Introduction
Depression is a major health concern, which is relatively prevalent in the modern world (World Health Organization, 2017). In the US, over 6% of the population experience moderate to severe depression (Center for Behavioral Health Statistics and Quality, 2016; National Institute of Mental Health, 2018). An additional 15% experience mild depression (National Center for Health Statistics, 2014). Depression of any severity is also associated with decreased quality of life, increased healthcare spending, and greater risks of suicide, as well as various complications (National Center for Health Statistics, 2014; National Institute of Mental Health, 2018; World Health Organization, 2017). 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). The issues can be explained by the fact that some of the types of depression and related treatments remain understudied. Mild depression is one of the insufficiently researched topics that require increased attention. Thus, the project intends to investigate the comparative effectiveness of the treatments that are currently used for mild depression.
Some of the approaches to treating mild depression include psychotherapy and pharmacotherapy. Psychotherapy is currently recommended for the condition, even though the evidence supporting its effectiveness for this specific type of depression has been characterized as inconclusive (Olfson, Blanco, & Marcus, 2016; Reid, Cameron, & MacGillivray, 2014). 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: the limited evidence that is currently available suggests so.
Regarding pharmacotherapy, there are more concerns concerning its use for the condition. There is some evidence of pharmacotherapy having only minor effectiveness in treating mild depression when compared to placebo effects (Olfson et al., 2016). However, this evidence is not very conclusive and indicates uncertainty, which is connected to the methodological flaws of existing studies, including, for example, a high risk of bias (Cameron, Reid, & MacGillivray, 2014), as well as the discrepancies in assessing the severity of depression (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, both methods are used in the US, but pharmacotherapy is more typical for mild depression than for the more severe forms of the condition (Olfson et al., 2016). Technically, this fact demonstrates that practicing providers may not follow the described recommendations directly. 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, the practice of treating depression, which is a common and serious disease, is currently supported by insufficient research, and more information needs to be contributed to this discussion, which the proposed project intends to do.
Purpose
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. In particular, it will offer some additional data on the comparative effectiveness of psychotherapy and pharmacotherapy that will be generated by its quasi-experiment. It is also noteworthy that the project will help to attract some attention to the fact that depression is understudied and requires more evidence to make practitioners informed. Consequently, the study can assist in providing healthcare professionals with high-quality and evidence-based guidelines on mild depression management. Eventually, it will take a step towards improving the quality of care for patients with mild depression, and the latter outcome is the main aim of the project. While it is obvious that the contribution of more data cannot resolve the problem, it would still push the scientific community towards an improved understanding of the issue and provide support for treatment, which is the result that the researcher hopes to achieve.
Background
Depression is a major issue that requires investigation, and this statement can be proven with the help of the facts reported by major healthcare organizations. Depression is a common disease worldwide, and the World Health Organization (2017) states that the number of people suffering from it amounts to 300 million (par. 1). In the US, about 16.2 million people are reported to have moderate to severe depression, which means that about 6.7% of the whole population of the US experience the condition (Center for Behavioral Health Statistics and Quality, 2016; National Institute of Mental Health, 2018). Thus, depression is admittedly prevalent.
Statistics predominantly focus on moderate to severe depression, but the information concerning mild depression can also be traced. The most recent report by the Centers for Disease Control and Prevention and specifically the National Center for Health Statistics (2014) states that 15% of the population of the US had mild depression in 2009-2012 (National Center for Health Statistics, 2014, par. 13-14). The report also demonstrates that 41% of people with mild depression reported experiencing difficulties in social activities, as well as personal and work-life; an additional 4% classified the difficulties as serious (National Center for Health Statistics, 2014, par. 17-18). Therefore, mild depression is a significant condition that needs to be taken into account, treated, and monitored.
According to the National Center for Health Statistics (2014), depression is inadequately treated throughout the US. Apart from that, according to the National Institute of Mental Health (2018), delays in inappropriate treatment can affect its effectiveness negatively. In summary, healthcare organizations report that even the mild forms of the studied disease can cause significant issues, and it is widespread and needs prompt treatment. However, the fact that mild depression is relatively rarely mentioned in statistics is also reflected in the research on the topic: the latter is insufficient, which limits the ability of practitioners to employ high-quality, evidence-based interventions.
Some several recent systematic reviews and meta-analyses consider both psychotherapy and pharmacotherapy or one of them, even though they predominantly investigate the studies that are older than five years. In their meta-analysis and systematic review, Cameron et al. (2014) focus on the use of antidepressants for mild depression and demonstrate that the randomized controlled trials of the intervention are very few and have a high risk of bias. Moreover, they are heterogeneous in their methodology, which complicates their meta-analysis. Consequently, the authors conclude that there is no sufficient evidence for conclusions on the matter. This idea is supported by another literature review that considers several meta-analyses that are less recent (Reid et al., 2014). Thus, the effectiveness of the use of pharmacotherapy for treating mild depression is understudied.
Similarly, Cuijpers et al. (2014) review 18 studies with psychological interventions, demonstrating that the majority of the sources are not high-quality, which limits the applicability of their evidence. They suggest that psychotherapy can be effective, but more investigation is required for conclusive statements. Also, the study focuses on subclinical depression rather than a mild one, which limits its applicability to the present study. However, the need for additional research on psychotherapy for mild depression is highlighted by other literature reviews as well (Olfson et al., 2016; Reid et al., 2014). Thus, the evidence suggests that additional research is required to cover this topic.
A preliminary investigation has found 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. The authors used the data for their original analysis and demonstrated 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 did not specify the correlations of the severity of depression with this outcome. The remaining 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. The article is unique in considering depression severity and comparing the effectiveness of both treatments, and while it does not yield sufficient information concerning mild depression, it illustrates the fact that the latter remains understudied.
Some studies that review the effectiveness of the individual types of psychotherapy have been found. Fonagy et al. (2015) conducted a randomized controlled trial to test the effectiveness of long-term psychoanalytic psychotherapy, demonstrating that it was associated with improved long-term outcomes in treatment-resistant depression. The authors determined 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 did 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.
Some studies focus on specific antidepressants, but they rarely consider mild depression. Mosca et al. (2017) collected the individual patient data from nine short-term studies that compared desvenlafaxine to placebo and used them for analysis. The results demonstrate that desvenlafaxine can be effective for moderate and severe depression treatment, but the authors highlight the fact that there is not enough data to make conclusions about mild depression. Fann et al. (2017) conducted an individual randomized controlled trial in the population with a recent traumatic brain injury and showed 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 (with a recent traumatic brain injury), 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) examined the “2012 and 2013 Medical Expenditure Panel Surveys (MEPS) conducted by the Agency for Healthcare Research and Quality” (p. 2). MEPS included a valid screening tool and a tool for determining the treatments received by respondents. The authors analyzed a total of 46,417 responses and made conclusions about the interventions 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 stated that the reasons for this fact should not be interpreted conclusively. However, 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. Few recent works on the matter are original studies; mostly, meta-analyses and literature reviews can be found, and they tend to consider the data that is not particularly recent. Most recent studies either do not mention patients with mild depression, which is the topic of the proposed project as stated in the PICO question, or do not sufficiently represent the group in their samples even though 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, 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 has been shown, the quality of the treatment of mild depression is currently questionable because relevant guidelines are based on inconclusive evidence. This statement is supported by multiple studies on the topic which suggest that the currently available evidence is not sufficient for definite statements about the effectiveness of psychotherapy and pharmacotherapy in treating mild depression (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014). This issue can be viewed as a threat to the quality of care and safety of patients. Indeed, depression is relatively prevalent and can hurt patients, including, for instance, an increased risk of suicide (National Center for Health Statistics, 2014; National Institute of Mental Health, 2018; World Health Organization, 2017). Moreover, the National Institute of Mental Health (2018), highlights the fact that adequate and timely treatment is necessary for improved patient outcomes. However, specialists are not equipped with sufficient evidence for high-quality treatment.
Therefore, from the perspective of nursing, the primary significance of the project consists of producing evidence that can potentially improve the quality of care for people with mild depression. This evidence will expand the body of knowledge used by nurse practitioners (in particular, advanced practice nurses) who work with patients 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. 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, which is supported by multiple studies on the topic (Mosca et al., 2017; Reid et al., 2014), is one of the problems that can be connected to the issue. 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 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 shed some light on the issue, which can be a beneficial factor for future research. 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). The described project will promote this research by disseminating its findings and communicating the concern for the issue. The latter activity will be performed with the explicit call for action in an attempt to prompt future investigation. 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 the advanced practice nurses of Florida can prescribe antidepressants. Similarly, psychiatric advanced practice nurses can treat depression without supervision, diagnosing depression, and tailoring 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, their guidelines are based on the evidence that is not very conclusive or complete. This idea is supported by the previously discussed studies that highlight the lack of evidence pertinent to the use of pharmacotherapy and psychotherapy in treating mild depression (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014). In other words, there exists only limited evidence which the existing guidelines can employ. 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 might make another step towards providing advanced practice nurses with improved guidelines that could 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 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. The procedures of the project, which mostly consist of depression assessment, intervention choice, and its application, are aligned with the current activities of the care providers and can be easily integrated into their everyday work. Due to the well-established processes of the New Horizons Community Mental Health Center, the project is likely to progress smoothly 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.
The 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 as has been shown by the previously discussed literature (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014). With the help of the discussed project, more evidence will be contributed to the topic, and it will be popularized among the professionals of the New Horizons Community Mental Health Center. Specifically, the evidence pertinent to the comparative effectiveness of the two treatments will be collected. By attracting the attention of the specialists of the New Horizons Community Mental Health Center to the issue, the project will increase their awareness of the potential shortcomings of the existing treatments and, possibly, prompt future research. The described study cannot resolve the difficulties that the New Horizons Community Mental Health Center currently faces, but it can contribute to their removal from multiple perspectives. Consequently, the project is going to be beneficial to the New Horizons Community Mental Health Center.
Review of Literature
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. This chapter will critically analyze the literature on depression treatment, review the theories pertinent to it, summarize the relevant evidence, define the key concepts of the project, and explain the framework chosen for it.
Depression Management
Effective depression management should be comprehensive, which is why it typically consists of assessment, treatment, adherence enhancement, and monitoring, the latter of which can lead to reassessment and a revision of the chosen treatment (National Institute for Health and Care Excellence, 2016). The present study, however, is concerned specifically with the treatment element of depression management. The National Center for Health Statistics (2014) states that inadequate depression treatment is a problem in the US, which proves the significance of investigating this topic.
Nowadays, pharmacotherapy and psychotherapy are major approaches to depression treatment (National Institute of Mental Health, 2018; World Health Organization, 2017). A combination of the two is also recommended for some cases (National Institute for Health and Care Excellence, 2016), and when symptoms persist, other options like electroconvulsive therapy may be considered (National Institute of Mental Health, 2018). Some lifestyle changes are also recommended, including improved sleep hygiene and exercise (National Institute of Mental Health, 2018). For mild depression, the first-line recommended treatment is psychotherapy, but pharmacotherapy may also be an option (National Institute of Mental Health, 2018; Olfson, Blanco, & Marcus, 2016; Reid, Cameron, & MacGillivray, 2014). The following sections will consider both to determine if depression management guidelines are based on sufficient evidence.
Depression and Psychotherapy
A variety of psychotherapy approaches apply to depression, including “cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy” (National Institute of Mental Health, 2018, par. 24). Apart from that, psychotherapy varies in intensity from low to high. For mild, as well as moderate, depression, low-intensity CBT interventions are viewed as the first-line treatment, which can be followed by group CBT and high-intensity interventions, including high-intensity CBT and IPT (National Institute of Mental Health, 2018). A recent study on depression management supports the fact that psychotherapy is employed for depression management in the US (Olfson et al., 2016). Thus, psychotherapy is both a recommended and practiced treatment for mild depression.
The evidence to the effectiveness of CBT and IPT in depression treatment is rather robust (Cuijpers, Donker, Weissman, Ravitz, & Cristea, 2016; Naeem et al., 2015), but it does not review the cases of mild depression. Studies of mild depression and psychotherapy are rare. A recent pre-test post-test study considers art psychotherapy for mild-to-moderate depression and reports positive outcomes but highlights the need for further investigation (Zubala, MacIntyre, & Karkou, 2016). A very recent study also compares the effectiveness of psychotherapy to that of combined therapy in treating mild-to-moderate depression (Bekhuis et al., 2018). The results indicate that combined therapy may be more effective for certain symptoms (in particular, worry and obsessive thoughts), but the authors do not specify the outcomes for mild and moderate depression and point out that more research is needed for conclusive statements. As a result, as pointed out by Cuijpers et al. (2014) and Olfson et al. (2016), the research on the effectiveness of psychotherapy in treating mild depression is insufficient and inconclusive, which implies that more investigation is required.
Depression and Pharmacotherapy
Antidepressants are used to treat depression, and they are predominantly prescribed to people who have moderate or severe depression (National Institute of Mental Health, 2018). However, they are also used with the cases of persistent or chronic mild and subthreshold depression (National Institute for Health and Care Excellence, 2016; Reid et al., 2014). Most often, generic selective serotonin reuptake inhibitors (SSRIs) are recommended for depression treatment (National Institute for Health and Care Excellence, 2016; Reid et al., 2014). Combinations of drugs are also a possibility (National Institute for Health and Care Excellence, 2016; Olfson et al., 2016; Reid et al., 2014). The expected outcomes include the reduction of depressive symptoms, and the efficacy of treatment is usually reassessed two weeks after its introduction (National Institute for Health and Care Excellence, 2016; Reid et al., 2014). If an SSRI is not effective, it is recommended to try another SSRI; apart from that, a new-generation antidepressant may be a possibility (Reid et al., 2014).
According to a recent study on depression management, drugs are used for mild depression in the US despite not being recommended for it (Olfson et al., 2016). The authors of the report state that the reasons for the fact are unclear, but it could be connected to assessment errors and restricted resources. Thus, pharmacotherapy is used for mild depression in the US, but the current guidelines do not seem to view this practice as appropriate in most cases.
A very recent meta-analysis of over 500 trials by Cipriani et al. (2018) reports that antidepressants are more effective than placebo in treating depression, but this research does not focus on depression severity. Regarding mild depression, there is some evidence which indicates that antidepressants are not more effective than placebo when treating it, but this evidence is very scarce. For instance, a relatively recent meta-analysis by Barbui, Cipriani, Patel, Ayuso-Mateos, and Ommeren (2011) was able to locate only six relatively high-quality studies that considered three antidepressants (paroxetine had three studies dedicated to it; fluoxetine, amitriptyline, and isocarboxazid had only one each). No long-term follow-ups were present in the literature, and the majority of them had small samples (fewer than 50 patients). Similarly, when attempting to determine the effectiveness of a specific antidepressant (desvenlafaxine) Mosca, Zhang, Prieto, and Boucher (2017) found no sufficient evidence to offer any statements about its effectiveness in treating mild depression.
Cameron, Reid, and MacGillivray (2014) conduct a meta-analysis concerning mild depression and antidepressants and conclude that the current data on the topic is not sufficient to offer any definite statements because of inadequate follow-ups, high risk of bias, and heterogeneous methodologies. Similarly, Reid et al. (2014) review several meta-analyses and state that there is not enough evidence for conclusive statements about the use of pharmacotherapy for mild depression; the data that is present is generated through studies that tend to have methodological shortcomings. In summary, the effectiveness of pharmacotherapy for mild depression is not adequately documented, and the current guidelines might be based on insufficient evidence. Consequently, it may be helpful to consider the theoretical underpinnings of pharmacotherapy and psychotherapy.
Critical Analysis of Conceptual and Theoretical Literature
The examination of theoretical literature and evidence is crucial for the development of a study (Moran, 2017). 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 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 is also of importance.
Synthesis of Evidence: A Conclusion
As shown above, 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 a placebo in the case of mild depression (Olfson et al., 2016). Consequently, it is assumed that pharmacotherapy is not the best choice for the treatment of mild depression, which may have hindered the research on the topic.
However, systematic reviews and meta-analyses indicate that more investigation 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 et al., 2014; Mosca et al., 2017; Reid et al., 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.
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 (National Institute of Mental Health, 2018; 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. The study chooses the Hamilton Rating Scale for Depression (HRSD) (Sharp, 2015) for this purpose.
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 the latter, 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 (biological and psychological). The desired outcome is improved health. Within the study (and by the model), health can be measured with the help of the changes in the severity of the illness. HRSD can measure such changes. Indeed, HRSD 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 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 numerous 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 particular treatments on the severity of depression 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.
It should also be pointed out that a nursing project does not have to use nursing theory as its conceptual framework. It is not unusual for nurses to employ non-nursing theories as pointed out by Polit and Beck (2017). Moreover, the biomedical model fits the project. Based on Polit and Beck (2017), a conceptual framework is a “means of organizing phenomena” that consists of “a perspective regarding interrelated phenomena” and “presents an understanding of the phenomenon of interest” (p. 128). The biomedical model arranges all the concepts that are employed by the proposed project, explains their interrelationships, and specifies the researcher’s perspective on them (in particular, the idea that health can be “measured”). Therefore, the use of a non-nursing theory that is capable of framing all the concepts of the present project is justified.
Conclusion
As a serious and widespread health condition, the significance of addressing which is acknowledged by multiple American and international organizations, depression requires adequate management. However, the lack of appropriately conclusive evidence concerning some of its aspects may decrease the quality of care for depressed patients. 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 for treating adults with mild depression.
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 under-researched topic and attract attention to it. Thus, the proposed project can be viewed as significant, and it is a study that needs to be done.
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.
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