evidence-based review of treatment for Adolescent depression
NSG6999 Graduate Project in Nursing
Dr. Kristin Belderson
August 10, 2021
Depression is common and treatable, yet many people do not seek treatment. Dunphy, Winland-Brown, Porter, and Thomas (2019) describe depression or Major Depressive Disorder as a common condition that depict a wide variety of negative emotional states, ranging from sadness to loss of interest or pleasure in activities, to irritability and self-hate. It causes psychological pain, prompting for any solution that may bring relief. Depression presents some common characteristics such as sadness and anhedonia (loss of pleasure), that can be distinguished from ordinary changes in mood. Additionally, patients may have difficulty describing their pain and may make vague references to “hurting” or “feeling bad.” Thoughts of death or suicide are common.
The population suffering from depression in the U.S. and European nations is estimated at about 20%, and approximately 9% in other developing countries. However, prevalence in those 65 years and older is significantly less compared with the younger population; except for those who are sick and/or in pain, in nursing homes, and in community-dwelling, or suffering from chronic medical conditions at 30 to 40% (Dunphy, Winland-Brown, Porter, & Thomas, 2019).
The COVID-19 pandemic, financial hardship, social isolation, heightened the risk for depression, particularly in the adolescent population (Schleider, et al., 2021).
Variations in the clinical presentation of depression can make it difficult to recognize.
Patients often present with somatic complaints and ambiguous symptoms of unexplained fatigue.
|Changes in appetite and weight Changes in sleep patterns Feelings of sadness Tearfulness Apathy, irritability Anger Anxiety Hyperactivity, low energy||Slowed thinking Emotional numbness Changes in grooming Interpersonal interactions Substance abuse Aggression Social withdrawal Decreased interest (Cheung & Sinyor, 2021)|
DSM-5 requires five (or more) symptoms present during 2-week period.
Including depressed mood and/or anhedonia.
Have you felt down or hopeless over the past few weeks?
Have you had little interest in doing things over the past few weeks?
Patient Health Questionnaire-9 (PHQ-9) with sensitivity (85%) and specificity (84%).
Quick Inventory of Depressive Symptomatology (QIDS-SR).
(Dunphy, Winland-Brown, Porter, & Thomas, 2019)
The current guidelines for treatment of mild to moderate depression, recommends the use of antidepressants and/or psychotherapy, reserving combination therapy for more severe symptoms.
(Dunphy, Winland-Brown, Porter, & Thomas, 2019).
The Spirit of Inquiry Ignited
The management of adolescent depression is crucial in the primary care setting.
Primary care has readily available tools for diagnosing, treating, and managing it.
Available treatment guidelines should not replace clinical judgment but be a guide.
Possible side effects, withdrawal symptoms, and lack of evidence of the effectiveness of monotherapy unavoidably provokes intriguing questions about the real efficacy of the treatment. Does medication help? Does psychotherapy help? Or does the answer lay somewhere in a combination of psychotherapy and medication?
(Cheung, et al., 2018)
Among nurse practitioners caring for adolescents diagnosed with depression in a primary care setting (P), does a nurse-led pharmacological therapy plan (I), compared to psychotherapy only (C), decrease depression symptoms (O) over a 1-year period (T)?
Searching for evidence Strategy
The search for evidence included a Boolean advance search of terms such as adolescent, depression, and treatment in databases such as the CINAHL Plus, PubMed, Cochrane Library, Dynamed, TRIP Medical, and South University Library. The search resulted in hundreds of studies.
Critical Appraisal of the Evidence
The studies went through a strict but objective selection process
They are level 1, systematic reviews or meta-analysis published with in the last five years.
Especial attention was focused on sample size, variables, analysis of data, results and the implication on clinical practice.
The studies focused on the comparative efficacy of antidepressants, psychotherapies, and their combination for the treatment of adolescents suffering from depression.
They revealed effectiveness and inadequacies of the current recommended treatments.
The systematic review of available data suggest that there is urgent need for additional research of evidence-based practice to treat depression in adolescents.
There is evidence a few successful treatments for adolescents, including psychotherapy and some medications (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017). Only SSRI medications have been approved by the FDA to be used in adolescents (Viswanathan, et al., 2020).
The outcomes agree that CBT is the leading intervention to treat adolescent depression, with no side effects when compared with pharmacotherapy (Viswanathan, et al., 2020), (Zhou, et al., 2020), (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017).
Adolescents suffering from depression should be treated with a combination of cognitive-behavioral therapy (CBT), and antidepressant medication for better results (Cheung, et al., 2018; Davey, et al., 2019; Foster, Mohler-Kuo, Tay, Hothorn, & Seibold, 2019; Viswanathan, et al., 2020; Zhou, et al., 2020).
Evidence Integration in Clinical practice
To change the current depression treatment approach in adolescents to a combination of CBT and antidepressant treatment due to evidence reviewed points toward a higher chance of success than monotherapy when treating adolescents.
1- Key stakeholders = All adolescent patients diagnosed with depression and their parents or guardians and their healthcare providers.
2- ARNPs, PAs, and physicians, will help champion project implementation.
3- Main barriers = Resistance to change and partial adherence by providers.
4- Modified Treatment Satisfaction Questionnaire for Medication (TSQM 14), to assess the patient satisfaction with the recommended combination therapy treatment.
Goals and evaluation
1- Measuring provider participation monthly.
2- Measuring patient response to the change.
3- Evaluating the implementation effect on the clinic.
• The COVID-19 pandemic affected adolescents to a higher degree.
• New recommendations urge that proper and reasonable treatment in primary care.
• All the research findings presented here suggest that a combination of CBT and antidepressants is the best option for the treatment of adolescent depression.
• There is a need for additional research on the subject.
• This project recommends a shift of the current treatment policy toward evidence-based combination therapy treatment.
• This change is not yet reflected in the current clinical practice in primary care, potentially missing its demonstrated benefits.
(Kapetanovic, Gurdal, Ander, & Sorbring, 2021; Cheung & Sinyor, 2021; Davey et al. 2019; Foster, Mohler-Kuo, Tay, Hothorn, & Seibold, 2019; Gunlicks-Stoessel, Klimes-Dougan, VanZomeren, & Ma, 2020; Viswanathan et al. 2020; Zhou et al. 2020; Hussain, Dubicka, & Wilkinson, 2018).
Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & GLAD-PC STEERING GROUP. (2018, March 01). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141, pp. 1-18. doi:10.1542/peds.2017-4082
Cheung, A., & Sinyor, M. (2021, February 28). Depression in children and adolescents in primary care. Pediatric Medicine, 4, pp. 1-10. doi:10.21037/pm-20-82
Davey, C. G., Chanen, A. M., Cotton, S. M., Hetrick, S. E., Kerr, M. J., Berk, M., . . . McGorry, P. (2019, July 29). The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): study protocol for a randomised control trial. The Lancet Psychiatry, 9, pp. 735-744. doi:10.1016/S2215-0366(19)30215-9
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: Art and Science of Advanced Practice Nursing – An Interprofessional Approach (5th ed). Philadelphia, PA: F. A. Davis Company.
Foster, S., Mohler-Kuo, M., Tay, L., Hothorn, T., & Seibold, H. (2019, May). Estimating patient-specific treatment advantages in the ‘Treatment for Adolescents with Depression Study’. Journal of Psychiatric Research, 112, pp. 61-70. doi:10.1016/j.jpsychires.2019.02.021
Kapetanovic, S., Gurdal, S., Ander, B., & Sorbring, E. (2021, January 15). Reported changes in adolescent psychosocial functioning during the COVID-19 outbreak. Adolescents, 1, pp. 10-20. doi:10.3390/adolescents1010002
Schleider, J. L., Mullarkey, M. C., Fox, K., Dobias, M. L., Shroff, A., Hart, E., & Roulston, C. A. (2021, April 08). Single-session interventions for adolescent depression in the context of COVID-19: A nationwide randomized-controlled trial. PsyArXiv, pp. 1-29. doi:10.31234/osf.io/ved4p
Viswanathan, M., Kennedy, S. M., McKeeman, J., Christian, R., Coker-Schwimmer, M., Middleton, J. C., . . . Forman-Hoffman, V. (2020, April 01). Treatment of depression in children and adolescents: A systematic review. Comparative Effectiveness Review No. 224, pp. 1-1145. doi:10.23970/AHRQEPCCER224
Weersing, V. R., Jeffreys, M., Do, M.-C. T., Schwartz, K. T., & Bolano, C. (2017, January 01). Evidence- Base Update of Psychosocial Treatments for Child and Adolescent Depression. Journal of clinical child and adolescent psychology, 46, pp. 11-43. doi:10.1080/15374416.2016.1220310
Zhou, X., Teng, T., Zhang, Y., Giovane, C. D., Furukawa, T. A., Weisz, J. R., . . . Xie, P. (2020, July 01). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry, 7, pp. 581-601. doi:10.1016/S2215-0366(20)30137-1
Department, Institutional Affiliation
Urinary tract infections (UTI) are the top cause of healthcare-acquired infections. Based on the proposed EBP, the removal of the UTIs within 72 hours helps in the reduction of the number of infections that occur to the hospitalized patients on a general medicine unit with the Foley Catheter. Foley bundles together with education on the Foley bundles are amongst the strategies that are used to ensure that there is a reduction in the incidences of CAUTIs (Li et al., 2019).
The topic is of interest is based on the adverse impacts associated with CAUTIs. For example, there are increased reported cases of morbidity, mortality, increase in-hospital stay, and an increase in healthcare cost. The topic is important since it informs about the need to have a successful intervention that can be used to help in addressing the issue of CAUTIs (Li et al., 2019).
To address the issue of CAUTIs, it is important to have an EBP that gives nurses to make necessary improvements. Therefore, the development of the intervention (EBP) is based on the created PICOT question of For hospitalized patients on a general medicine unit with Foley catheters (P), does implementation of nursing Foley bundles, accompanied with continual education on Foley bundles (I), compared to using no nursing Foley bundles/continual education (C), decrease the incidence of hospital-acquired catheter-associated urinary tract infections (O), over one year (T)?
Concerning the search strategy, the picot question will be used to frame the search engine. Within the picot question, various descriptors terms will be highlighted by identifying the main elements that would be important in finding the pre-reviewed sources. Using the time case factor element of 5 years from 2021, the search will be narrowed to ensure that suitable articles are found (Fukuoka et al., 2018). The evidence will then be filtered through narrowing or expansion of the research.
The implementation of the EBP will first involve informing the healthcare team as well as the hospital management. This is important in ensuring that there is little resistance from the nurses when it comes to the implementation of the EBP. Informing the management ensures that adequate resources for the implementation are provided. The baseline data concerning the incidences of CAUTIs in the absence of EBP are collected. After taking the opinions from the nurses, their views are incorporated into the implementation process. nurses are then educated on the implementation procedures. While the implementation takes place, the results from the implementation are compared to the baseline data before the implementation (Fukuoka et al., 2018). It helps in revealing whether the EBP is working towards addressing the issue.
The Outcome evaluation
The evaluation of the outcome is based on the collection of the information from the implementation results to determine whether there was a positive change. It is expected that the successful implementation process will lead to a reduction in the incidence of CAUTIs. Consequently, there will be a reduction in the length of hospital stay, the cost of healthcare, and the morbidities associated with CAUTIs.
The proposed EBP is not only aimed at benefiting this organization, but also other healthcare facilities that are facing the problems of CAUTIs. Therefore, it is important to ensure that the information about the EBP is disseminated to the targeted audiences. The dissemination process, therefore, occurs publication in national journals or recognized journals. It is also done during nursing conferences, professional meetings, special interest newsletters, and sharing through the organizational websites or the informal professional networks (Stewart et al., 2019).
CAUTIs are a major issue that affects the quality of healthcare services that is being delivered to the healthcare providers. it is important to ensure that there is the existence of evidence-based intervention aimed at assisting in addressing the issue. Therefore, this capstone project will help in the generation of the EBP that can be used to ensure that nurses implement the procedure in reducing the risks of CAUTIs. Within healthcare facilities.
Study by Li et al (2019) focused at looking at the risk factors for the CAUTIs among the hospitalized patients. It is a systematic review study and this implies that the evidence presented in this case are based on the literature review or past articles. The errors made in the past studies might have affected the study outcome thus interfering with the reliability and validity of the article. The study outcome reveals that there was high risks of female exposure to CAUTIs as a result of the long hours, longer stay in hospital, and the previous diagnosis with diabetes. The study is important to the capstone project or topic of study since it shows some of the factors associated with high risk of exposure to CAUTIs.
Study by Hernandez et al (2019) was based on experimental study aimed at looking at the prevention approaches and the role of the documentation checklists. The outcome of this study are based on the primary data that are collected from observing the experimental work. This increases the authenticity of the study hence making it more reliable and valid. The outcome of the study reveals that checklist of the indwelling catheter management practices are important in the prevention of CAUTIs. Therefore, the study is important to the topic since it offer an effective approach that can be adopted to help in the reduction of the CAUTIs.
Fukuoka et al (2018) aimed at looking at the impacts of the longer duration of catheter use on the risk of CAUTIs infection and it was a retrospective cohort study. Th study outcome shows that longer use of catheterization results in the increased risk of exposure to CAUTIs by 5 percent on the daily basis. Therefore, the study is important since it shows that one of the risk factors for CAUTIs is the extended use of catheters.
Fukuoka, K., Furuichi, M., Ito, K., Morikawa, Y., Watanabe, I., Shimizu, N., & Horikoshi, Y. (2018). Longer duration of urinary catheterization increases catheter-associated urinary tract infection in PICU. Pediatric Critical Care Medicine, 19(10), e547-e550. doi: 10.1097/PCC.0000000000001628.
Hernandez, M., King, A., & Stewart, L. (2019). Catheter-associated urinary tract infection (CAUTI) prevention and nurses’ checklist documentation of their indwelling catheter management practices. Nursing Praxis in New Zealand, 35(1).
Li, F., Song, M., Xu, L., Deng, B., Zhu, S., & Li, X. (2019). Risk factors for catheter‐associated urinary tract infection among hospitalized patients: A systematic review and meta‐analysis of observational studies. Journal of advanced nursing, 75(3), 517-527. https://doi.org/10.1111/jan.13863
|Citation||Design||Sample size: Adequate?||Major Variables:|
|Study findings: Strengths and weaknesses||Level of evidence||Evidence Synthesis|
|Li, F., Song, M., Xu, L., Deng, B., Zhu, S., & Li, X. (2019). Risk factors for catheter‐associated urinary tract infection among hospitalized patients: A systematic review and meta‐analysis of observational studies. Journal of advanced nursing, 75(3), 517-527. https://doi.org/10.1111/jan.13863||A systematic review and meta-analysis of observational studies||8785||Independent variable: Risk factors|
Dependent Variable: CAUTIs
|Female were highly exposed to CAUTIs. They had an extended hour of catheterization. Other risk factors for CAUTIs included diabetes, previous catheterization, and longer hospital stay||Level V: A systematic review and meta-analysis of observational studies.||The Study confirms that prolonged duration of catheterization is a risk factor associated with CAUTIs|
|Hernandez, M., King, A., & Stewart, L. (2019). Catheter-associated urinary tract infection (CAUTI) prevention and nurses’ checklist documentation of their indwelling catheter management practices. Nursing Praxis in New Zealand, 35(1)||Experimental study||50 nurses||Independent variable: nurses’ checklist documentation of their indwelling catheter management practices|
Dependent variable: CAUTIs
|The management practices in the catheter use is causing a great impact on|
CAUTI prevention efforts
|Level I: Experimental study||The study shows that the checklist of the indwelling catheter management practice is effective in the prevention of CAUTIs|
|Fukuoka, K., Furuichi, M., Ito, K., Morikawa, Y., Watanabe, I., Shimizu, N., & Horikoshi, Y. (2018). Longer duration of urinary catheterization increases catheter-associated urinary tract infection in PICU. Pediatric Critical Care Medicine, 19(10), e547-e550. doi: 10.1097/PCC.0000000000001628||Retrospective cohort study.||1890 Children with urethral catheter||Dependent Variable: Longer Duration of Urinary Catheterization|
Independent Variable: Risk for CAUTIs
|An extended period of catheterization leads to the increase in the risk of exposure to CAUTIs by 5% everyday within PICU.|