Mild Depression: Pharmacotherapy and Psychotherapy
Words: 7115 Subject: Psychiatry
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% of people experience mild depression (National Center for Health Statistics, 2014).
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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 such as 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, this project intends to investigate the effectiveness of psychotherapy and pharmacotherapy in the treatment of 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.
Regarding pharmacotherapy, there are more concerns with respect to its use for the condition. There is some evidence to 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, high risk of bias (Cameron, Reid, & MacGillivray, 2014), as well as the discrepancies in assessing the severity of depression (Reid et al., 2014).
The latter issue, according to Reid et al. (2014) refers to different approaches to measuring depression; currently, there are at least three methods of doing so which do not produce identical results. Consequently, the comparison of the findings of the studies that use different approaches is problematic. Mosca, Zhang, Prieto, and Boucher (2017) and Reid et al. (2014) also report that, in general, few high-quality studies have addressed the topic of the use of pharmacotherapy in treating mild depression while adequately assessing depression severity.
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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). Antidepressants also need to be considered in particular cases (for example, persistent or chronic depression) (National Institute for Health and Care Excellence, 2016). 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).
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. The proposed project intends to provide some evidence by conducting a retrospective chart review that will consider the current use of pharmacotherapy and psychotherapy in treating mild depression, as well as the related outcomes.
In order to address the problem introduced above, a project with the following research question is proposed: in psychiatric patients with mild depression, what is the effect of psychotherapy on health compared with pharmacotherapy? The purpose of this project is to explore psychotherapy and pharmacotherapy treatment of psychiatric patients diagnosed with mild depression. It is also noteworthy that the project will help to attract some attention to the fact that the treatment of mild depression is understudied and requires more evidence so that practitioners can make better-informed decisions based on evidence.
The main outcome of the study is to improve the quality of care for patients with mild depression. While it is obvious that the contribution of more data cannot resolve the issue of depression, it would still push the scientific community towards an improved understanding the treatment for mild depression.
Depression is a major issue that requires investigation. It is a common disease worldwide, and the World Health Organization (2017) states that the number of people suffering from it amounts to 300 million (para. 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 entire 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 information on mild depression is available. The most recent report by the Centers for Disease Control and Prevention and 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, para. 13-14). The report also demonstrates that 41% of people with mild depression reported experiencing difficulties in social activities and personal and work life; an additional 4% classified the difficulties as serious (National Center for Health Statistics, 2014, para. 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. According to the National Institute of Mental Health (2018), delays in appropriate treatment can affect its effectiveness in a negative way. 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.
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There is some evidence which indicates that psychotherapy is effective in the treatment of mild depression (Bekhuis et al., 2018; Fathi, Renner, & Juen, 2016; Fonagy et al., 2015; Jakobsen, Andersson, Havik, & Nordgreen, 2017; Zubala, MacIntyre, & Karkou, 2016).
However, the majority of the mentioned studies consider both mild and moderate depression without focusing on the former. Moreover, there is also some evidence which indicates that further investigation is needed. Cuijpers et al. (2014) reviewed 18 studies with psychological interventions, demonstrating that the majority of the sources are not high-quality, indicating that more investigation is required for conclusive statements. 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).
Multiple recent studies, meta-analyses, and critical literature reviews suggest that the use of pharmacotherapy in treating mild depression is understudied, which limits the ability of researchers to make conclusive statements regarding its effectiveness (Barbui, Cipriani, Patel, Ayuso-Mateos, & Ommeren, 2011; Cameron et al., 2014; Mosca et al., 2017; Reid et al., 2014). There are also studies that focus on specific antidepressants, but they rarely consider mild depression (Mosca et al., 2017), which demonstrates the lack of attention to it. In summary, little is known about the stated research problem, but since both pharmacotherapy and psychotherapy are used in modern practice (Olfson et al., 2016), the issue needs to be addressed.
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 may be endangered because relevant guidelines are based on inconclusive evidence. In particular, the evidence which indicates the effectiveness of using psychotherapy and pharmacotherapy in treating mild depression is not sufficient as shown by multiple studies (Cuijpers et al., 2014; Cameron et al., 2014; Mosca et al., 2017; Reid et al., 2014).
This issue can be viewed as a threat to the quality of care and safety of patients. Indeed, mild depression is relatively prevalent and can have a negative impact on 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.
Therefore, the scientific community needs to produce a conclusive statement about the effectiveness of different mild depression treatments, including psychotherapy and pharmacotherapy since they are currently used (Olfson et al., 2016). Consequently, From the perspective of nursing, the primary significance of the project consists of producing the evidence that can contribute to the improved understanding of depression treatment and, therefore, advance 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.
The inefficient treatment of depression is an apparent issue. 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 matter. 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 effectiveness and recommended use would be beneficial from the point of view of modern healthcare. The described project will contribute some evidence devoted to the treatment of mild depression. Moreover, the project will also attract some attention to the issue by disseminating its own findings and communicating the concern for the problem, which can be beneficial for future research.
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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, advanced practice nurses can prescribe antidepressants, even though there are some limitations related to the field of nurses’ expertise and age of patients (Stokowski, 2018). 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: it will contribute the information that can be used to improve the modern understanding of depression treatment, which will be practically applied by advanced practice nurses.
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 setting of my practice. In particular, the project will be carried out at my workplace (New Horizons Community Mental Health Center in Miami, FL). Thus, the location of the New Horizons Center will host the procedures related to the project. Similarly, the people of the Center will also make a major contribution since the support of the management of the Center will be required for the project. The letter of support was already provided (see Appendix A). The data collection procedures of the project are aligned with the current activities of the Center.
Benefit of Project to Practice
The benefit of the project to practice is related to its significance. Mild depression is among the conditions that the New Horizons Community Mental Health Center treats. Therefore, the absence of conclusive evidence on the topic, which is shown by the previously discussed literature (Mosca et al., 2017; Olfson et al., 2016; Reid et al., 2014), is problematic for the Center. With the help of the project, more evidence will be produced, and the research problem will be popularized among the professionals of the New Horizons Community Mental Health Center. Specifically, the evidence pertinent to the effectiveness of psychotherapy and pharmacotherapy in treating mild depression 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.
Depression is a serious and widespread health condition, the significance of which is acknowledged by multiple American and international organizations. However, the lack of appropriately conclusive evidence concerning some of its aspects may decrease the quality of care for the depressed patients. In particular, the treatment of mild depression is an understudied topic. A review of literature indicates that modern studies rarely consider the problem of mild depression treatment, focusing on other forms of the condition. 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 setting 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 related to mild depression management. From the perspective of healthcare, the project will contribute data and information to an underresearched topic and attract attention to it.
Review of Literature
The research question 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? This study will explore the effect of psychotherapy and pharmacotherapy in psychiatric patients with mild depression. In order to respond to the question, 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, summarize the relevant evidence, define the key concepts of the project, and explain the framework chosen for it.
Depression Management: Critical Analysis of Literature
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 chosen treatment (National Institute for Health and Care Excellence, 2016). This research study is concerned with the treatment of mild 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 et al., 2016; Reid et al., 2014).
Depression and Psychotherapy
A variety of psychotherapy approaches are applicable to depression, including “cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy” (National Institute of Mental Health, 2018, para. 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 of 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).
In it, the authors employed the “2012 and 2013 Medical Expenditure Panel Surveys (MEPS) conducted by the Agency for Healthcare Research and Quality” to investigate the use of depression treatments in the US (p. 2). MEPS included a valid screening tool and a tool for determining the treatments received by respondents. The authors analyzed the total of 46,417 responses and proved that psychotherapy was employed for depression of varying severity, although it was less likely to be prescribed to people with mild depression than to people with its more serious forms. 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 center on mild depression. The investigation 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, including a sustainable decrease in depressive symptoms and improved perceived well-being (Zubala et al., 2016).
However, the study also highlights the need for further investigation. A very recent research also compared the effectiveness of psychotherapy to that of combined therapy in treating mild-to-moderate depression (Bekhuis et al., 2018). The results indicated that combined therapy might be more effective for certain symptoms (in particular, worry and obsessive thoughts), but the authors did not specify the outcomes for mild and moderate depression and pointed out that more research would be needed for conclusive statements.
Similarly, 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 depression scores and social adjustment. 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 might not be very conclusive.
Fathi et al. (2016) carried out a qualitative investigation of the effectiveness of CBT that targeted Iranian migrants with mild and moderate depression. The sample included twenty-three people. Reduced depressive symptoms after the interventions were the primary outcome, but it was not sustainable in all the studied cases (some participants reported feeling worse during the six-month follow-up). Furthermore, Jakobsen et al. (2017) launched a pilot Guided Internet-Based CBT that was administered to twenty-two participants with mild and moderate depression; no control group was present. The study demonstrated statistically significant decreases in depressive symptoms, but the authors highlighted the need for an experiment with a bigger sample.
In summary, the sources that consider mild depression are scarce, and they typically do not focus on mild depression alone. Many of them indicate positive outcomes of psychotherapy, but not all of them are randomized controlled trials, some of them have small samples, and many suggest the need for future research. As a result, as pointed out by Cuijpers et al. (2014) and Olfson et al. (2016), the research of the effectiveness of psychotherapy in treating mild depression is insufficient, and more investigation is required.
Depression and Pharmacotherapy
Antidepressants are used to treat depression, and they are predominantly prescribed to the people who have moderate or severe depression; they are not recommended for mild depression. This statement is supported by the guidelines developed by the National Institute of Mental Health (2018) and the review of best practices by Reid et al. (2014). However, the same sources also suggest using antidepressants with the cases of persistent or chronic mild and subthreshold depression. They also find that generic selective serotonin reuptake inhibitors (SSRIs) are recommended for depression treatment, but combinations of drugs are also a possibility (National Institute for Health and Care Excellence, 2016; Reid et al., 2014).
According to the National Institute of Mental Health (2018), the expected outcomes of pharmacotherapy include the reduction of depressive symptoms, and the efficacy of treatment is usually reassessed two weeks after its introduction. 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 the study by Olfson et al. (2016), drugs are used for mild depression in the US despite not being recommended for it. 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, which are mentioned above, do not seem to view this practice as appropriate in most cases (National Institute for Health and Care Excellence, 2016; Olfson et al., 2016; Reid et al., 2014).
Based on a meta-analysis of over 500 trials, Cipriani et al. (2018) reported that antidepressants are more effective than placebos in treating depression, but this research does not focus on depression severity. On the other hand, Kirsch et al. (2008) reviewed 47 trials and demonstrated that the use of pharmacotherapy becomes more effective than that of placebos with the increase in depression severity. It follows that for mild depression, the effectiveness of antidepressants is not superior to placebo effects. However, the authors do not focus on mild depression and do not specify the number of mildly depressed patients in their sample.
A meta-analysis by Barbui et al. (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). Based on two studies with the total sample of 93 patients, the authors stated there was some evidence indicating the lack of statistically significant difference between the effectiveness of the studied antidepressants and placebo. Thus, there is some evidence which suggests that antidepressants are not more effective than placebos when treating mild depression, but this evidence is very scarce.
Concerning more recent studies, 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) and studies only one antidepressant, which limits the applicability of its results. Furthermore, Mosca et al. (2017) found no sufficient evidence to offer any suggestions about the effectiveness of desvenlafaxine in the treatment of mild depression.
Cameron et al. (2014) conducted a meta-analysis concerning mild depression and antidepressants and made the conclusion 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 (that is, differences in methodologies that complicate their meta-analysis). Similarly, Reid et al. (2014) found in their study that there was not enough evidence for conclusive statements about the use of pharmacotherapy for mild depression. In summary, there are few studies that consider the use of pharmacotherapy in treating mild depression, and the topic needs further investigation.
Synthesis of Evidence
As shown above, the evidence concerning 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 research studies 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 evidence indicates that antidepressants have the same effect as placebos in the case of mild depression (Barbui et al., 2011).
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, the limited amount of literature indicates that more investigation is required on the matter, and this idea is pointed out by multiple studies on the topic, including those by Cameron et al. (2014), Mosca et al. (2017), and Reid et al. (2014).
Psychotherapy has been evidenced to have positive effects on mild depression (Bekhuis et al., 2018; Fathi et al., 2016; Jakobsen et al., 2017; Reid et al., 2014). However, few recent studies of psychotherapy’s effect on mild depression exist, and some of them have small samples or have other limitations (Fathi et al., 2016; Jakobsen et al., 2017). Therefore, in order to inform future guidelines, more recent and high-quality evidence is required for both types of treatment.
Concepts and Definitions
The key concepts that are used in the study 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 affect, cognition, and neurovegetative functions” (American Psychiatric Association, 2013, p. 155). 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, including CBT, IPT, and other options (National Institute of Mental Health, 2018; Reid et al., 2014).
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 the purposes of this research, it would be more convenient to adopt a more reductionist perspective in order to be able to measure health.
Frameworks are the tools that assist in the organization of the concepts employed by a study (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 research 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) stated that such studies would not be enough for psychological treatments since they could not provide the information that would 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 in order 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 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 in accordance with the model), health can be measured with the help of the changes in the severity of the illness. Thus, the framework organizes the concepts and demonstrates the way in which the research question of the study can be answered. Since the project is aimed 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 own 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 a nursing theory as its conceptual framework. In fact, it is not unusual for nurses to employ non-nursing theories as pointed out by Polit and Beck (2017). The biomedical model remains the dominant perspective on health in modern research, and it has been involved in multiple studies on depression, including those that incorporated the review of psychotherapy (Deacon, 2013). Therefore, it is appropriate for the present study.
The review of literature and evidence on the topic of depression treatment indicates that there are some notable gaps in them. In particular, pharmacotherapy and psychotherapy are insufficiently studied where mild depression is concerned. Supposedly, psychotherapy should be appropriate, but this statement is based on few modern studies. As for pharmacotherapy, the literature review suggested that there is not sufficient evidence 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.
The present chapter will consider the methodology of the proposed project. In particular, the design, data collection and analysis, timeline, budget, resources, and ethical concerns, as well as needs assessment, will be reviewed. The research question is phrased as follows: in psychiatric patients with mild depression, what is the effect of psychotherapy on health compared with pharmacotherapy?
The study is going to focus on quantitative methodology, although some qualitative data may also be gathered in the process. The choice is explained by the PICOT question: it seeks to determine the effects of specific causes, which is typically addressed through quantitative research in nursing (Polit & Beck, 2017, p. 201). The project is a retrospective chart review that will involve the charts of the patients receiving different treatments (psycho- or pharmacotherapy).
The information will be gathered with the help of a specifically developed tool (see Appendix B). Qualitative data will be analyzed thematically (with the help of thematic analysis), and a statistical test (most definitely, t-test) will be used for quantitative data (Polit & Beck, 2017). In summary, the present project is likely to use the mixed methods approach to respond to the research question.
The literature review indicates a need for the study. Indeed, nowadays, the evidence regarding the use of psycho- or pharmacotherapy for mild depression treatment is insufficient. The existing guidelines focus on psychotherapy with the exception of some specific cases (National Institute for Health and Care Excellence, 2016; Olfson et al., 2016; Reid et al., 2014). However, the evidence on the use of pharmacotherapy is very scarce, which is why conclusive statements about it are not possible (Mosca et al., 2017; Reid et al., 2014). Psychotherapy may also need more research (Olfson et al., 2016; Reid et al., 2014). At the same time, it is established that both approaches are used to treat mild depression in the US (Olfson et al., 2016). Thus, to inform the practice better, additional investigation of mild depression treatment is required, which the present project intends to do.
The study will involve the collection of de-identified data from existing patient records, which constitutes a retrospective chart review (Sarkar & Seshadri, 2014; Vassar & Holzmann, 2013). It is a popular approach to investigation that employs patient records, which can be viewed as a very important source of information for nursing and healthcare research (Vassar & Holzmann, 2013). The project’s research question can be answered with the help of this design since it can produce the data which would describe the effectiveness of different treatments, including psychotherapy and pharmacotherapy. The design also involves minimal risks for participants (Sarkar & Seshadri, 2014; Vassar & Holzmann, 2013), which is a major advantage. Thus, the choice of the design is justified.
The proposed sampling strategy will involve gathering the data from the charts of the patients from a specific clinic (the New Horizons Community Mental Health Center), which is characteristic of convenience sampling (Polit & Beck, 2017; Remler & Ryzin, 2014). The inclusion criteria will consist of the clinic of the patient (New Horizons), their diagnosis (mild depression only), and their treatment (either psychotherapy or pharmacotherapy). Also, only adults (aged 18-65) will be recruited. Vulnerability will be the exclusion criterion.
The number of charts that are going to be reviewed will have to be limited by the number of patients with mild depression in the New Horizons Center; according to its management, they are not very numerous. The maximum number of charts that can be feasibly analyzed during the project is 100; it would also make a good sample from the point of view of power analysis (Polit & Beck, 2017). Only the records made before April 2018 will be reviewed. The New Horizons Community Mental Health Center was informed about the project, and it has already provided a letter of support (see Appendix A), granting access to its charts.
The procedures will include the collection and analysis of the data. The collection will be carried out in a private room of the New Horizons Center. No charts will be taken from the Center. For data abstraction, a specifically developed tool will be used (see Appendix B); it will ensure the de-identification of the data. The de-identified data will be entered into a digital file for analysis; this procedure will require verification and cleaning (Polit & Beck, 2017; Sylvia, 2016).
In particular, it will be necessary to ensure that the entered information corresponds to the one present in the initial file. After the data is transferred, verified, and cleaned, it will be analyzed statistically (with the help of a t-test) and thematically (with the help of thematic analysis) to determine the differences in the outcomes of the patients receiving pharmacotherapy and psychotherapy.
Data Collection Tools. Validity and Reliability
Appendix B contains the data collection tool that was developed for the project. It ensures the de-identification of the data (uses codes for the participants) and requires the collection of non-identifying subject data, their diagnosis, treatment, and the outcomes of the latter. The tool’s validity and reliability have not been checked, but they will be reviewed during its pilot use, and the instrument will be adjusted as needed.
Plan for Data Analysis
The data collection tool can gather both qualitative and quantitative data. The former will be analyzed thematically (with the help of thematic analysis), which is a common approach to the analysis of qualitative data that is frequently used in nursing research (Polit & Beck, 2017). On the other hand, quantitative data will be analyzed statistically. In particular, the effectiveness of pharmacotherapy and psychotherapy will be reviewed by comparing the pre- and post-intervention state of the patients, as well as the outcomes of the groups of patients receiving the two treatments. The study will aim to determine if a statistically significant difference can be found.
The primary investigator will recruit a statistician for consultations to improve the quality of the work, but it is still possible to make some predictions regarding potential data analysis methods. The choice of the test will need to be based on the specifics of the study. It is known that the outcomes are likely to be measured on a ratio scale (depression severity scores).
Also, it is known that two comparisons will be made: for dependent groups (the changes in the pre- and post-intervention state of the patients) and for independent groups (the differences in the outcomes of the patients receiving pharmacotherapy and psychotherapy). In accordance with this information (Polit & Beck, 2017), it can be suggested that the paired and independent t-tests can be used for the study. However, depending on the final size of the sample and individual groups, as well as the specifics of the data, a different test might be needed.
The key resources that are required for the study are human resources and time necessary to review the charts and analyze the collected information (Burson & Moran, 2017). The principal investigator’s time and efforts required for planning, implementing, and leading the project, as well as engaging the stakeholders (specifically, the management of New Horizons), are also a major resource of the study (Moran & Burson, 2017). Other than that, the project will involve the use of specific equipment (in particular, computers and USB drives) by the investigator. Also, the settings can be viewed as a resource since they are going to host the data collection activities.
Project Budget and Justification
The project’s budget is going to be minimal. No funding is anticipated, and very little spending is necessary. All the required equipment is already available. The materials needed for the study may consist of the copies of the data collection tool if the use of its paper version proves useful; a generous estimate of the costs of printing the tool amounts to a little below $50. However, it is most likely that the electronic versions will be used, which means no spending. Statistician services are also anticipated; their compensation varies, but a preliminary investigation suggests that it can be reasonable to expect to pay about $300-500. Thus, the minimal budget of the project is justified by its needs.
The proposed project has been in development for about nine weeks. As it is a part of the principal investigator’s courses, it can be anticipated to last for twenty-one weeks more. A timeline with an emphasis on the order of key activities, as well as their approximate duration, can be found in Appendix C. As can be seen from Appendix C, two continuous activities are present in the project: the literature review, which provides the necessary framing for all the stages of the project, and feedback, which is required to introduce additional insights and different perspectives (Moran, 2017). The proposal will be finalized after the IRB approval is received; then, the data will be collected and analyzed, and the report with the results will be developed. Dissemination is planned as well (Sylvia, 2016); it will become the final stage of the project.
Protection of Human Subjects
The primary ethical consideration of a retrospective chart review is confidentiality (Sarkar & Seshadri, 2014; Vassar & Holzmann, 2013). Given its significance (American Psychological Association, 2009), the present study ensures confidentiality with the help of multiple safeguards. A consent and HIPAA form will be obtained from the New Horizons Center. No personal information about the participants will be collected, and each patient will be assigned a code to mark their charts (see Appendix B).
The coded data will also be stored in a secure location (the place of the principal investigator) on a password-protected computer during the analysis procedures; after the analysis, the data will be returned to the New Horizons and destroyed. The data will not be shared with anyone outside of the study. The reports will be shared with the principal investigators’ peers and instructors, but they will not contain any identifying information. There is also the possibility of the publication of the results, but no personal information will be included in publications either. Thus, the concerns related to participant protection have been reviewed in the proposed project.
No direct benefits to the participants (that is, the people whose charts will be reviewed) are anticipated. However, the project can potentially contribute some evidence on the topic of appropriate mild depression treatment. The development of evidence-based guidelines on the use of pharmacotherapy and psychotherapy in treating mild depression can result in the advancement of the quality of care and, eventually, the improvement of the quality of the life of people with mild depression. Since the risks of the study for the participants are minimal, the potential benefits for future patients outweigh them.
The proposed project is a retrospective chart review that will gather the data of up to 100 patients with mild depression who receive pharmacotherapy or psychotherapy. The support of the project setting (New Horizons) was obtained. All the major ethical concerns of the study have been reviewed and appropriately managed to ensure participant protection. The project will take 30 weeks; the data will be collected with the help of a specifically developed data abstraction tool. The gathered information will be analyzed thematically and statistically. The required budget is minimal. The need for the project is based on the literature review.
Letter of Support
Retrospective Review Form
Subject Code: _______________________________________
Abstractor initials: ___________________________________
Date of abstraction: __________________________________
Diagnosis: mild depression (confirm): Y/N
Treatment (underline the applicable one): Psychotherapy/Pharmacotherapy
Duration of treatment (days): _____________________________________________________________
Check one and specify the outcomes:
Improvement (specify): __________________________________________________________________________________________________________________________________
Lack of change (specify): __________________________________________________________________________________________________________________________________
Worsening (specify): __________________________________________________________________________________________________________________________________
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