Exploring psychotherapeutic issues and agents in clinical practice
In learning to be nurses, we take courses to understand human beings from physical, psychological, and social perspectives based on substantiated theories, as well as courses in nursing interventions to help restore and maintain health. In advanced mental health nursing, practice courses extend to specific psychotherapies and pharmacotherapies as well as research skills to create more knowledge and responsibly consume new research. However, the majority of generalist and advanced practice nursing relies heavily on received knowledge or traditional practice (Irland, 2019; Storey et al., 2019). What does it mean to base practice on evidence? What are the barriers to basing practice and prescribing on research evidence? How can nurses improve their evidence-based practice (EBP)? The current article addresses these questions and offers suggestions to advanced practice psychiatric nurses (APPNs) for improving their prescriptive practice.
What is Evidence-Based Practice?
Although some form of evidence-based medicine has been practiced since the early 1800s, the term reached prominence in 1996 due to an editorial by Sackett et al., who defined evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). EBP is a problem-solving approach to making clinical decisions based on the best scientific evidence available, the clinician's experience and expertise, and the client's preferences. This three-pronged approach proposed by Sackett et al. (1996) provides guidance in making the best decisions within a flexible framework. Those who argue that EBP is heavily rule-driven may not recognize the importance of the clinician's expertise and appropriately informing clients in matching their preferences. Presenting evidence to clients in a warm and sensitive manner invites collaboration and participation in treatment.
Research pours forth in innovative psychotherapies and strategies to manage symptoms and change behaviors. In addition, neurophysiological research continues to identify deeper understanding in neurotransmitters, neurotransporters, and neuroreceptors that can be used in developing pharmaceutical agents to exploit new mechanisms of action to treat neuropsychiatric symptoms. Indeed, in the past 6 months, two new pharmaceutical innovations were approved to treat severe depression (ketamine, esketamine) (U.S. Food & Drug Administration [FDA], 2019b) and post-partum depression (brexanolone) (FDA, 2019a). Staying current with research requires diligence, time, and access to scholarly publications via libraries and websites, as well as expertise in reading, critiquing, and interpreting complex research.
The average time for research to enter into clinical practice is approximately 17 years, with only 14% of evidence ever being translated into practice (Tucker, 2019). Translating research into practice first requires that research be published and reviewed and optimally supported by additional replicated studies. Clinicians seeking research to support practice will best be served by finding meta-analyses of studies, which can be found in the Cochrane Library. Because meta-analysis is a method of combining many studies of similar levels of quality and reanalyzing the accumulative data, these types of studies are invaluable sources of evidence for clinicians. The Cochrane Database publishes systematic reviews and meta-analyses in an unbiased manner and is cautious of industry-sponsored drug and device studies (Lundh, Lexchin, Mintzes, Schroll, & Bero, 2017).
Barriers to Evidence-Based Prescribing
If the argument to base practice on evidence from research is so convincing, why do clinicians continue to use treatments for which there is little evidence to support or may even have evidence to refute the treatment? A clear case in point is the common practice of prescribing medication for depression and/or anxiety without first assuring the client is in psychotherapy. Data are overwhelmingly convincing that the best treatment outcomes for depression and anxiety require concurrent psychotherapy and pharmacotherapy (Kamenov, Twomey, Cabello, Prina, & Ayuso-Mateos, 2017; Leichsenring & Hoyer, 2019; Molenaar et al., 2011). Common explanations for not using research evidence include: “this is the treatment I was taught”; “this is what someone else (i.e., a supervisor or colleague) recommends”; and lack of knowledge about alternatives (Arango, 2013).
Finding the time to conduct a literature search while maintaining a busy clinical practice is daunting enough. Many nurses note lack of confidence and expertise in reading and interpreting research and lack of organizational support through time, access, and collegial assistance (Storey et al., 2019; Tucker, 2019). Just recognizing a quality study with an adequate effect size is difficult even for nurses with graduate degrees (Rice, 2011). It is easier to fall back on prescribing by diagnosis (i.e., schizophrenia means antipsychotic agent, depression means antidepressant agent) than to reason through the symptomatology, putative neurophysiology, and appropriate drug that corresponds to the neurophysiology by mechanism of action.
Clinical decision making is a complex process in which clinicians must weigh the formal and informal sources of information, influences and priorities of when and how to initiate medications, whether and when to alter treatment, and when to stop treatment. These decisions in the prescribing process usually need to be made within a short period of time and with the added pressure of the client, family members, and other providers wanting an immediate decision. Frequently, APPNs inherit other providers' treatment regimens that fall outside of best practices, and APPNs must risk their own therapeutic relationship to act in an evidence-based manner or to maintain a treatment that may cause harm. One of the most common discussions on a popular psychiatric–mental health nurse practitioner Facebook® page is how to confront the need to taper a client off benzodiazepine agents that another provider started and maintained for years, even though the FDA recommendation for benzodiazepine treatment is no longer than 3 weeks.
How Can Nurses Improve Their Evidence-Based Practice?
The American Nurses Credentialing Center (2017) requires organizational support for EBP in settings awarded magnet status. This support may come through agency-wide resources or in collaboration with academic centers, and usually includes online library search access as well as collegial coaching (Storey et al., 2019). Creating a culture of excellence begins with a commitment to staying current in the scientific literature and translating that knowledge into practice as appropriate. Psychiatric nurse generalists can stay up to date by maintaining continuing education and asking organizational leadership to support their attendance at these offerings. In addition, nurses can form journal clubs that meet regularly and discuss current literature, possibly with the help of colleagues with research expertise.
In advanced practice, prescribing requires thoughtful consideration of the individual client's assessment data, paired with the medication that most appropriately addresses the symptoms by the drug's pharmacodynamics within the pharmacokinetics of the client and the drug together, and with the client's understanding and acceptance. This is a tall order. Selecting the medication is not simply looking at a decision tree (i.e., algorithm) and following the branches. Furthermore, response to a drug changes in different phases of illness and comorbidities or physical conditions, such as pregnancy, breastfeeding, over-the-counter supplements, and other drugs interactions. For example, fluoxetine (Prozac®) is a strong CYP 2D6 inhibitor and its active metabolite, norfluoxetine, is a moderate 3A4 and 2C19 inhibitor. Both have a long half-life, which makes switching from fluoxetine to another serotonin reuptake inhibitor (SRI) difficult to predict and requires a longer trial period with the new medication that the prescriber needs to explain to the client in addressing likely withdrawal and side effects during the transition (Schjøtt, 2016).
A national internet-based survey of 752 physicians in the American Society of Clinical Psychopharmacologists found that substantial respondents reported using dosages beyond the recommended maximum, especially of citalopram, escitalopram, venlafaxine, and gabapentin. There was infrequent use of serum levels to assess response except for lamotrigine and lithium, and <15% used pharmacogenomic testing to assess pharmacokinetics (Goldberg et al., 2015).
Psychopharmacology algorithms are one means of acquiring research-based recommendations for pharmacological interventions. Algorithms are abbreviated guidelines with full options of supporting evidence found elsewhere. They provide standardization of care driven by the need to control costs within a quality of care. Using algorithms can be helpful, especially to APPNs new to prescribing; however, they still require judgment in deciding on the most objective and current algorithms. With the more than three dozen FDA-approved drugs for mood disorder, there is little consensus about the best route to take after an inadequate response to initial treatment (Goldberg et al., 2015). Even the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study found no specific pharmacological or psychotherapeutic intervention that yielded robust efficacy after poor response to SRIs (Gaynes et al., 2008).
Two well-known, objective algorithms include the International Psychopharmacology Algorithm Project (access https://www.ipap.org) (Adamson, 2006) and the Psychopharmacology Algorithm Project at Harvard South Shore Department of Psychiatry (access http://www.psychopharm.mobi/algo_live) (Abejuela & Osser, 2016). The Texas Medication Algorithm Project (TMAP), first developed in 1997 as a collaboration between the Texas Department of Mental Health and Mental Retardation, University of Texas Southwestern, and several pharmaceutical companies (Kashner et al., 2006) has been discredited and removed from the Texas Department of Mental Health due to possible fraud (Rutherford Institute, 2006). The TMAP experience is a cautionary tale of the need to evaluate information sources for possible industry sponsorship and bias.
Beyond actual prescribing is the client's adherence to a treatment plan, which is highly correlated with the therapeutic relationship with the prescriber (Zilcha-Mano, Roose, Barber, & Rutherford, 2015). When clients are not responding to a treatment, are they taking the medication as prescribed? Are they metabolizing the medication sufficiently to achieve a therapeutic response? Do they need more time at a dosage level to achieve steady state before deciding on increasing the dosage or changing to another medication? Are there external psychosocial events that are influencing the client's response? Might the placebo effect be influencing response? The placebo effect lasts approximately 12 weeks (for better or worse) and may affect the client's response (Osser, 2007). Clients will have greater trust in the therapeutic relationship and collaborate with treatment when prescribers educate them from the beginning and with each visit about the pharmacodynamics, possible side effects, and ways to manage side effects, as well as indicating that side effects precede therapeutic effects, allowing enough time for the medication to take effect, and providing help with managing environmental influences.
Summary and Recommendations
EBP is essential in providing safe, quality patient care. In advanced practice, this poses a challenge to APPNs who are prescribing in a busy practice. Yet by the necessity of the standards of practice, APPNs must maintain current knowledge to practice (American Nurses Association, 2014). Prescribing entails complex knowledge of medications and pharmacology; skills in assessment and relationship building; and attitudes of acceptance, compassion, curiosity, creativity, and collaboration. The process of seeking evidence to support practice is continuous with variation based on the duration and support in that practice. Having a consultation group of other APPNs who meet regularly to discuss treatment plans and research to support those plans is an efficacious way of demonstrating EBP. APPNs rightfully struggle with time management of providing care, documenting services, and negotiating with other elements of the health care system, such as insurance companies, pharmacies, and primary care providers; however, these tasks do not relieve clinicians of the responsibility of continuing education and consultation. Table 1 provides some helpful resources to aid in meeting that responsibility.
Online Resources to Support Evidence-Based Prescribing
Medication algorithms provide additional assistance in making decisions about drugs, especially for those new to prescribing. It is important to recognize that algorithms tend to reflect traditional patterns of prescribing by diagnosis rather than neurobiological symptomatology and may be outdated.
Some commonly accepted practices will serve APPNs in making thoughtful prescriptive decisions (Osser, 2007):
- Make one medication change at a time.
- Allow enough time for effectiveness before augmenting or switching medications (at least 5× the drug half-life to reach steady state plus 2 weeks for full benefits).
- Educate clients about side effects and how to manage them until benefits begin.
- Avoid augmentation before completing a full trial of the original drug.
- Manage environmental stressors that may influence drug effects and adherence.
- Assess clients' metabolism (fast vs. slow metabolizers) and drug–drug interactions that may affect metabolism.
- Account for placebo effect lasting approximately 12 weeks.
- Assess serum levels of the drug to assure therapeutic levels.
Most importantly, APPNs need the commitment to EBP and a support group of colleagues to maintain that commitment. Having a journal club to share in the responsibility of reading difficult research and meeting regularly helps with life-long learning that this profession requires.
- Abejuela, H.R. & Osser, D.N. (2016). The psychopharmacology algorithm project at Harvard South Shore Program: An algorithm for generalized anxiety disorder. Harvard Review of Psychiatry, 24, 243–256. doi:10.1097/HRP.0000000000000098 [CrossRef]
- Adamson, M. (2006). White paper: Blueprint for collaboration. In Symposium on diffusion, adoption, and maintenance of psychiatric treatment algorithms. (pp. 1–45). Buffalo, NY: International Psychopharmacology Algorithm Project.
- American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
- American Nurses Credentialing Center. (2017). Knowledge, innovations & improvements: Criteria for nursing excellence. Washington, DC: American Nurses Association.
- Arango, C. (2013). To treat or not to treat? and How to treat? Two questions whose answers are far removed from evidence informed practice in child psychiatry. European Child & Adolescent Psychiatry, 22, 521–522. doi:10.1007/s00787-013-0457-z [CrossRef]
- Gaynes, B.N., Rush, A.J., Trivedi, M.H., Wisniewski, S.R., Spencer, D. & Fava, M. (2008). The STAR*D study: Treating depression in the real world. Cleveland Clinic Journal of Medicine, 75, 57–66. doi:10.3949/ccjm.75.1.57 [CrossRef]
- Goldberg, J.F., Freeman, M.P., Balon, R., Citrome, L., Thase, M.E., Kane, J.M. & Fava, M. (2015). The American Society of Clinical Psychopharmacology survey of psychopharmacologists' practice patterns for the treatment of mood disorders. Depression & Anxiety, 32, 605–613. doi:10.1002/da.22378 [CrossRef]
- Irland, N. (2019). Evidence-based practice: Are you working at the top of your license. Retrieved from https://www.oregon.gov/OSBN/Documents/Sentinel_2019_February.pdf
- Kamenov, K., Twomey, C., Cabello, M., Prina, A.M. & Ayuso-Mateos, J.L. (2017). The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, 47, 1337. doi:10.1017/S003329171600341X [CrossRef]
- Kashner, T.M., Rush, A.J., Crismon, M.L., Toprac, M., Carmody, T.J., Miller, A.L. & Suppes, T. (2006). An empirical analysis of cost outcomes of the Texas Medication Algorithm Project. Psychiatric Services, 57, 648–659. doi:10.1176/ps.2006.57.5.648 [CrossRef]
- Leichsenring, F. & Hoyer, J. (2019). Does pharmacotherapy really have as enduring effects as psychotherapy in anxiety disorders? Some doubts. British Journal of Psychiatry, 214, 53. doi:10.1192/bjp.2018.225 [CrossRef]
- Lundh, A., Lexchin, J., Mintzes, B., Schroll, J.B. & Bero, L. (2017). Industry sponsorship and research outcome. Cochrane Database of Systematic Reviews, 2, MR000033. doi:10.1002/14651858.MR000033.pub3 [CrossRef]
- Molenaar, P.J., Boom, Y., Peen, J., Schoevers, R.A., Van, R. & Dekker, J.J. (2011). Is there a dose-effect relationship between the number of psychotherapy sessions and improvement in social functioning?British Journal of Clinical Psychology, 50, 268–282. doi:10.1348/014466510X516975 [CrossRef]
- Osser, D. (2007). The role of guidelines and algorithms for psychopharmacology in 2007. Psychiatric Times, 24(4), 55–79.
- Rice, M.J. (2011). Evidence-based practice principles: Using the highest level when evidence is limited. Journal of the American Psychiatric Nurses Association, 17, 445–448. doi:10.1177/1078390311426289 [CrossRef]
- Rutherford Institute. (2006). Allen Jones reveals TMAP drug scam linked to then Governor George W. Bush. Retrieved from https://ahrp.org/rutherford-institute-interview-allen-jones-reveals-tmap-drug-scam-linked-to-then-governor-george-w-bush
- Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B. & Richardson, W.S. (1996). Evidence based medicine: What it is and what it isn't. BMJ, 312, 71–72. doi:10.1136/bmj.312.7023.71 [CrossRef]
- Schjøtt, J. (2016). Challenges in psychopharmacology: A drug information centre perspective. Journal of Clinical Pharmacy and Therapeutics, 41, 4–6. doi:10.1111/jcpt.12354 [CrossRef]
- Storey, S., Wagnes, L., LaMothe, J., Pittman, J., Cohee, A. & Newhouse, R. (2019). Building evidence-based nursing practice capacity in a large statewide health system: A multimodal approach. Journal of Nursing Administration, 49, 208–214. doi:10.1097/NNA.0000000000000739 [CrossRef]
- Tucker, S. (2019). Implementation: The linchpin of evidence-based practice changes. American Nurse Today, 14(3), 8–13.
- U.S. Food & Drug Administration. (2019a, March19). FDA approves first treatment for post-partum depression. Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm633919.htm
- U.S. Food & Drug Administration. (2019b, March5). FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor's office or clinic. Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632761.htm
- Zilcha-Mano, S., Roose, S.P., Barber, J.P. & Rutherford, B.R. (2015). Therapeutic alliance in antidepressant treatment: Cause or effect of symptomatic levels?Psychotherapy & Psychosomatics, 84, 177–182. doi:10.1159/000379756 [CrossRef]
Online Resources to Support Evidence-Based Prescribing
|Agency for Healthcare Research and Quality Clinical Guidelines and Measures||https://www.ahrq.gov/gam/index.html|
|Cochrane Library Research Databases||https://www.cochranelibrary.com|
|PubMed U.S. National Library of Medicine National Institutes of Health||https://www.ncbi.nlm.nih.gov/pubmed|
|Neuroscience Education Institute||https://www.neiglobal.com (Industry sponsored, fee for membership)|
|Psychopharmacology Institute||https://www.psychopharmacologyinstitute.com (Free to subscribe, fee for premium membership, without industry sponsorship)|