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Running head: INTEGRATED REVIEW 1

Integrated Review

Deirdre Brown

Bon Secours Memorial College of Nursing

Dr. Arlene Holowaychuk MSN, RN

Nursing Research - NUR 4122

March 6, 2018

“I Pledge”
INTEGRATED REVIEW 2

Abstract

Purpose. The purpose of this integrated review is to compare studies researching whether

depression rating scales administered by providers are more accurate in detecting depression in

adolescents aged 12-18 than the usual standard of care. Background. The incidence of

depression rises sharply in teenage years and it is estimated that up to 10% of young people will

have experienced a clinically significant depressive disorder by age 16 and yet it often goes

undetected and untreated. Design methods. Methods consisted of retrospective chart reviews,

interviews, and focused group discussions. Analyses involved descriptive statistics and thematic

analysis. Limitations. Limitations include lack of variability within screening to be able to adjust

to multifaceted environments, lack of follow-up by participants and the screening of participants

who were experiencing episodic illness may have affected outcomes.

Findings. Results suggest that implementation of depression screening tools improves depression

detection rates among adolescents and promotes early management of the depressive disorder

and yet use of tools are often not used or are not consistent. Patients are shown to be more likely

to adhere to treatment when a screening tool is administered. A provider’s relationship with the

patient and family also plays a significant role in provider motivation to treat. Implications and

Recommendations. Depression detection among adolescents improves with screening and

treatment leads to improved outcomes. Screening implementation to improve treatment access

within primary care is recommended.


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Integrated Review

The purpose of this integrated review is to determine the relationships among key

variables that influence detection of depression in adolescents between the ages 12-18.

Depression in adolescents is under-recognized and undetected and the United States Preventive

Services Task Force (USPSTF) recommends screening for depression in adolescents 12–18 years

old (US Preventative Services Task Force, 2016) . These recommendations include screening to

ensure accurate diagnosis, treatment, and follow-up of if adequate systems are in place. This is

important because a standardized approach improves communication between provider and

patient, improves detection rates and outcomes and promotes early initiation of treatment and

referral. Early detection of depressive symptoms makes the referral for formal evaluation

possible. Hence, early intervention for depression during adolescence can have an important

impact on adult mental health outcomes. This integrated review is to analyze and examine

published data in order to answer the PICO question: In adolescents aged 12-18, is the use of a

screening tool for depression compared with the usual standard of care, more accurate in

detecting depression.

Design and Research Methods

The research design is an integrative review and is focused on five research articles.

EBSCO Discovery and PubMed and Academic Search Complete were the computer-based

search engines utilized to obtain scholarly, evidenced-based articles. Words explored in the

search engine platforms included ‘depression’, ‘screening’, ‘adolescent’, ‘detection’, ‘tool’

‘provider’ and ‘teenager’. This search yielded 202 articles from the EBSCO Discovery, PubMed

and Academic Search Complete databases, indicating a reasonable amount of information on this

topic. In order to obtain current information on the issue, the search was limited to peer-reviewed
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qualitative and quantitative journal articles, published in English, and written between the years

2013 and 2018. Two studies were qualitative and three were qualitative. The articles were

relevant to the researcher’s PICO question, “In adolescents aged 12-18, is the use of a screening

tool for depression, compared with the usual standard of care, more accurate in detecting

depression?”

The articles were then screened and selected based on the following inclusion criteria:

adolescents age 12-18, screening tool used, revelation of current depression tool and results of

tested tools. The articles were screened based on this inclusion criteria and the relevancy to the

PICO question. If the articles found did not meet this criteria they were excluded from the

review. This screening process yielded five articles on depression screening results, including

four qualitative and one quantitative study.

Findings and Results

The findings and results of all five reviewed studies indicated a strong correlation

between implementation of a screening tool with an increase in detection of adolescent

depression (Bhatta, Champion, Young, & Loika, 2018; Richardson, Lewis, Casey-Goldstein,

Mccauley, Katon, 2017; Shochet, Montague, Smith, & Dadds, 2014; Taliaferro et al., 2013;

Wikberg, Pettersson, Westman, Björkelund, & Petersson, 2016). All five studies are summarized

in tables at the conclusion of this review. This review is structured based on the following

categories: patients’ perceptions of screening tests and barriers to treatment.

Patients’ Perceptions of Screening Tests

Two qualitative studies took the phenomenological approach to determine whether

adolescents who had been screened for depression felt that they had gained any benefit (Shochet
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et al., 2014; Wikberg et al., 2015). The purpose of the meta-analysis conducted by Shochet et al.,

2014, was to broaden the understanding of the impact of depression prevention programs as well

as highlight the reported benefits. Despite the evidence that points to a ned in this population, the

mechanisms that underlie successful prevention interventions with adolescents are still largely

unclear. The study consisted of a random sampling of 109 Grade 9 students’ reported on what

they felt they had gained from an evidence-based depression prevention intervention, the

Resourceful Adolescent Program (RAP-A). RAP-A is a program that screens for depression and

then works with adolescents with depression to promote resilience, positive coping, and

cognitive restructuring. Three months after students completed RAP-A, short structured

interviews were conducted with each participant. Students were asked if they could identify

specific examples of skills they had used from the PAP-A program and if they thought people

had noticed any changes in them since completing the RAP-A program. They were also asked

what they liked and didn’t like about the program. The interviews were analyzed using thematic

analysis. The students were able to identify a range of changes and 54% identified at least one

program benefit as a result of their participation in the program screening. Two themes emerged:

students felt that their interpersonal relations had improved as well as their improvement in self-

regulation. More girls (61%) than boys (47%) were able to identify a change. A further 8% stated

that the program was beneficial but were unable to identify specific examples. Approximately

25% of participants were either unsure that they had experienced any changes following their

participation in RAP-A or they stated that they had not used the skills much or at all.

Similarly, the purpose of the qualitative study by Wikberg et al., 2015, was to better

understand how patients with depression perceive the use of a depression screening tool. Studies

indicate that routine assessments of patients’ depressive symptoms in clinical practice are
INTEGRATED REVIEW 6

beneficial and they can help providers evaluate the progress of depression. The Montgomery-

Åsberg Depression Self-assessment scale (MADRS-S) was the screening tool used in primary

care consultations with providers and the results were analyzed in the study. A systematic

sampling of nine patients with mild to moderate depression reported on the effects of the

application and use of the MADRS-S during GP consultations. Focus groups were conducted and

the data was recorded. The resulting data was analyzed using Systematic Text Condensation

(STC). STC is suitable for summarizing data gathered from multiple participants or a few

participants. The study showed that participants perceived MADRS-S as an instrument that

showed them that they had depression as well as their level of depression. Participants also stated

that the screening tool helped them to understand which medication and treatments were

necessary and felt relieved that they were being taken seriously. Patients perceived that the self-

assessment scale added something to the consultation and functioned as a tool for the patient and

practitioner. MADRS-S was used both as a tool to visualize and to confirm the depression and as

a facilitator for treatment. The participants were unanimously positive that the GP should use

screenings during consultations.

Screening Outcomes

The purpose of the quantitative study by Bhatta et al., 2017, was to assess whether the

implementation of the Patient Health Questionnaires (PHQ-9) screening tool would identify

adolescents with depression. This retrospective chart review analyzed outcomes of 144

adolescents accessing pediatric primary care clinic services over a four month period to

determine screening outcomes for depression. Patients of the practice, who had not been

previously screened, were given the screening protocol to complete and the resulting data was

analyzed using descriptive statistics and frequency tables to describe depression screening status,
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depressive symptoms and referral status., Using descriptive statistical methods, researchers

determined that of the 144 charts reviewed, 12.5% (18) of adolescents that had been screened

had a score greater than 10. A score greater than or equal to 10 was an indicator for referral for

depression. Implementation of the depression screening protocol PHQ-9 improved depression

detection rates in the school-based pediatric primary care clinics and consequently promoted

early management of depression.

Barriers to Treatment

The purpose of the qualitative study by Richardson et al., 2017, was to address the

barriers to treatment of adolescent depression. In survey studies, PCPs report many barriers to

treating depression, including inadequate referral resources, poor insurance coverage for mental

health services, and inadequate time and training to diagnose or provide patient education. The

surveys identify barriers but add little insight into eliminating barriers. Researchers conducted

focus groups interviews and collected data from 35 pediatric providers from different practices in

Washington State. Providers were asked questions like: what are some of the barriers you face in

treating depression, how do you address those barriers and how successful do you think you are

in treating depression? Tape recordings of the recorded focus groups were transcribed and

analyzed using qualitative data analysis software to code text passages and facilitate comparison

within and across interviews. Providers reported seeing an increase in patients with depression

than in the past. About half of the providers expressed an interest in using a screening tool as

most felt an obligation to diagnose depression but not to treat. These providers were more prone

to refer their patients with depression due to not feeling qualified. The most influential factor in

provider’s decision to treat depression was whether there was access to quality mental health

care in the community. Others barriers revealed in the study were wait times to see a psychiatrist
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or therapist, insurance limitations, distance patients had to travel and long-standing relationships

between providers and their families.

The purpose of the quantitative study by Taliaferro et al., 2013, was to compare

depression identification management perceptions between professions in primary care and

examine factors that increase the likelihood of administering a standardized screening tool.

Primary care Physicians (PCPs) who provided ambulatory, primary care services to adolescents

12-18 years of age were identified and invited to participate in an online survey. Of the 3337

PCPs contacted, 537 completed the survey. The survey consisted of 28 questions and took about

10 minutes to complete. Providers were asked questions about their current practice of screening

for depression, which instrument they use and if they would be willing to implement a screening

tool if they were not already utilizing a tool in practice. Descriptive statistics, bivariate tests and

linear regression analyses were used to analyze the data collected. Independent variables entered

simultaneously into regression models were selected based on their potential to impact training,

practice or policy within the provider’s practice. Some of the barriers identified were: nurse

practitioners felt significantly less prepared than physicians to diagnose adolescents with

depression; providers felt more prepared for referring than addressing non-suicidal self-injury

patients; more than 75% of respondents reported not administering screening tests to adolescents;

most screen only after seeing warning signs; PCPs reported more often using their observational

impressions to identify depression.

Discussion and Implications

The five articles that were chosen for this integrative review each address the effects of

screening tools of adolescents in detecting depression. Each of the articles reviewed an aspect of
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screening and factors that influenced detection. The results of the research articles discussed in

this review clearly identify a positive relationship between the implementation of depression

screening tools and the detection of depression in adolescents aged 12-18. This review supports

the PICOT question set by the researcher.

Research shows that depression is common among adolescents and is associated with

functional impairments and increased morbidity and mortality and yet screening is not routine.

Due to its high prevalence and under treatment, improvement in screening and treatment access

in this population is needed. Implementing screening may be time consuming but the costs are

shown to be minimal and early detection benefits outweigh implementation challenges

(Taliaferro et al., 2013). Early detection also allows for further discussions around mental health

and education on how best to manage depression. Research data showed that adolescents

reported additional benefits of screening and depression treatment such as: improved

interpersonal relationships, improved empathy, the appreciation for the opportunity to “talk it

through”, the ability to stay calm during a conflict after implementing newly learned coping

mechanisms, and increased use of social support (Bhatta et al., 2018). This implies that there are

several beneficial aspects from the patients’ point of view and research shouldn’t be limited to

detection only.

Limitations

Limitations of this integrated review include information limited to five research articles

written within the last five years. The review is a class assignment with criteria limited to 5

research articles. This is the first integrative review experience for the researcher who is enrolled

in a full-time undergraduate program and has limited knowledge and application skills in
INTEGRATED REVIEW 10

research. Lack of clinical practice influences understanding of the research. General limitations

to the research include generalizability to adolescents of other ethnic and cultural backgrounds.

Likewise, although the plan for follow-up was discussed with adolescents per protocol, the

majority did not follow-up with primary care providers, and follow-up was not assessed in this

project. Screening for the majority of adolescents in one study occurred during visits for episodic

illness which may have been a confounding source of depressive symptoms. Pediatric provider-

reported antidepressant use was related to poor specialty care access, provider confidence, and

provider belief in the efficacy and safety of antidepressants. The lack of asking probing questions

and following responses that were short, unclear, or lacking in detail may have contributed to the

considerable percentage of participants (46%) who were unable to articulate a specific benefit of

the program.

Conclusion

This integrative review concludes that the implementation of a depression screening tool

does identify depression among adolescents age 12-18 and sufficiently addresses the PICOT

question. Many patients were not aware of their depression or for some, how serious it was, until

they were screened. This information emphasizes the importance of being patient-centered as

well as the importance and need of developing new approaches to support providers in treating

adolescent depression. Efforts to improve detection and outcomes while enhancing clinician

competence to address depression could help providers implement universal screening in

primary care.
INTEGRATED REVIEW 11

References

Bhatta, S., Champion, J. D., Young, C., & Loika, E. (2018). Outcomes of Depression

Screening Among Adolescents Accessing School-based Pediatric Primary Care Clinic

Services. Journal of Pediatric Nursing,38, 8-14. doi:10.1016/j.pedn.2017.10.001

US Preventative Services Task Force, (2016). Depression in Children and Adolescents:

Screening. Retrieved from

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStateme

ntFinal/depression-in-children-and-adolescents-screening

Richardson, L. P., Lewis, C. W., Casey-Goldstein, M., Mccauley, E., & Katon, W.

(2007).Pediatric Primary Care Providers and Adolescent Depression: A Qualitative Study

of Barriers to Treatment and the Effect of the Black Box Warning. Journal of

Adolescent Health,40(5), 433-439. doi:10.1016/j.jadohealth.2006.12.006

Shochet, I., Montague, R., Smith, C., & Dadds, M. (2014). A Qualitative Investigation of

Adolescents’ Perceived Mechanisms of Change from a Universal School-Based

Depression Prevention Program. International Journal of Environmental Research and

Public Health,11(5), 5541-5554. doi:10.3390/ijerph110505541

Taliaferro, L. A., Hetler, J., Edwall, G., Wright, C., Edwards, A. R., & Borowsky, I. W.

(2013).Depression Screening and Management Among Adolescents in Primary

Care. Clinical Pediatrics,52(6), 557-567. doi:10.1177/0009922813483874

Wikberg, C., Pettersson, A., Westman, J., Björkelund, C., & Petersson, E. (2016).Patients’

perspectives on the use of the Montgomery-Asberg depression rating scale self-

assessment version in primary care. Scandinavian Journal of Primary Health Care,34(4),

434-442. doi:10.1080/02813432.2016.1248635
INTEGRATED REVIEW 12

References

Bhatta, S., Champion, J. D., Young, C., & Loika, E. (2018). Outcomes of Depression

Screening Among Adolescents Accessing School-based Pediatric Primary Care Clinic Services. Journal of Pediatric Nursing,38, 8-14. doi:10.1016/j.pedn.2017.10.001

US Preventative Services Task Force, (2016). Depression in Children and Adolescents:

Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-children-and-adolescents-screening

Richardson, L. P., Lewis, C. W., Casey-Goldstein, M., Mccauley, E., & Katon, W.

(2007).Pediatric Primary Care Providers and Adolescent Depression: A Qualitative Study of Barriers to Treatment and the Effect of the Black Box Warning. Journal of

Adolescent Health,40(5), 433-439. doi:10.1016/j.jadohealth.2006.12.006

Shochet, I., Montague, R., Smith, C., & Dadds, M. (2014). A Qualitative Investigation of

Adolescents’ Perceived Mechanisms of Change from a Universal School-Based Depression Prevention Program. International Journal of Environmental Research and Public

Health,11(5), 5541-5554. doi:10.3390/ijerph110505541

Taliaferro, L. A., Hetler, J., Edwall, G., Wright, C., Edwards, A. R., & Borowsky, I. W.

(2013).Depression Screening and Management Among Adolescents in Primary Care. Clinical Pediatrics,52(6), 557-567. doi:10.1177/0009922813483874

Wikberg, C., Pettersson, A., Westman, J., Björkelund, C., & Petersson, E. (2016).Patients’ perspectives on the use of the Montgomery-Asberg depression rating scale self-

assessment version in primary care. Scandinavian Journal of Primary Health Care,34(4), 434-442. doi:10.1080/02813432.2016.1248635
INTEGRATED REVIEW 13

NUR 4122: Summary of Article-Integrative Review


Reference (APA) Bhatta, S., Champion, J. D., Young, C., & Loika, E. (2018). Outcomes of Depress
Adolescents Accessing School-based Pediatric Primary Care Clinic Servi
Pediatric Nursing,38, 8-14. doi:10.1016/j.pedn.2017.10.001

Author All three of the authors that conducted this research study are affiliated with The U
(Year)/Qualifications Austin, Texas. Three of the authors have a Doctorate of Nursing Practice (DNP) a
is a Registered Nurse (RN). Therefore, each of these authors is qualified to do qua
considered experts in this field of study.

Introduction/ The purpose of this qualitative study was to “Implement a routine Patient Health Q
Background/Problem screening among adolescents aged 12-18 year, accessing school-based pediatric p
Statement services to identify adolescents at potential risk for Major Depressive Disorder (M
Introduction: MDD is common among adolescents and associated with functiona
increased morbidity and mortality. Due to its high prevalence, it is imperative to i
treatment access in this population via school based clinics.

Background: Depression in adolescents is under-recognized and undetected. The


screening for MDD in adolescents 12–18 years old. These recommendations inclu
accurate diagnosis, treatment, and follow-up of MDD if adequate systems are in p
MDD promotes early initiation of treatment and referral. Early detection of depres
the referral for formal evaluation possible. Hence, early intervention for mental di
adolescence can have an important impact on adult mental health outcomes.

Problem Statement: Despite these guidelines, limited screening by primary care


opportunity to identify depression is missed. Primary care providers report they la
in depression assessment and management These findings indicate the need for ut
improvement processes for implementation of screening within primary care settin
INTEGRATED REVIEW 14

this project was to implement routine mental health screening among adolescent a
were accessing school-based pediatric primary care clinic services for identificatio
depression.

Conceptual/ The Donabedian model provided the framework for development of the screening
Theoretical Framework assessment of mental health screening outcomes following implementation of the
assesses outcomes via three factors: structure, process, and outcome. Structure inc
organization such as finances, staff, equipment; process describes implementation
mental health screening; outcome refers to the results of the process such as timel
management of mental health problems.

Design/Research Design: The research design is a retrospective chart review (N = 256 cases) docum
Methods/Sample/ depression screening outcomes among adolescents accessing school-based pediatr
Setting/Ethical services for episodic illness and wellness visits.
Considerations/
Major Variable Studied/ Method: Data analyses included descriptive statistical methods.
Measurement Tool/Data
Sample: included 137 (53.5%) females and 119 (46.5%) males
Collection Tool/Data
Analysis
Setting: Pediatric school-based primary care clinic located in the southwestern US

Ethical Considerations: Approval was given by the Institutional Review Board bu


considerations undertaken were not discussed in the article. Privacy was not discu
protect privacy were made as patients were screened in a private clinic exam room
that patients were protected under HIPAA

Major Variables Studied: age, (2) gender, (3) ethnicity (4) payer source, (5), reaso
whether depression screening was obtained, (7) MDD screening result, (8) mental
treatment plan, (9) referral, (10) referral source, (11) mental health history, (12), s
depression, and (13) chronic medical problems

Measurement/Data collection tool: Patient Health Questionnaires (PHQ-9)

Data Analysis: The data were analyzed using SPSS 24.0 software. The study was
descriptive and non-parametric statistics. Data analyses included descriptive statis
tables to describe socio-demographics, depression screening status, referral status
symptoms. Pearson's chi-squared analysis tested associations between socio-demo
screening status, depressive symptoms and gender, depressive symptoms by age g
and referral status, severity of depressive symptoms and referral status. Age categ
groups (12–14 years vs. 15–18 years). Ethnicity categories included two groups, H
INTEGRATED REVIEW 15

Findings/Results Chart review included 137 (53.5%) females and 119 (46.5%) males. PHQ-9 depre
identified for 56.3% (n = 144) of charts with scores ≥10 for 12.5% (n = 18) among
Mental health referrals were made for 83.3% (n = 15) with PHQ-9 scores ≥10. Dy
concerns were reported among 20.1% (n = 29) of which 55.2% (n = 16) received
Female adolescents reported more sleep problems (χ2 = 9.174, p = 0.002) and tired
0.013) than males. The 15–18 year age group (χ2 = 5.443, p = 0.020) was more lik
sleep problem and low self-esteem than 12–14 year age group (χ2 = 5.143, p = 0.0

Implementation of depression screening protocol PHQ-9 improved screening rate


pediatric primary care clinic. Depression screening for adolescents accessing a sch
promotes early management of major depressive disorder. Episodic illness may be
of depressive symptoms identified during routine screening among adolescents

Discussion/ MDD is common among adolescents and associated with functional impairments
Implications morbidity and mortality. Due to its high prevalence, it is imperative to improve sc
access in this population via school-based clinics.

Limitations/ Limitations include generalizability to adolescents of other ethnic and cultural bac
Conclusions although the plan for follow-up was discussed with adolescents per protocol, the m
follow-up with primary care providers, and follow-up was not assessed in this pro
majority of adolescents occurred during visits for episodic illness which may have
source of depressive symptoms.

Conclusion: Implementation of PHQ-9 depression screening protocol identified M


accessing pediatric school-based primary care clinic services facilitating referrals
providers, potentially improving morbidity and mortality among adolescents.

Appraisal/Worth to The research supports the PICOT question. The results show that when a depressi
practice implemented, adolescents with depression are identified at a greater rate.
INTEGRATED REVIEW 16

NUR 4122: Summary of Article-Integrative Review


Reference (APA) Richardson, L. P., Lewis, C. W., Casey-Goldstein, M., Mccauley, E., & Katon, W
Pediatric Primary Care Providers and Adolescent Depression: A Qualitati
Treatment and the Effect of the Black Box Warning. Journal of Adolescen
439. doi:10.1016/j.jadohealth.2006.12.006

Author Four of the five authors that conducted this research are associated with The Univ
(Year)/Qualifications in Seattle, Washington. Three of the five authors are medical doctors (M.D.), one
Philosophy (Ph.D.) and one has a Master of Science in Education (M.A.Ed.). All
considered experts in their field

Introduction/ Purpose: The recent black box warning on antidepressants has drawn attention to
Background/Problem regarding the treatment of adolescent depression in primary care settings, but little
Statement providers decide to treat depressed youth and what resources are employed.

Background: In survey studies, PCPs report many barriers to treating depression,


referral resources, poor insurance coverage for mental health services, and inadeq
to diagnose or provide patient education. While identifying common barriers, thes
provide little insight into how encountering such barriers shapes the treatment PC
happens once treatment is initiated. New guidelines from the FDA recommend tha
frequently in the first three months after a new antidepressant prescription; howev
found that only 29% of youth were seen at least three times in the three months af
whereas 30% had no visits during this time. In a study since the black box warnin
30% of adolescents received the FDA-recommended number of seven visits over
about 40% of youth had no record of physician contact in the month after a new p

Problem Statement: The black box ruling has significant implications for PCPs wh
to initiate new episodes of depression treatment in the face of an inadequate suppl
resources and a primary care system that usually provides only brief and infrequen

Conceptual/ A conceptual model was developed detailing factors influencing primary care pro
Theoretical Framework decisions about depression treatment

Design/Research Design and research methods: Focus group interviews were conducted at nine pra
Methods/Sample/ October 2004 and April 2005. Two were not conducted due to scheduling difficul
Setting/Ethical before the interview. As barriers to treating depression have been shown to differ
INTEGRATED REVIEW 17

Considerations/ practices were specifically chosen to represent a range of rural (five practices) and
Major Variable Studied/ settings. Practice types ranged from solo practitioner to large group practices.
Measurement Tool/Data
Collection Tool/Data Sample size: Thirty-five providers (median per clinic = 4, range = 1 to 6) participa
Analysis pediatricians and three were pediatric nurse practitioners. Provider experience var
and within practices, with some having been in practice for more than 20 years an
years. Most of the group practices had at least one senior member who was often

Setting: Pediatric practices in rural and urban settings of western Washington Stat

Ethical considerations: This project was approved by the University of Washingto


Division. Written informed consent was obtained from all providers before condu

Data Collection: Focus group interviews were conducted with all available provid
The focus group method was selected to encourage individuals to share their ideas
regarding the treatment of depression and to encourage enhanced conversations th
between providers. Global questions were used to stimulate discussion among pro
experiences in treating depression and follow-up questions were used as needed to
specific themes or areas. An individual interview was conducted using the same q
provider in the solo practice.

Data Analysis: Qualitative data analysis software, ATLAS.ti, (Scientific Software


Berlin, and Germany) was used to code text passages and facilitate comparison w
interviews. To assure trustworthiness and credibility, interviews were analyzed in
researchers. The coding scheme was developed using grounded theory methodolo
analysis strategy is driven by the data collected. Each researcher coded categories
questions that were determined a priori (e.g., barriers to treatment and effect of th
along with any new themes that arose. Themes were coded, explored in greater de
groups, and then modified to further clarify major themes. Frequently encountered
and studied for patterns and discordance to incorporate the richness of data collec
model. Examples of new themes that arose through discussion were the concept o
impact of patient relationships, and the association between provider role and resp
warning. Practices continued to be recruited until new themes were no longer bein

Major Variables Studied: barriers to treating depression, including adequacy of re


insurance coverage for mental health services, and adequacy of time and training
patient education.
INTEGRATED REVIEW 18

Findings/Results Most providers reported that they saw one to two youth with depression per week
day to one to two per month. PCPs with an older patient panel, more female patien
youth in foster care reported seeing more patients with depression. The number of
varied by practice and was higher in practices in rural communities with limited m
and higher Medicaid penetration.

None of the practices had a specific protocol for screening for depression. Provide
practices expressed interest in screening but one provider pointed out “we don’t h
because it would overwhelm the practice’s limited staff and time. About half of th
identify a written depression tool that they used when diagnosing depression or en
engage in or continue with treatment. Use of these tools was not consistent within

Discussion/ Using qualitative methods, we have described the factors that influence the treatm
Implications pediatric PCPs in nine western Washington State practices. The model developed
an important background for understanding why PCPs are frequently treating you
antidepressants. The results of this study also provide insights into provider respo
warnings on antidepressants. Although providers were more reluctant to use antid
black-box warnings, poor access to mental health resources and the needs of the p
continued use of antidepressants when no other options were present.

Our findings about provider role in treatment are consistent with a prior survey stu
pediatric provider-reported antidepressant use was related to poor specialty care a
confidence, and provider belief in the efficacy and safety of antidepressants. A ne
current study is that the provider’s relationship with the patient and family also pl
in provider motivation to treat.

Limitations/ Conclusion: The decision of when and how PCPs decide to treat adolescent depre
Conclusions influenced by PCP perceptions of their role in treatment, availability of other treat
family and patient preferences and resources. Few practices have developed chang
practice needed to meet FDA black-box recommendations regarding close monito
medications.

Appraisal/Worth to The research supports the PICOT question. The results show that when a screenin
practice adolescents with depression are more easily identified.
INTEGRATED REVIEW 19

NUR 4122: Summary of Article-Integrative Review


Reference (APA) Shochet, I., Montague, R., Smith, C., & Dadds, M. (2014). A Qualitative Investig
Perceived Mechanisms of Change from a Universal School-Based Depres
Program. International Journal of Environmental Research and Public He
doi:10.3390/ijerph110505541

Author All four authors that conducted the research study are affiliated with universities i
(Year)/Qualifications Doctors of Philosophy (PhD) in Psychology. All four authors are qualified to do
and are considered experts in this field of study

Introduction/
Background/Problem Depression prevention interventions are particularly appropriate for use with adol
depression considered one of the most common mental health problems of this de
Statement Many programs exist that target the socio-emotional health of adolescents in orde
disorders and a recent meta-analysis supports the universal application of these pr
evidence, the mechanisms that underlie successful prevention interventions with a
largely unclear. The question remains whether we accurately understand the impa
In this study we examined the impact of an evidence-based depression prevention
Resourceful Adolescent Program (RAP-A), from a qualitative perspective. This m
the exploration of perceived mechanisms of change that may underlie the program
wider range of outcome variables than quantitative methods allow.
INTEGRATED REVIEW 20

Conceptual/ The researchers aimed to understand the mechanisms and impact that underlie suc
Theoretical Framework prevention interventions.

Design/Research
Methods/Sample/ Short structured interviews (5 to 10 min duration) were conducted with each parti
after completion of RAP-A. The interviewer was not previously known to the stud
Setting/Ethical the likelihood of students' need to please the interviewer. The taped interviews we
Considerations/ Sample: 109 students were selected to participate in the current qualitative study
Major Variable Studied/
Measurement Tool/Data
Collection Tool/Data Ethical Considerations: This research received the appropriate ethical clearance fr
Analysis Human Research Ethics Committee and complies with the Australian National He
Research Council ethical standards.

Data Analysis: The transcribed interviews were analyzed using thematic analysis,
was deemed appropriate for summarizing the data and identifying patterns in the d
an interpretation. The six steps outlined by Braun and Clarke [24] were followed.
themselves with the data to gain a solid grasp of the interview content.

Findings/Results Identified changes that were attributed to program participation were analyzed fur
extracted from the data are summarized in Figure 1. As can be seen, two strong th
improved interpersonal relations and improved self-regulation; and one less robus
cognitions. These first two themes are further broken down into subthemes. Table
of interviews with adolescents during which each theme and sub-theme was ident

Discussion/
Implications This study used qualitative methodology to explore a range of perceived benefits
participation in RAP-A, an evidence-based depression prevention program. Over
interviewed adolescents could articulate specific examples of program benefit in t
two major themes that arose in analysis of the data were improved interpersonal re
improved self-regulation, in addition to one minor theme—more helpful cognition
theme of improved interpersonal relationships were the sub-themes improved emp
through”, staying calm during a conflict, and increased use of social support. Sub-
within improved self-regulation were improved self-esteem, keeping calm, and m

Limitations/ In conclusion, students appear to acquire a range of skills from universal depressio
Conclusions programs and make use of them in different situations. As such, we do a disservic
restrict our interest in program outcomes to a reduction in depressive symptoms. I
improved interpersonal relationships and improved self-regulation appear to enco
significant perceived program benefits in adolescents’ daily lives, and it is sugges
INTEGRATED REVIEW 21

have a reciprocal relationship. It seems important to continue exploring such pote


change of depression prevention programs in order to inform best practice interve

Appraisal/Worth to This research supports the PICOT question


practice

NUR 4122: Summary of Article-Integrative Review


Reference (APA) Taliaferro, L. A., Hetler, J., Edwall, G., Wright, C., Edwards, A. R., & Borowsky,
Depression Screening and Management Among Adolescents in Primary C
Pediatrics,52(6), 557-567. doi:10.1177/0009922813483874
INTEGRATED REVIEW 22

Author All five researchers have a Doctorate of Philosophy (PhD) in Psychiatry and are c
(Year)/Qualifications their field on the topic.

Introduction/ Introduction: To compare depression identification and management perceptions a


Background/Problem professions and disciplines in primary care and examine factors that increase the l
Statement administering a standardized depression screening instrument, asking about patien
symptoms, and using best practice when managing depressed adolescents.

Conceptual/ Quantitative
Theoretical Framework

Design/Research Methods. Data came from an online survey of clinicians in Minnesota (20% respo
Methods/Sample/ involved bivariate tests and linear regressions. Results. The analytic sample comp
Setting/Ethical medicine physicians, 127 pediatricians, 96 family nurse practitioners, and 54 pedi
practitioners. Overall, few differences emerged between physicians and nurse prac
Considerations/
and pediatric clinicians regarding addressing depression among adolescents. Two
Major Variable Studied/ with administering a standardized instrument included having clear protocols for f
Measurement Tool/Data depression screening and feeling better prepared to address depression among ado
Collection Tool/Data Enhancing clinicians' competence to address depression and developing postscree
Analysis help providers implement universal screening in primary care.

Findings/Results Few differences emerged between physicians and nurse practitioners or family an
regarding addressing depression among adolescents.

Discussion/ Clear protocols are needed for follow up


Implications

Limitations/ Enhancing clinician competence to address depression could help providers imple
Conclusions screening in primary care

Appraisal/Worth to The research supports the PICOT question


practice
INTEGRATED REVIEW 23

NUR 4122: Summary of Article-Integrative Review


Reference (APA) Wikberg, C., Pettersson, A., Westman, J., Björkelund, C., & Petersson, E. (2016).
on the use of the Montgomery-Asberg depression rating scale self-assessm
care. Scandinavian Journal of Primary Health Care,34(4), 434-442.
doi:10.1080/02813432.2016.1248635

Author All five authors hold PhDs in their field of study and are qualified to do qualitativ
(Year)/Qualifications

Introduction/ In Sweden, as in most other countries, the majority of people with depression are
Background/Problem in primary care. Scales that rate the severity of depression are becoming increasin
Statement primary care; approximately a third of Swedish GPs use them in their practice. Th
assess the severity of the disease and to follow the effects of treatment. Many such
Montgomery-Asberg Depression Rating Scale (self-rating version) (MADRS-S) i
used in Sweden. A new depression scale designed to be sensitive to change. Studi
assessments of patients’ depressive symptoms in clinical practice are beneficial; th
evaluate the progress of depression. The self-reported Montgomery-Asberg Depre
useful evaluative tool in major depressive disorder

Conceptual/ Qualitative Study


Theoretical Framework

Design/Research
Methods/Sample/ Purpose: The aim of the current study was to better understand how patients with
Setting/Ethical the use of MADRS-S in primary care consultations with GPs.
Considerations/
Design: Qualitative study. Focus group discussion and analysis through Systemat
Major Variable Studied/
Measurement Tool/Data Setting: Primary Health Care, Region Västra Götaland, Sweden.
Collection Tool/Data
Analysis
Ethical Considerations: Ethical approval Dnr 746-09, T 612-10. The authors repor
interest. The authors alone are responsible for the content and writing of this artic

Findings/Results Almost all participants in our focus group discussions shared the same view that M
them to reveal and picture their depression black on white. In contrast to a previou
perceptions. To score or not to score: a qualitative study on GPs views on the use
depression. Patients perceived that the self-assessment scale added something to t
functioned as a tool for the patient and GP. MADRS-S was used both as a tool to
confirm the depression and as a facilitator for treatment. The participants were som
when, where and how the self-assessment scale should best come to use but they w
positive that the GP should use them during the consultation. MADRS-S, which is
to change, can be used to follow changes in the patient’s depression, and repeated
required. For many informants a self-assessment scale confirmed their suspicions
INTEGRATED REVIEW 24

depressed. All methods that enhance patients’ understanding of their diagnosis an


are receiving are based upon good communication. Patients are shown to be more
if they know more about their condition and have a GP with a patient-centered co

Discussion/
Implications This study investigated how patients with depression perceived the use of MADR
consultations with GPs. The results showed a diversity of perceptions from the pa
was perceived as an instrument that showed them, in black and white, that they re
how serious the depression was, and changes in symptoms over time. Participants
important aspect of the consultation was for the GP to listen to them and take them
having the chance to fill out MADRS-S during the consultation was one way to kn
them seriously. They also thought MADRS-S could help the GP decide which tre
appropriate. Additionally, participants felt that the information they got from fillin
discussing their answers with the GP made it easier to understand why the GPs re
treatments. If the GP taught the patients a bit more about depression with the help
suggested treatment could make more sense.

Many participants found the instrument difficult to complete, and the participants
physician neglected them while they completed the scale.

Limitations/
Conclusions Use of MADRS-S was perceived as a confirmation for the patients that they had d
serious it was. MADRS-S showed the patients something black on white that desc
diagnosis. The informants emphasized the importance of patient-centeredness; of
to be taken seriously during the consultation. Use of self-assessment scales such a
find its place, but needs to adjust to the multifaceted environment that primary car

 Key Points

 Patients with depression in primary care perceive that the use of a self-assessme
consultation purposefully can contribute in several ways. The scale contributes

 Confirmation: MADRS-S shows that I have depression and how serious it is.

 Centeredness: The most important thing is for the GP to listen to and take me se

 Clarification: MADRS-S helps me understand why I need treatment for depress

Appraisal/Worth to This research relates to the PICO question by addressing the effects of adolescent
practice depression.
INTEGRATED REVIEW 25