NS3118 Evidence-Based Practice

Introduction:

Evidence based practice (EBP) is one of the necessary professional standards for registered nurse. The NMBA registered nurse standards for practice values EBP and encourages nurse to use best available evidence in taking health care decisions and providing safe and quality care to patient (Nursing and Midwifery Board of Australia, 2016). The necessity for competencies in EBP has been realized for its potential to enhance patient outcome and promoting better quality of life in patients. EBP can also be regarded as a patient-centered approach to care which supports nurses to positively influence care of patient (Stevens, 2013). A nurse must always use their research skills and clinical judgment for the safety and beneficence of patient. With this context, the main purpose of this report is to consider a scenario where a patient prefers self-administered preventative treatment compared to conventional treatment that deviates from the best practice. In the role of a nurse, this report analyzes whether the self-administered practice is evidenced based or not and compare it with conventional treatment options. The suggestion is also presented for inclusion of evidence into practice.

Rationale for evidence based analysis for self-administered practice in the scenario

The scenario is related to a patient who has disclosed to the nurse that about her decision to go for cognitive behavior therapy, nutritional therapy and exercise therapy without antidepressants for treatment of depression. The dilemma in this scenario is that pharmacological intervention like antidepressant drug is most widely used and conventional treatment options for people with depression. Evidence has revealed that antidepressants are efficacious and safe treatment options for depression particularly in patients with chronic disease. The systematic review of several randomized controlled trial on the effect of antidepressants on patients has revealed that antidepressants of all types are effective in alleviating symptoms of depression in chronically ill patient (Taylor et al., 2011). However, since the patient has decided to go for cognitive behavior therapy, nutritional therapy and exercise therapy without antidepressants for treatment of depression, the efficacy of this treatment option needs to be decided in terms of outcome for patient. This is also necessary because many cognitive therapies works best when combined with antidepressants, however their beneficial effect without antidepressants is a key question for including this intervention into practice.

Evidence based analysis of self-administered practice

The effectiveness of self administered practice of cognitive therapy without antidepressants for patients with depression can be confirmed if the benefits of the therapy are sufficiently covered in literature. A research literature that compares the efficacy of the cognitive therapy compared to antidepressants would be suitable to understand the impact of the intervention for achieving positive outcome in depressive patient. The article by Hollon et al. (2014) is the most suitable evidence to decide whether the patient decision can be implemented in practice or not. Hollon et al. (2014) focused on evaluating the effectiveness of cognitive therapy (CT) with antidepressants medication (ADM) compared to antidepressants alone on the recovery of patient with depression. A randomized controlled trial was done by randomly assigning patients to ADM treatment alone group and CT combined with ADM treatment group. The recovery was measured in patient by 17 item Hamilton Rating Scale and the follow up evaluation. The results of the study revealed that recovery rate was higher for ADM plus CT group compared to ADM alone group. The significance of this result is that effectiveness on recovery was determined by its interaction with severity and chronicity. This research evidence mainly clarified regarding the efficacy of CT when combined with ADM. However, one element that is missing in this research is that it has not covered the effectiveness of  CT alone and comparison has been done only for a ADM alone. Hence, this review gives insight into the efficacy of CT as a complementary therapy and not as standalone treatment for depression.

The evidence by Hollon et al. (2014) is not considered reliable because of certain methodological limitations too. For example, there was no addition control for CT therapy to assess the specificity of CT in combined treatment advantage. This would have solved the main purpose of finding out evidenced based data for chosen self-administered practice. This shortcoming limited the generalizability of the findings. Another limitation was that blinding for patients and treatment providers to the condition was not done which is a major requirement in randomized controlled trail (Karanicolas, Farrokhyar, & Bhandari, 2010). To confirm the benefits of CT on depression outcomes, there is a need to review other evidences that clarifies effectiveness of CT therapy alone for depression. Kuyken et al. (2015) evaluated the effectiveness of mindfulness-based cognitive therapy alone compared with antidepressant therapy for depression. The participants with three or more major depressive episodes were randomly assigned to CT group and antidepressant group. Relapse of prevention of depression was the main primary outcome that was measured in the study. This evidence proved the efficacy of the therapy for preventing recurrence. However, this evidence cannot be applied in the scenario because the main purpose is to treat depression and not prevent recurrent of depressive symptoms.  

As anti-depressants remain the main stay for depression, the evidence basis for beneficial effect of CT compared to orthodox treatment is also understood by the review of study by Jakobsen et al. (2011). It aimed to compare the effects of cognitive therapy versus treatment as usual in major depressive disorder patients. The systematic review of randomized controlled trial studies was done to evaluate effect of interventions of primary outcomes such as depressive symptoms, adverse events and quality of life. The main rational for analyzing this research for EBP is that it is focused on evaluating impact of intervention based on depressive symptoms, adverse events and quality of life parameters. For a nurse, these are the important parameters to consider while deciding to implement the evidence. This consideration will promote safety of patient as well as quality of care. The evidence proved that cognitive therapy is not an effective treatment for major depressive disorder compared to treatment as usual. The meta-analysis of evidence based therapy has also proved that there is little evidence regarding the effectiveness of CT as a standalone therapy for depression and benefits has been found for combination treatment compared to CT alone (Hofmann et al., 2012). Cuijpers et al. (2014) also proved that combined treatment enhances the rate of recovery in patients with depression compared treatment with ADM alone. Hence, it can be concluded there is lack of evidence regarding the benefits of CT alone for treating depression, instead more evidence has proved superior effects of combined treatment rather than single therapy without psychotherapy.

In the scenario presented, the patient had also disclosed that about going for nutritional and exercise therapy apart from CT therapy for depression. Hence, there is a need to review whether evidence exist for impact all of the three on improving symptoms of depression in patients. There is no relevant research evidence that evaluates the effect of all three interventions for treating patient with depression. However, evidence exists for individual effectiveness of exercise therapy and nutritional therapy for depression. The study by Knapen et al. (2015) focused on analyzing the effect of exercise therapy in improving mental and physical health in patients with major depression by reviewing four meta-analyses on the intervention. The study confirmed that exercise is effective treatment for depression however it is comparable with antidepressants and psychotherapy for patients with mild to moderate depression. In case of severe depression, exercise can promote health in depressive patient when combined with traditional treatment.

The above evidence is not generalizable as it is based on analysis of past work, however a research interpreting outcomes in patients would be more reliable to understand the evidence basis for the intervention. This criteria is fulfilled by Hallgren et al. (2015) as the researcher compared the effectiveness of physical exercise, internet based cognitive therapy and treatment as usual in patients with mild to moderate depression. Patients were randomly assigned to one of three interventions for 12 weeks and they were assessed after 3 months for severity of depression and self-rate work capacity. Although all three interventions showed improvement in outcome of patient at follow-up, however mean reduction is depression score was high for physical exercise and cognitive therapy group. The strength of the evidence is the RCT design and comparison of three treatment options for depression. However, the evidence cannot be applied in EBP because it did not considered antidepressants medications in treatment as usual groups, however some patients taking medication ADM were taken thus limiting the reliability of evidence for the scenario.

Compared to CBT and exercise therapy, there is less evidence for use of nutritional therapy in patients with depression. However, Jacka et al. (2017) is considered relevant evidence as it focused on investigating the efficacy of dietary program for treating depression. A single blind, randomized controlled trial method was used to evaluate the effect of the intervention on depressive patient. Dietary support was found to reduce depression symptoms and improve mental health in patient. However, the key highlight of this evidence is that all participants were using some form of other therapies like psychotherapy alone or psychotherapy combined with pharmacotherapy thus indicating that nutritional therapy can work when combined with these treatments.

Conclusion:

The report summarized the efficacy of three interventions (cognitive behavior therapy, nutritional therapy and exercise therapy without antidepressants) for treatment of depression by analyzing their evidence basis in current research literature. By analysis of the evidence, it can be said that there is lack of evidence where the impact of all three intervention has been evaluated in one single study. However, evidence exist for comparison of individual intervention with ADM. Based on the analysis of such studies, it can be said that all these have been found effective in treatment of depression, however there efficacy has been enhanced when they are combined with ADM. Hence, it is suggested to incorporate the three interventions into practice, the patient must be encouraged to take those three intervention combined with ADM to get better outcomes. Secondly, in case of exercise therapy, there is a need to analyze specific exercise that would be suitable for patient based on her current health status. Secondly, nutritional therapy and exercise therapy may work for patients with mild to moderate depression. However, for patients with high severity of symptoms, combining the three interventions with ADM is a more efficacious strategy to implement in clinical practice.

References:

Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta?analysis. World Psychiatry, 13(1), 56-67, DOI: 10.1002/wps.20089

Hallgren, M., Kraepelien, M., Öjehagen, A., Lindefors, N., Zeebari, Z., Kaldo, V., & Forsell, Y. (2015). Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: randomised controlled trial. The British Journal of Psychiatry, 207(3), 227-234, DOI: 10.1192/bjp.bp.114.160101

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and research, 36(5), 427-440, doi:  10.1007/s10608-012-9476-1

Hollon, S. D., DeRubeis, R. J., Fawcett, J., Amsterdam, J. D., Shelton, R. C., Zajecka, J., … & Gallop, R. (2014). Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: a randomized clinical trial. JAMA psychiatry, 71(10), 1157-1164,  doi:10.1001/jamapsychiatry.2014.1054

Jacka, F. N., O’Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., … & Brazionis, L. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’trial). BMC medicine, 15(1), 23, available at: https://doi.org/10.1186/s12916-017-0791-y

Jakobsen, J. C., Hansen, J. L., Storebø, O. J., Simonsen, E., & Gluud, C. (2011). The effects of cognitive therapy versus ‘treatment as usual’in patients with major depressive disorder. PloS one, 6(8), e2289, available at: https://doi.org/10.1371/journal.pone.0022890

Karanicolas, P. J., Farrokhyar, F., & Bhandari, M. (2010). Blinding: Who, what, when, why, how?. Canadian journal of surgery, 53(5), 345, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947122/

Knapen, J., Vancampfort, D., Moriën, Y., & Marchal, Y. (2015). Exercise therapy improves both mental and physical health in patients with major depression. Disability and rehabilitation, 37(16), 1490-1495, DOI: 10.3109/09638288.2014.972579

Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., … & Causley, A. (2015). Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet, 386(9988), 63-73, available at:
https://doi.org/10.1016/S0140-6736(14)62222-4

Nursing and Midwifery Board of Australia (2016). Registered nurse standards for practice. Retrieved 6 February 2018, from https://file:///C:/Users/User00/Downloads/Nursing-and-Midwifery-Board—Standard—Registered-nurse-standards-for-practice—1-June-2016%20(2).PDF

Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), 4, DOI: 10.3912/OJIN.Vol18No02Man04

Taylor, D., Meader, N., Bird, V., Pilling, S., Creed, F., & Goldberg, D. (2011). Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy. The British Journal of Psychiatry, 198(3), 179-188, Doi: 10.1192/bjp.bp.110.077610.