strategies used by advanced practice psychiatric nurses in treating adults with depression

232 Perspectives in Psychiatric Care Vol. 44, No. 4, October 2008

Blackwell Publishing IncMalden, USAPPCPerspectives in Psychiatric Care0031-59900031-5990XXX

ORIGINAL ARTICLE

Strategies Used by Advanced Practice Psychiatric Nurses in Treating Adults With Depression


Evelyn Parrish, APPN, PhD, Ann Peden, DSN, and Ruth “Topsy” Staten, PhD

PURPOSE.

Strategies used by psychiatric advanced

practice registered nurses (APRNs) in treating

clients with depression are described to explore

their effectiveness.

DESIGN AND METHODS.

Ten APRNs participated

in semistructured individual interviews for this

qualitative descriptive study. The use of either a

symptom severity scale or symptom reduction

checklist was used to measure the effectiveness

of the strategies used.

FINDINGS.

APRNs identified a biopsychosocial

approach as the primary component of their

treatment of clients with depression. Other

strategies identified include psychopharmacology,

cognitive-behavioral therapy, and partnering with

the client.

PRACTICE IMPLICATIONS.

Treatment of

depression can be enhanced with the incorporation

of the biopsychosocial strategies along with

standard treatment modalities.

Search terms:

Biopsychosocial strategies,

depression, psychiatric clinical nurse specialists,

psychiatric nurse practitioners

Evelyn Parrish, APPN, PhD, is an Associate Professor, Eastern Kentucky University, Richmond, KY; Ann Peden, DSN, is Professor, and Ruth “Topsy” Staten, PhD, is Associate Professor, both at the University of Kentucky, College of Nursing, Lexington, KY.

M

ental illness in the United States is at an all-timehigh and continues to increase. It is estimated that 22%of American adults are diagnosed with a mental illnessin any given year (National Institutes of Mental Health[NIMH], n.d.). The leading cause of disability in theUnited States is major depression (NIMH), which affectsone in five individuals. According to the NIMH, the mosteffective care for people suffering from depressionis a combination of medication and psychotherapy. Intoday’s healthcare arena, psychiatrists typically managethe client’s medication while other mental healthcareprofessionals provide psychotherapy. Psychiatricadvanced practice registered nurses (APRNs) areprepared to use both medication management andpsychotherapy in treating mentally ill clients(Bjorklund, 2003).

Regardless of the profession, all providers faceunique barriers related to the type and quality oftreatment for clients with depression that must beaddressed. Currently, there is not enough research-basedevidence that identifies which psychiatric nursingstrategies are associated with successful outcomes.The major issue for psychiatric APRNs is the lack ofdocumentation of clinical outcomes that indicate themost effective psychiatric nursing strategies for treatingdepression. For decades, psychiatric APRNs havesurvived highly competitive healthcare environmentswith minimal empirical evidence of the effectiveness oftheir practice. It is necessary for nursing practice to beevidence based, and nursing research needs to clearlyidentify the strategies that psychiatric APRNs use.

The purpose of this qualitative descriptive studywas to describe the strategies used by 10 APRNs whotreat clients with depression. An additional purposewas to describe how psychiatric APRNs evaluate the

Perspectives in Psychiatric Care Vol. 44, No. 4, October 2008 233

effectiveness of those strategies. For the purposes ofthis paper, a strategy is defined as a skill used by theAPRN in treating clients with depression.

Review of the Literature

There has been limited research evaluating treatmentprovided by psychiatric APRNs to individuals withdepression. Baradell (1995) conducted an ex post factostudy of 233 patients seen by six psychiatric APRNs.The purpose of the study was to determine clinicaloutcomes and the level of patient satisfaction withpsychotherapeutic strategies provided by APRNs. Thestudy included all psychiatric diagnostic categories.Outcome measures included the Profile of Mood States–Short Form (POMS-SF; McNair, Lorr, & Droppleman,1992), Quality of Life (QOL, Lehman, 1991), and anauthor-developed Patient Satisfaction Survey. Theclients were asked to complete the POMS-SF andQOL both at the initiation of treatment and also at theend of treatment. The Patient Satisfaction Survey wascompleted at the end of treatment. Of the 233 patientswho were mailed the questionnaires, 100 usable surveyswere returned. The

t

test for the difference in meansfor the POMS-SF was reported as 15.72 for depression(

p

< .0001). In addition, the authors reported that the

t

tests for the difference in means for the QOL was 6.32for family (

p

< .0001) and 6.21 for social (

p

< .0001).The greater the report of quality of life and thegreater the clinical improvement, the more satisfiedthe client was with care provided by the APRN.

Baradell and Bordeaux (2001) replicated the previousstudy in order to further validate clinical outcomesand patient satisfaction. Seventy-two subjects completedthe questionnaires at the three data collection points:initiation and termination of treatment and at 6 monthsafter treatment ended. The authors reported that clinicalsymptoms had improved at termination of therapy(

M

= 30.97;

SD

= 14.05) when compared to initiationof therapy (

M

= 51.93;

SD

= 17.46). In addition, theyreported that quality of life also improved at termi-nation (

M

= 115.27;

SD

= 20.66) as compared to initiation

of therapy (

M

= 103.11;

SD

= 20.83). Scores on the POMS-SF and on the QOL did not improve at the 6-monthfollow-up; however, they did not reach the pretreat-ment score. The authors reported high levels of clientsatisfaction with the care provided by the APRNs.

Fisher and Vaughn-Cole (2003) compared the pre-scribing practices of psychiatric APRNs and psy-chiatrists in a community mental health center. Thesample consisted of 5,507 clients who were treated byan APRN or psychiatrist or both at different timepoints with medications. They included 13 APRNs and40 psychiatrists. Of the 5,507 patient charts reviewed,1,589 were treated by APRNs, 3,293 were treated bypsychiatrists, and 625 were treated by both prescribers.The authors concluded that the APRNs were morelikely to problem solve with their clients and identifyalternative ways to deal with the illness.

Their findings indicated more similarities thandifferences in the types of clients seen and medicationsprescribed. The primary difference reported was relatedto the amount of time APRNs spent with clients; theAPRN spent more time than psychiatrists. APRNsalso reported using a more holistic approach with theirclients. They defined holistic treatment as consideringa variety of causes and solutions to a problem andworking with the client to determine the most effectivestrategy in managing the problem. Psychiatrists didnot report using a holistic approach to care but reliedheavily on pharmacotherapy.

To date, there is limited documentation on the specificstrategies used by APRNs in treating clients with depres-sion. In order to better serve psychiatric clients, APRNsneed to identify these strategies as well as document theireffectiveness. Additional studies are needed to more spe-cifically describe strategies used with specific diagnoses.

Research

Methodology

A qualitative descriptive study was conducted todescribe specific strategies used by APRNs in treating



clients with depression. Qualitative description is oftenthe first step in an exploration of a phenomenon thathas not been previously described. According toSandelowski (2000), “qualitative descriptive studiesoffer a comprehensive summary of an event in theeveryday terms of those events” (p. 336). This studywas a first exploration of strategies used by psychiatricAPRNs in treating clients with depression. Second, howthese APRNs evaluated their own clinical effectivenesswas sought.

Sample Population

Ten psychiatric APRNs who had a minimum of5 years’ experience treating clients in an outpatientsetting participated in the in-depth interviews. Themean age of the APRNs was 42.5 years and the meannumber of years in practice was 10.5. The interviewswere audio-taped and transcribed verbatim.

Purposive sampling was used to obtain volunteersfrom a local psychiatric APRN association. Theprincipal investigator approached two members ofthe group regarding participation in the study. Usingsnowball techniques, 10 APRNs volunteered toparticipate in an audio-taped interview in theirrespective offices. The sample consisted of nine Whitefemales and one White male. Seven of the APRNspracticed in a group practice while the other threewere in a solo practice.

Data Collection

In-depth interviews were conducted in the APRNs’offices regarding their treatment of clients withdepression. The project was explained in detail, and theparticipants signed a consent form approved by aninternal review board (IRB) from the University ofKentucky prior to data collection. Each received a copyof the signed consent form. A semistructured interviewcomprised of six open-ended questions was used toguide the 60-min interview. Questions included: (a) Tellme about the strategies you use in treating clients

diagnosed with depression. (b) Tell me where you gotthe information on the strategies. (c) Tell me how youlearned about the strategies you use. (d) How doyou know if the strategies are effective? (e) Describe atreatment success using the strategies. (f) Describea treatment failure/challenge using the strategies.All interviews were scheduled at the participants’convenience, audio-taped, and transcribed verbatim.

Data Analysis

Data were analyzed using content analysis pro-cedures. The transcripts were reviewed for accuracy,and any missing data or errors in the transcriptsidentified when compared to the tapes were corrected.Prior to analysis, each question was addressed andpotential codes were identified. The transcripts wereanalyzed and coded using the computer softwareAtlas ti-5 for Windows (2005). Examples of codesincluded strategies used, knowledge about the strategies,and effectiveness of the strategies. Additional codesemerged from the data. These included therapeuticand holistic approaches. For the purposes of this paper,holistic care is defined as a biopsychosocial view ofthe client. After the third reading of the transcripts,the data were reviewed by another psychiatric APRNfrom outside the group of APRNs, for validation of thefindings. After the codes were found to be valid, they werereduced into categories. The final step in the analysisprocess was the identification of themes extrapolatedfrom the categories. The categories were then used togroup information into three common themes used bythe APRNs to treat clients with depression.

Validity

In qualitative studies, “elements of trustworthinessinclude credibility, transferability, dependability, andconfirmability” (Lincoln & Guba, 1985, p. 316). Thetechnique of member checking is considered byLincoln and Guba to be the most critical techniquefor establishing credibility. Member checking was


accomplished by two of the psychiatric APRNs whoparticipated in the study. They reviewed the findingsto verify that the coding accurately reflected the content.Separately, they each read the findings. They agreedthat the researcher correctly interpreted their treat-ment approaches in caring for clients with depression.

Lincoln and Guba (1985) used the term

transferability

to imply generalizability of the study findings to othersettings, situations, populations, and circumstances.The detailed description of the strategies used totreat clients with depression helped to confer the trans-ferability of these findings.

Dependability of the study can be assessed by howwell the researcher has reported and documented anychange within the study that might affect its outcome.The researcher made no changes after receiving IRBapproval from the University of Kentucky. Confirma-bility was established based on the logical progressionfrom the study goal to the conclusions.

Findings

The findings of these APRNs’ practices are repre-sented in the model in Figure 1. The clients were viewedas a partner in their own care as represented by theprofile in the center circle. Assessment, diagnosis,planning, and evaluation are continuous, interrelatedprocesses of APRN practice. From the nursing process,the APRNs in this study identified three major areas oftherapeutic strategies for depression. The strategiesinclude partnering with the client using active listening,and the use of psychopharmacology and psychothera-peutic strategies. These strategies are used with aholistic focus identified by all of the APRNs as centralto their practices.

Psychiatric APRNs’ Central Processes of Care

Holistic Approach

All of the APRNs described having a holistic viewof the individual as a primary component of their

treatment of clients diagnosed with depression. Forthese participants, a holistic view was defined asincluding a thorough assessment based on a biopsy-chosocial view that guided the interactions with theclient. The APRNs described a comprehensive approachwhen intervening and working with their clients. Notonly were biopsychosocial concerns addressed but alsospiritual, cultural, and environmental aspects wereconsidered.

One APRN stated:

In terms of our assessment sheet, we ask questionsthat are related to mood swings, anxiety, anddepression. I also consider their physiological needsand ask if there are thyroid disorders in the family.Untreated endocrine problems that could look likea primary depressive episode need to be diagnosed.

Figure 1. APRN Model of Care



And as another described:

I think clinicians not educated in biology would notthink to look for physiological reasons for depression.They would not be connecting menopause or post-partum status with hormonal changes that couldresult in depression.

An APRN stated:

APRNs know social and family systems as well asthe biology. We know that you don’t necessarilytreat the patient and send them back into theenvironment that was making them crazy andexpect that they’re going to behave normally. Welook at the whole person and all the systems andput it all together as best we can.

Active Listening

Combined with the holistic philosophy and clientas expert theory, active listening began the process usedby the psychiatric APRNs in making an assessment,arriving at a diagnosis, and selecting the strategiesmost effective in alleviating the clients’ depressivesymptoms. Active listening was defined by one APRNas a process of “being focused on what the client issaying and asking questions related to what is beingsaid in an attempt to gain understanding.” As statedby one APRN: “I just listen to the client and they tellme what they need. I think this is so important to helpus determine what the best treatment is, matchingmeds with symptoms.”

Interpersonal Relationship

Involving the client initially was seen by the APRNsas critical to the client’s receptiveness to the care theyneeded and would receive. As Peplau (1997), Raingruber(2003), and Travelbee (1966) described, the under-pinning of all psychiatric nursing is the developmentof a therapeutic relationship between client and nurse.

Included in the therapeutic relationship is activelistening and assessment. One APRN stated it succinctly:

I guess I always fall back on the interpersonal aspectof treatment, believing the relationship with theperson is part of the healing process. I want them tofeel completely heard, understood, and accepted.Once I convey this through accurate empathy, therelationship changes and more healing momentsoccur.

Primary Strategies of APRN Care

With input from the client, the treatment plan is for-mulated. The treatment strategies used by the APRNsincluded cognitive-behavioral therapy, medications,self-help strategies and books, positive feedback forthe accomplishments, and referral to other providers.To further enhance the therapeutic relationship, in theinitial phase of treatment, the APRNs scheduled atleast biweekly appointments with the client. When theclient was stabilized, visits were scheduled on a monthlybasis.

Partnering With the Client Through Active Listening

The most important skill described by all of theparticipants in this study was active listening, whichaided in partnering with the clients in assessment anddecision-making related to treatment. When partner-ing with the clients is established, a component of theinitial assessment, listing both the physical and mentalsymptoms as outlined in the

DSM–IV–TR

(AmericanPsychiatric Association [APA], 2000), is implemented.These are identified by the clients, and their perceivedseverity of each symptom is rated. The majority of theAPRNs also reported wanting the clients’ input intotheir care. For example, they asked clients: “Whatmedications have you heard about? Have you oranyone you know been treated for depression? And ifso, how were they treated?”


Psychotherapeutic Strategies

Cognitive-Behavioral

Cognitive behavioral therapy and interpersonaltherapy were the most commonly used psychothera-peutic strategies by these APRNs with depressed clients(see Figure 1). Depression causes irrational and dis-torted thinking, as well as an inability to perform dailyactivities. Cognitive restructuring is a specific strategythat the clinician uses to challenge the irrational beliefsand lead the client to a more rational conclusion (Beck,Rush, Shaw, & Emery, 1979). Research studies (NIMH,n.d.) demonstrate that the combination of pharmacologyand cognitive behavior therapy is most effective fortreating depression. The APRNs in this study concurwith that finding.

In reference to cognitive-behavioral therapy, oneAPRN stated: “I use it by teaching the patient about itfirst, and I give them things to take home and read. Ido it in modules so they don’t feel more overwhelmed.One woman recently told me that it was a revelationwhen she realized that she could change the way shefelt by the way she thought. She described it as almosta physical experience.”

Another APRN described her use of cognitive-behavioral therapy:

We do a lot of talking about assumptions, validatingassumptions, assessing assumptions, and then focusupon irrational thinking. I also use a behavioralfocus and point out what clients are doing as opposedto what are they thinking about or what are theyworrying about. I try to help the client see that theirfeelings and behavior follow from their distortedthinking.

Psychopharmacology

The 10 APRNs all have prescriptive authority andare prescribing medications for their patients. Theyall agreed they obtained information about prescribingstrategies and stayed current by attending workshops,

reading journal articles, attending pharmaceuticalmeetings, and by supervising and collaborating withpeers. One APRN was the sole mental health providerfor most of her clients, providing both medicationmanagement and cognitive-behavioral therapy. Themajority of the APRNs described their practice asapproximately 50% medication management only,with the clients getting psychotherapy from anotherprovider, and the other 50% being a combination ofmedications and cognitive-behavioral therapy. Regardingthe use of medications in treating clients with depression,one APRN stated:

I believe that you can match the medicine that youchoose to the primary neurotransmitters that seemto be implicated in their symptoms. So I choose themedication based on that. Or if they’ve hadmedication in the past that has worked, I just try tomatch it to the person based on those issues.

Effectiveness of Strategies

The ability to reassess the clients at each visit was seenas critical in the patients’ abilities to achieve remissionof their symptoms. A variety of approaches weretaken to measure the effectiveness of the treatmentprovided. The APRNs relied heavily on the patients’assessment of their own progress. Seven of the APRNsrelied on patient self-report of symptom reduction,which was based on the criteria outlined in the

DSM–IV–TR

(APA, 2000; see Table 1). Three mentioned usingspecific outcome measures, the Zung (1965) and theHamilton Depression Inventory (Hamilton, 1960). Theydescribed them as being readily available and inex-pensive to use. Seven of the participants used a scalingquestionnaire (see Figure 2). Clients were asked to ratethe severity of their symptoms using a 1–10 scale, rangingfrom 1 as the most severe symptoms to 10 beingsymptom free. When asked about patient assessment,one APRN stated: “Well I really don’t use a formalscale. Probably the most I do scale-wise is to get themto rate themselves on a scale of 1–10.” Another stated:



I usually ask the patient to give a quantitativeexplanation about how they feel. I want to knowhow they’re doing in terms of their normal sense ofself versus where they are today. Sometimes I ask,out of 100 percentage points, what percent are youright now, 100 being best? I agree that it’s going tobe specifically different for each patient. But whatmatters is where they think they are.

A third APRN stated:

I do the checklist every session. The clients subjec-tively rate themselves on the scale. Zero percentmeans you don’t have any energy, you can’t get outof bed, and you feel horrible. One hundred percentmeans you are back to where you want to be. Theybegin to see improvement, even if gradual, and theyreport their families often see the improvementbefore the client does.

Seven of the APRNs relied on patients’ self-reportsof symptom reduction based on the

DSM-IV-TR

’s(APA, 2000) criteria for depression. One APRN stated:

I’ll go back through the symptom checklist and say,“When you first came in, you shared with me thatyou were having difficulty with your sleep andrelationships. You were only sleeping 2 hr a nightand you were withdrawing from people and feelingreally irritable.” But as we went through each of thesymptoms the client said, “Well you know I didn’tthink about it but I haven’t ruminated and I’mgetting along better with people and I’m sleepingbetter.” So to go down and go through the thingsthat were a problem will sometimes give me a much

better picture of where they are and what needsto be better.

Discussion

According to the NIMH (n.d.), the combination ofmedications and therapy are the most effective strate-gies in treating depression. APRNs and psychiatrists are,for the most part, the only mental health disciplinestrained in both treatment modalities. Primarily,APRNs provide both modalities as treatment optionsfor their clients (Bjorklund, 2003). Based on thefour documented studies (Baradell, 1995; Baradell &Bordeaux, 2001; Bjorklund, 2003; Fisher & Vaughn-Cole,2003), an area of concern for APRNs, not only in thisstudy but also nationally, is the lack of documentationof the effectiveness of the strategies used in treatingclients with depression. Seven of the APRNs relied onpatient self-report of symptom reduction, while threementioned specific outcome measures used to evaluateoutcome of treatment. Seven of the participants usedthe symptom severity scaling question and fourused both the symptom severity scaling question andsymptom reduction checklist to evaluate the strategy.

Unlike the studies by Baradell (1995) and Baradelland Bordeaux (2001) that used three different instru-ments, none of the 10 APRNs interviewed in thisstudy used standardized instruments to evaluate theirtreatment. The standardized instruments the APRNsin this study used were primarily for assessmentpurposes. However, in evaluating progress, they useda symptom checklist based on the

DSM–IV–TR

(APA,2000).

The findings, in medication management, cognitive-behavioral therapy, therapeutic use of self, andintervention strategies, are representative of findingsin larger studies by Fisher and Vaughn-Cole (2003),Baradell and Bordeaux (2001), and Raingruber (2003).The most important strategy identified by these APRNsin treating clients with depression was partnering withthe client through active listening that guided theassessment of the client. This became the building

Figure 2. Depression Symptom Severity Scale


block for developing a therapeutic relationship as wellas developing the treatment plan with the client.

Despite the fact that the majority of the APRNs didnot use a standardized outcome measure, each did usea scaling question in evaluating the clients’ symptomsat each session. These findings suggest APRNs doevaluate the effectiveness of their strategies, but differ-ently from what has been reported in the literature.

Recommendations

The numerical rating scale for pain is similar to thenumerical rating scale for depression in that thepatients are asked to rate the intensity of their physicalpain on a 1–10 scale with 10 being the most severepain possible (Bijur, Latimer, & Gallagher, 2003).Patients with depression are asked to rate their overalllevel of discomfort based on the 1–10 scale with 10being the lowest level of discomfort. Perhaps usinglessons learned from evaluating pain and pain man-agement strategies (Bijur et al.), a numerical ratingscale used to evaluate symptoms of major depressionand depression treatment might be effective.

While the data from this study are useful, morestudies are needed to further the understanding of thestrategies used by APRNs in treating clients withdepression. An area of concern for APRNs, not only inthis study but also nationally, is the lack of documen-tation of the effectiveness of strategies used in treatingclients with depression. This study provided a steppingstone to begin addressing this issue as well as identifyingAPRNs as essential members of the mental healthcaredelivery system.

Limitations of the Study

The main limitation of this study was that it onlyincluded 10 APRNs who participated in a one-time,single interview. An additional limitation is that theseAPRNs practiced in the same geographical area, andthe majority was educated at the same university andare White females.

Implications for Nursing Practice

Based on the findings of this study, APRNs treatclients with depression using a holistic approach andfocusing on the development of an interpersonalrelationship that guides the treatment plan. Thesepractitioners reported using a combination of pharmaco-therapy and cognitive-behavioral therapy in treatingdepressive symptoms. These practitioners also reportedusing several techniques for measuring the effectivenessof their treatment. Based on these findings, a checklist,based on the

DSM–IV–TR

(see Table 1), of physical andmental symptoms of depression, and a numeric ratingscale (see Figure 2), are recommended to assist theclient in achieving wellness. The scaling question “Ona scale of 1–10 with 10 being the best you have been,where are you today?” provided a quick, easy-to-administer evaluation of a client’s progress since the lastsession. They also used a symptom reduction checklistto ask clients to rate their level of symptoms based onthe

DSM–IV–TR

(APA, 2000) criteria for depression.The APRNs saw rating scales as advantageous

when they partnered with the clients to involve themin monitoring their care and progress. Despite theAPRNs not reporting the use of standardized outcomemeasures routinely, these two evaluation strategieswere used as effective alternatives to standardizeddepression questionnaires in evaluating the effectivenessof treatment strategies. The majority of the APRNsreported that the scaling question and symptomreduction checklist were used at each session. Inaddition, the Hamilton Depression Inventory, BeckDepression Inventory, Zung, and Patient HealthQuestionnaire-9, standardized instruments withproven validity and reliability, were used to measurethe level of depressive symptoms. Based on the informa-tion obtained from the scaling question and symptomsseverity checklist, the APRN could further validatesymptom improvement by using a standardizedinstrument. Areas for future research include morestudies that use standardized measures to evaluate theoutcomes of care provided by the APRN. Studies that



describe the client’s perception and experience in beingtreated by an APRN, and determining the client’s andAPRN’s perceptions of the therapeutic experience areneeded.

Conclusions

APRNs bring to the treatment arena an understand-ing of the multiple causes of depression. APRNs relyon the holistic treatment approach in treating theirclients with depression. Incorporation of the biopsy-chosocial strategies is a hallmark of their practice. Notonly are biological causes addressed but psycho-social issues are also considered. Despite not usingstandardized measures to evaluate the effectiveness ofthe strategies used in treating clients with depression,the majority of the APRNs did evaluate their practicebased on verbal feedback from their clients.

Author contact: [email protected], with a copy to theEditor: [email protected]

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