Depression is one of the most frequently occurring mental disorders among adults. Worldwide estimates of lifetime prevalence of depression range from 14.6% in high-income countries to 11.1% in low- to middle-income countries (Bromet et al., 2011). Depression affects 9.1% of Americans 18 and older (Centers for Disease Control and Prevention, 2010), with an estimated annual treatment cost of $26.1 billion (Greenberg et al., 2003) and workplace cost (i.e., absenteeism and lost productivity) of $36.6 to $51.5 billion (Lerner & Henke, 2008). Depression is one of the more treatable mental illnesses (Halfin, 2007). Given the good prognosis of depression with early intervention (Halfin, 2007), exploration of unique treatments, such as this Advanced Practice Nurse (APN) Psychiatric Bridging Intervention, are necessary.
People with mental disorders, including depression, experience significant barriers to accessing psychiatric health care, such as limitations on third-party coverage, a shortage of mental health professionals in certain geographical areas, and lengthy wait times for appointments (Cunningham, McKenzie, & Taylor, 2006; Sherman, Barnum, Nyberg, & Buhman-Wiggs, 2008; Wilk, West, Narrow, Rae, & Regier, 2005). Halfin (2007) reported that clients with depressive symptomatology who lacked private insurance waited several months before receiving an initial psychiatric evaluation (IPE), which placed these clients at high risk for psychiatric comorbidities and increased the likelihood of IPE non-attendance. Zivin et al. (2009) investigated the demographic and clinical factors associated with attendance of initial mental health treatment within a predominantly insured population in the United States. They found that patients who failed to initiate treatment following a telephone assessment were more likely to have had difficulty functioning at work and in other daily activities, experienced legal problems, and reported previous suicide attempts compared to patients who scheduled a behavioral health appointment. The authors concluded that health plans and providers cannot assume that patients who fail to attend appointments for IPE are in need of less care. In fact, these patients may have as much or greater need for treatment (Zivin et al., 2009). Therefore, development of interventions to increase attendance at IPE appointments is warranted.
Research on strategies to improve access to and decrease waiting times for outpatient IPE appointments is limited. Several studies have shown that reminder letters, phone calls, and text messages can improve attendance at IPE appointments (Lefforge, Donohue, & Strada, 2006; Sims et al., 2012). However, these strategies are unlikely to improve attendance rates among low-income or homeless individuals who may not have permanent addresses to receive postal mail or access to landline or cell phones.
Approaches to reducing wait times for mental health care have been studied in other countries. Mireau and Inch (2009) reported the use of a strengths-based brief solution-focused counseling (BSFC) model offered to mental health clients seeking care at a community-based mental health service in the Saskatoon Health Region of Canada. BSFC is a time-limited (10-session) program that was provided by social workers on the adult counseling team. Prior to the availability of BSFC, clients faced wait times as long as 1 year for individual counseling. Mireau and Inch (2009) found that clients who engaged in BSFC not only experienced shorter wait times, but also showed significant symptom reduction and had a higher rate of service completion.
Due to the paucity of studies on strategies to reduce wait times for outpatient psychiatric appointments, several studies were reviewed that examined the role of APNs in reducing wait times of patients seeking mental health treatment in the emergency department (ED) (Wand, White, Patching, Dixon, & Green, 2011). In Australia, following deinstitutionalization and integration of mental health services with conventional medical services, the ED has become a key entry point for individuals with mental health issues (Wand, 2004). The mental health nurse practitioner (MHNP), an APN credentialed at the master’s level, provided assessment close to the time of triage, direct care for individuals with mental health problems, care coordination, and follow up. Wand and Fischer (2006) reported that the MHNP saw 75% of mental health clients in the ED within 1 hour of triage. Consumer data revealed a high level of satisfaction with the services provided by the MHNP (Wand, White, Patching, Dixon, & Green, 2012).
In summary, this evidence-based practice project, required for completion of the doctorate of nursing practice (DNP) degree, was an effort to reduce wait times for treatment and increase attendance at IPEs through a psychiatric bridging intervention implemented by a psychiatric APN. The project was approved by a DNP faculty committee, carried out under the supervision of a DNP faculty advisor, and successfully defended at a final oral examination. Because the project involved collection of data from clients and review of client records, an application was submitted to and approved by a regional human subject review board and the clinical setting.
Brown County Community Treatment Center (BCCTC), a division of the Brown County Human Services Department (BCHSD), is the main provider of psychiatric services, including IPE, for indigent people who reside in Brown County, Wisconsin. Many psychiatrists within the private sector of Brown County refuse to accept clients without insurance and those receiving medical assistance. Additionally, various community sources refer patients to BCCTC for an IPE by a psychiatrist or a psychiatric clinical nurse specialist. Clients referred to BCCTC may be seen for an intake by a psychologist within 1 week of initial contact. Intake assessments by psychologists were added to the Brown County treatment process several years ago to decrease the likelihood of IPE nonattendance that occurred when clients scheduled directly with the psychiatrists for an IPE, but often failed to attend. During the intake, the psychologist conducts the initial assessment, provides a diagnostic impression, and determines the service need for an IPE at BCCTC and/or for referral to a community therapist. However, there is a 5-month waiting period for an IPE appointment (Brown County Human Services Board [BCHSB], 2010). An appointment with a community therapist also requires a waiting period of several months. During the extensive waiting period for the IPE, the referred clients are highly vulnerable. Additionally, when the IPE becomes available, the failure to attend rate is high (BCHSB, 2010).
The lead author of the article (L.S.), a psychiatric clinical nurse specialist, APN prescriber, and long-term employee of BCCTC, approached the BCCTC Clinical Service Manager to initiate discussions regarding an evidence-based project to reduce the wait time for IPE appointments. The concept, supported by the research literature, was to develop an intervention that could be offered to clients to bridge the time between the intake appointment and the IPE. The author was given approval by the Clinical Service Manager to develop ideas for the project.
Rogers’ Diffusion of Innovations framework for adopting an evidence-based innovation in an organization was used to guide this project (Dobbins, Ciliska, Estabrooks, & Hayward, 2005). Rogers’ theory was selected because it is a well-known and credible theory of practice change within an organization. Rogers’ theory proposes five stages through which an innovation spreads through an organization including: (a) knowledge, (b) persuasion, (c) decision, (d) implementation, and (e) confirmation. These stages are presented as they applied to the project.
Rogers’ Diffusion of Innovation
Knowledge Stage. The first step of the process was to identify and evaluate the quality of clinical practice guidelines and research evidence pertinent to the proposed intervention. Three clinical practice guidelines for the treatment of depression in adults were found: Kaiser Permanente’s (2010) Adult Depression Clinical Practice Guideline; Michigan Quality Improvement Consortium-Professional Association (Michigan Quality Improvement Consortium, 2008); and University of Michigan Health System: Depression (University of Michigan Health System, 2005). (The Kaiser Permanente and Michigan Quality Improvement Consortium clinical practice guidelines have been revised several times since completion of the project, with the latest revisions for both guidelines occurring in 2012. A review of both guidelines showed that the evidence-based treatments used in the project remain consistent with the current version of the guidelines.)
The clinical practice guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and determined to be of high quality (The AGREE Collaboration, 2001). Additionally, all three clinical practice guidelines included Level I evidence. Ranking criteria used were developed by Ackley, Swan, Ladwig, and Tucker (2008). In the ranking system, evidence is categorized from I to VII, with Level I derived from a systematic review or meta-analysis of relevant randomized controlled trials or evidence-based clinical practice guidelines and Level VII based on the opinions of authorities or expert committees.
Little research has been completed regarding the effectiveness of psychiatric APNs in treating depression. The following studies provided evidence of effectiveness based on Ackley et al.’s (2008) criteria (Level 1: evidence from a systematic review, or Level 2: evidence from a randomized controlled trial). Parrish and Peden (2009) conducted a systematic review of studies of clinical outcomes of depressed patients treated by psychiatric APNs, primary care providers, and other mental health care providers. Findings from these studies demonstrated that psychiatric APNs are as effective as other providers in treating patients with depression. Parrish and Peden (2009) reported that clients were highly satisfied with their relationships with psychiatric APNs and with the psychotherapy services provided. Furthermore, psychiatric APNs had greater appointment availability and spent more time with their clients than other mental health providers. A study by Baldwin, Pratt, Goring, Marriott, and Roberts (2004) demonstrated that interventions provided by experienced mental health liaison nurses resulted in significantly lower levels of depression in older patients admitted to acute medical wards compared to usual care provided by a psychiatrist or geropsychiatry team. In the Baldwin et al. (2004) study, a mental health liaison nurse was an RN with 3 years of post-qualification experience.
At the conclusion of the Knowledge Stage, the amount and quality of the evidence available were deemed sufficient to proceed with the project. An evidence-based bridging intervention, which included supportive psychoeducational counseling and prescription medication, was designed. Decades of research and meta-analyses have concluded that the therapeutic relationship is a crucial component for client change in psychiatric settings (Deering, 2009). Therapeutic use of self is the primary agent of psychiatric nurses working with psychiatric clients (Keltner, Schwecke, & Bostrom, 2007). The information gathered during the Knowledge Stage supported the use of Peplau’s Theory of Interpersonal Relations, which considers client difficulties throughout life that health care providers can identify and help clients resolve (Peplau, 1952).
Persuasion Stage. Several factors influenced the attitudes of decision-makers and other agency personnel regarding the proposed APN Psychiatric Bridging Intervention. Trialability is the extent to which an innovation can be implemented on a small scale within the organization (Dobbins et al., 2005). The APN Psychiatric Bridging Intervention was seen as trialable because it could be put into practice with a small group of clients to determine the feasibility, advantages, and disadvantages of the intervention. The intervention also had observability in that the effect of the intervention on IPE attendance rate would be evident in a relatively short period of time. The APN Psychiatric Bridging Intervention was compatible with the BCHSD mission of ensuring the provision of accessible, high-quality, and cost-effective services to Brown County residents. In addition, the intervention was consistent with the 10 values (e.g., consumers must be engaged as full and meaningful partners, regard for consumers must be unconditional, every consumer is capable of change) outlined on the BCHSD (2010) home page.
As described, the APN Psychiatric Bridging Intervention was a good fit with the institution. Therefore, persuasion regarding the significance of the project came naturally and was well supported.
Decision Stage. An essential aspect of the adoption of an innovation, such as the APN Psychiatric Bridging Intervention, is identification of the stakeholders. Ultimately, the recipients of care provided are the central focus of this study and the individuals most affected by the success/failure of this project. Additionally, BCCTC stakeholders included the clinic service manager, staff psychologist, secretarial staff, psychiatrists, nursing staff, BCHSB members, case managers, and corporation counsel. The APN Psychiatric Bridging Intervention was presented at a BCHSB meeting and to a group of psychiatrists and administrators at a monthly BCCTC medical meeting and received support. Nursing staff and case managers within BCCTC discussed the innovation individually with the lead author (L.S.) and also expressed project support. The corporation counsel reviewed and approved the contract for the APN Psychiatric Bridging Intervention.
Implementation Stage. Evidence identified in the knowledge stage provided the foundation for the design of the APN Psychiatric Bridging Intervention. The intervention included a combination of prescriptive medication and supportive psychoeducational counseling based on research literature, national guidelines, and Peplau’s (1952) Interpersonal Relations Theory. In addition to medication, short-term supportive psychoeducational counseling was initiated with a focus on problem solving and use of the interpersonal process and therapeutic use of self.
Frequency of client contact for supportive psychoeducational counseling and medication prescription in the APN Psychiatric Bridging Intervention was based on guideline recommendations in addition to client need (Kaiser Permanente, 2010; Michigan Quality Improvement Consortium, 2008). For example, patients experiencing other psychiatric symptoms, such as anxiety, required anti-anxiety medication for stabilization, allowing antidepressant medication to take effect in addition to more frequent supportive psychoeducational counseling with the APN. Clients were seen for one to seven psychoeducational counseling sessions with the psychiatric APN. All interventions were based on guidelines and client need.
Clients with depressive symptomatology were selected as the target population because this group comprised the majority of the population that historically presented at BCCTC for intake. A second reason for selection of this population was that antidepressant medication may take several weeks to become effective; therefore, initiation of medication prior to the IPE allowed time for the medication to take effect (Sadock & Sadock, 2007). Rush (2007) noted that one third of depressive adult outpatients with remission or ultimate response to antidepressant medication required 6 weeks or longer for reduction in symptoms.
Confirmation Stage. Confirmation involves evaluation of whether the intervention took place and whether it had the intended effect (Dobbins et al., 2005). This small pilot study was conducted to determine whether the APN Psychiatric Bridging Intervention improved IPE attendance rates among adult residents of Brown County with depressive symptoms. The question guiding the project was: Among adults referred to BCCTC for depressive symptomatology and who have had an intake appointment, will the attendance rate at the IPE be higher for clients who receive the APN Psychiatric Bridging Intervention compared to the attendance rate at the IPE for clients who did not receive the intervention?
The project comprised two groups of adult clients with depressive symptoms. The comparison group consisted of clients who had attended an intake appointment with the staff psychologist between December 2009 and March 2010, prior to the implementation of the APN Psychiatric Bridging Intervention and had a scheduled IPE appointment. The intervention group included adult clients with depressive symptoms who attended an intake appointment, scheduled an IPE appointment, and agreed to participate in the Bridging Intervention. The latter clients were seen for the APN Psychiatric Bridging Intervention between July 2009 and January 2010. Clients who were acutely dangerous to themselves or others, required inpatient hospitalization, or were younger than 18 were excluded.
The Community Mental-Health-Promotion Program Phases of Nurse–Client Relationship (NCR) form was used to measure the phases of the nurse–client relationship (Figure) (Forchuk & Brown, 1989). The NCR form consists of a 7-point scale, where 1 = orientation phase and 7 = resolution phase. According to Forchuk and Brown (1989), “intermediate points are included [on the form] between phases to accommodate the gradual shifts in the relationship, which includes the periods of overlap” (p. 31). The instrument provides a short summary of each phase that describes the evolving roles of the client and the nurse within the relationship. Evidence of construct and content validity of the NCR form has been demonstrated through development of the instrument directly from Peplau’s (1952) theory and a review of the instrument by three other clinical nurse specialists in mental health nursing (Forchuk & Brown, 1989).
Figure. The Community Mental-Health-Promotion Program Phases of Nurse–Client Relationship form. From Forchuk, C. & Brown, B. (1989). Establishing a nurse-client relationship. Journal of Psychosocial Nursing and Mental Health Services, 27(2), 30–34. Copyright 1989 by SLACK Incorporated. Reprinted with permission.
Clients in the preintervention comparison group were selected via a chart review of all clients who were seen by the intake psychologist and had scheduled an IPE. If the chart review indicated depressive symptomatology, the client was included in the preintervention comparison group. As previously stated, the preinter-vention clients were seen by the intake psychologist between December 2009 and March 2010 and had been scheduled for an IPE approximately 5 months later.
Potential APN Psychiatric Bridging Intervention participants were identified by the intake psychologist who completed an initial intake assessment. Clients with depressive symptoms who were referred by the psychologist for an IPE were provided with a description of the APN Psychiatric Bridging Intervention and offered an opportunity to receive the intervention while they waited for the IPE.
All intervention clients received prescriptions of antidepressant medication for depressive symptoms based on individual need. In addition, all intervention clients received supportive psychoeducational counseling focused on problem solving and use of the interpersonal process and therapeutic use of self. Clients were seen for follow up within 1 week after initiation of medication (consistent with evidence-based clinical practice guidelines). Additional follow-up appointments were scheduled as needed. At the conclusion of each appointment, the APN rated each client’s phase on the NCR scale and recorded the rating on a spreadsheet.
Nineteen clients received the APN Psychiatric Bridging Intervention; however, 2 had IPE appointments rescheduled by the clinic at a date too late to be included in the data analysis. The preintervention comparison group consisted of 38 clients who received standard care. Both clients groups were of low socioeconomic status and had depressive symptomatology. The age range of both client groups was 20 to 61. The preintervention comparison group had a mean age of 33.1 (SD = 10.86 years) and the APN Psychiatric Bridging Intervention clients had a mean age of 39.7 (SD = 13.38 years). Twenty-one (55%) of the 38 preintervention comparison group clients were men, whereas 5 (26%) of the 19 APN Psychiatric Bridging Intervention clients were men. The reason for this is unknown.
Cross tabulation and chi-square analysis was performed to compare the IPE attendance data for the preinter-vention comparison group with data from the APN Psychiatric Bridging Intervention group. The IPE attendance rate of the comparison preintervention group was 44.7% (17 of 38 IPE initial sessions attended), whereas the IPE attendance rate for the APN Psychiatric Bridging Intervention group was 70.6% (12 of 17 IPE initial sessions attended). The relationship between the attendance rate for the two groups was not significant (χ2 = 3.149, p = 0.08). A Fisher exact test analysis was performed to compare the IPE attendance data for the APN Psychiatric Bridging Intervention clients whose final NCR rating was high (> 3, progression to the identification phase or further in the nurse–client relationship) to those with low NCR (< 3, remained in orientation phase) ratings. No statistically significant relationship was found between final NCR rating and IPE attendance (Fisher exact test, one-sided p values: for p (observed ⩾ expected) = 0.06). An unexpected finding was that clients who participated in the APN Psychiatric Bridging Intervention required shorter IPE appointments, 30 minutes compared to the standard 60-minute appointment usually allotted for IPE appointments.
Implications and Conclusion
Clients experiencing depressive symptoms comprise a substantial proportion of those who seek mental health treatment in community mental health centers. However, lengthy wait times for IPE appointments constitute a barrier to prompt evidence-based treatment and are associated with high failure to attend IPE appointments, worsened symptoms, emergency hospitalizations, heightened suicide attempts, and reduced efficiency of mental health services (Mitchell & Selmes, 2007; Williams, Latta, & Conversano, 2008).
The APN Psychiatric Bridging Intervention described in this article offers a promising approach to the care of clients with depressive symptoms. A strength of the intervention is that it was grounded in the progression of the client through the nurse–client relationship as delineated by Peplau’s (1952) Theory of Interpersonal Relations.
This pilot project demonstrated the feasibility of implementing a small-scale intervention provided by a psychiatric APN in a community mental health center. Bringing about change within an organization is challenging and requires substantial time and resources. Use of a systematic change process guided by Rogers’ Diffusion of Innovations Theory (Dobbins et al., 2005) was critical to the adoption of the APN Psychiatric Bridging Intervention at BCCTC.
The limited research on strategies to improve access to and decrease wait times for outpatient IPE affords an opportunity for further study. Because the finding on the relationship between the attendance rate for the intervention and preintervention groups only approached significance, replication of the APN Psychiatric Bridging Intervention project with a larger, gender-balanced sample of clients would provide a stronger test of the intervention. The current project did not provide an opportunity for clients to evaluate the intervention. Measurement of client satisfaction and self-reported quality of life at baseline, completion of the APN Psychiatric Bridging Intervention, and at the IPE would provide an additional perspective on the effectiveness of the intervention. The unexpected finding of a reduction in the duration of IPE appointments merits further investigation to determine whether the intervention resulted in increased provider productivity, cost savings to the organization, or both.
This APN Psychiatric Bridging Intervention is in line with the transformation in health care delivery that is anticipated following the recent passage of the Patient Protection and Affordable Care Act (PPACA) of 2010, which clearly establishes mental health as a high national priority and identifies it as one of the “essential health benefits” (Government Printing Office, 2010, p. 45). The PPACA identifies the importance of and supports interventions to improve mental health care in community-based settings (Sec. 5604, Sec. 4202) and specifically cites the needs of those with depressive disorders. Reforms stemming from this act will result in the redesign of mental health care to promote consumer access to mental health services and a greater emphasis on prevention and early intervention.
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