs and preferences of participants.
As for health, the definition of this term is more difficult to establish. Nowadays, health is described as a complex concept that is dynamic and embraces multiple aspects of wellness, including biological, mental, emotional, spiritual, and social ones (Grodner, Escott-Stump, & Dorner, 2015). The holistic perspective on health is very important for nursing, and it ensures the high quality of care for patients. However, for this research, it would be more convenient to adopt a more reductionist perspective to be able to measure health.
Naturally, there are the means of measuring the social and spiritual aspects of health, but within the project that aims to determine the effectiveness of different depression treatments, it is more important to focus on the idea of health as the absence of illness. In other words, the present project will mostly view health as the lack of depressive symptoms that can be measured with the help of well-established tools. In particular, the study chooses the Hamilton Rating Scale for Depression (HRSD) (Sharp, 2015). This perspective will be further justified in the discussion of the conceptual framework of the study.
Conceptual Framework
Frameworks are relatively abstract tools that assist in the organization of the concepts employed by a study for rationalization purposes (Polit & Beck, 2017; Terhaar, Crickman, & Finnell, 2016). The present project suggests using the biomedical model to frame its key concepts and guide the procedures that will be adopted to respond to the study’s PICO question. Here, it should be pointed out that while biomedical theory typically searches for a biological cause of disease and medication-related solution, other causes and treatments are also an option. In fact, according to Deacon (2013), due to the biomedical model, psychological interventions were provided with sufficient evidence to prove their effectiveness. Admittedly, Deacon (2013) states that such studies are not enough for psychological treatments since they do not provide the information that could improve them, but the article still implies that the biomedical model can and has been applied to non-medication interventions. Consequently, the present study suggests using the terminology of the biomedical model to frame its concepts.
From the perspective of the biomedical model, health is the absence of illness, and treatment presupposes the use of specific interventions that target particular causes (typically, biological abnormalities). This framework can easily fit all the core concepts of the present study: in it, depression is the illness that is supposed to be treated with the help of specific interventions (pharmacotherapy and psychotherapy) that target the possible causes of illnesses. The desired outcome is improved health. Within the study (and by the model), health can be measured by the changes in the severity of the illness. This outcome will be achieved with the help of HRSD, which is a well-established and reliable tool for measuring the severity of depression that is not protected by copyright (Sharp, 2015), which facilitates its use and some aspects of the project planning (Burson & Moran, 2017). Thus, the framework organizes the concepts and demonstrates how the PICO of the study can be answered. Since the project is aimed specifically at discovering the effect that the interventions are going to have on depression reduction, a more comprehensive perspective on health would be less focused.
The biomedical model has had an incalculable impact on modern healthcare. It has promoted multiple fields of science that are pertinent to depression, including, for instance, neuroscience, and it is responsible for multiple advances in treating depression (Deacon, 2013). At the same time, it is admittedly reductionist and restrictive, and modern science and healthcare would benefit from the introduction of additional perspectives on health. However, given the utility of the biomedical model in certain cases, it appears logical to apply it to a study that is focused specifically on the impact of a particular treatment on the depression severity in its participants.
The present study acknowledges the fact that the biomedical model is problematic predominantly due to its reductionist nature (Botha & Dozois, 2015; Grodner et al., 2015). The study does not offer to reduce health to the absence of illness in any other context. Instead, it can be suggested that the study adopts the elements of the biomedical model that are suitable for it, developing its framework. For the sake of convenience and focus, the present project employs this tool to frame its concepts and guide the procedures required to answer the research question.
Conclusion
The review of literature and evidence on the topic of depression treatment indicates that there are some notable gaps in them. In particular, depression causes are still being researched, but modern theories support the feasibility of both pharmacotherapy and psychotherapy. However, the effects of both treatments are also insufficiently studied when mild depression is concerned. Supposedly, psychotherapy should be appropriate, but this statement is based on low-quality evidence. As for pharmacotherapy, modern literature reviews and meta-analyses suggest that the evidence is not sufficient to make comments on the matter. The present research seeks to address these gaps and proposes the use of a slightly altered biomedical model of health to organize its concepts. This framework will allow the study to focus on a relatively reductionist perspective of health and track specifically the changes in depression severity associated with the two treatment approaches.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders; DSM-5 (5th ed.). Washington, DC: American Psychiatric Publishing.
Botha, F., & Dozois, D. (2015). The influence of emphasizing psychological causes of depression on public stigma. Canadian Journal of Behavioural Science / Revue Canadienne des Sciences du Comportement, 47(4), 313-320. Web.
Burson, R., & Moran, K. (2017). Creating and developing the project plan. In K. Moran, R. Burson & D. Conrad (Eds.), The Doctor of Nursing Practice scholarly project: A framework for success (pp. 189-222). Sudbury, MA: Jones & Bartlett Learning.
Cameron, I., Reid, I., & MacGillivray, S. (2014). Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder. Journal of Affective Disorders, 166, 48-58.
Cuijpers, P., Koole, S., van Dijke, A., Roca, M., Li, J., & Reynolds, C. (2014). Psychotherapy for subclinical depression: Meta-analysis. British Journal of Psychiatry, 205(04), 268-274.
Deacon, B. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33(7), 846-861.
Grodner, M., Escott-Stump, S., & Dorner, S. (2015). Nutritional foundations and clinical applications (6th ed.). New York, NY: Elsevier Health Sciences.
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.
Miller, B., & Hen, R. (2015). The current state of the neurogenic theory of depression and anxiety. Current Opinion in Neurobiology, 30, 51-58.
Moran, K. (2017). The proposal. In K. Moran, R. Burson & D. Conrad (Eds.), The Doctor of Nursing Practice scholarly project: A framework for success (pp. 247-286). Sudbury, MA: Jones & Bartlett Learning.
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. Web.
Polit, D.F., & Beck, C.T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Pulcu, E., & Browning, M. (2017). Using computational psychiatry to rule out the hidden causes of depression. JAMA Psychiatry, 74(8), 777.
Reid, I., Cameron, I., & MacGillivray, S. (2014). Depression: Current approaches to assessment and treatment. Prescriber, 25(12), 16-20.
Sharp, R. (2015). The Hamilton Rating Scale for Depression. Occupational Medicine, 65(4), 340.
Slavich, G., & Irwin, M. (2014). From stress to inflammation and major depressive disorder: A social signal transduction theory of depression. Psychological Bulletin, 140(3), 774-815. Web.
Terhaar, M. (2016). Methods for translation. In K. White, S. Dudley-Brown & M. Terhaar (Eds.), Translation of evidence into nursing and health care (pp. 159-182). New York, NY: Springer Publishing Company.
Terhaar, M., Crickman, R., & Finnell, D. (2016). Project planning and the work of translaiton. In K. White, S. Dudley-Brown & M. Terhaar (Eds.), Translation of evidence into nursing and health care (pp. 183-210). New York, NY: Springer Publishing Company.