Here is the research paper that is the culmination of a course filled with so much deep, confusing emotion. I dedicate this to all of us that have lost loved ones to suicide. May we see the changes in our lifetime that it will take to save the lives of millions more who suffer from the worst antagonist: suicidality.
An area of concern in nursing practice is where primary care and mental illness meet. Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care nurses can make a lifesaving impact through education and frequent follow up phone calls. In 2016, 45,000 Americans died of suicide. “Research indicates that during 2012-2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry). Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes. In patients with mental health related office visits, is education on healthy lifestyle including mindfulness, diet and exercise in combination with regular follow-up phone calls every other week from primary care nurses effective in decreasing symptoms of mental illness as indicated by lower patient health questionnaire 9 (PHQ-9) score, fewer office visits and emergency room visits over a 12-week period? Research was reviewed from four articles found utilizing EBSCO-CINAHL Plus with Full-Text. Four types of research studies including quantitative, qualitative, mixed method and meta-analysis were reviewed and analyzed. The quantitative and mixed method samples were obtained randomly. The qualitative method sample was obtained purposively. The meta-analysis was a review of six randomized controlled trials. The quantitative and mixed methods articles utilized longitudinal data collection. The qualitative study utilized cross-sectional data collection. Sample sizes ranged from 5 patients to 696 patients.
Nearly one in five adult Americans experience the effects of mental illness ranging from depression to suicidality. Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care registered nurses can make a lifesaving impact through education and frequent follow up phone calls. In 2016, 45,000 Americans died of suicide. “Suicide is a leading cause of death in the US….Health care systems can provide high quality, ongoing care focused on patient safety and suicide prevention” (OADC). Lack of mental healthcare resources places primary care clinic registered nurses in a position to fill the gap. “Research indicates that during 2012– 2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry). Treating mental illness as a chronic disease process is where the key to change lies. Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes. “In 2014, there were an estimated 885 million office-based physician visits in the United States” (Ashman). This illustrates the tremendous opportunity for impact primary care registered nurses can make through patient education.
Most current nursing research revolves around the role of the psychiatric mental health nurse practitioner instead of the role of the office-based ambulatory care registered nurse. The gap between primary care nursing and mental health nursing would be further closed if there was one electronic medical record (EMR) to unite all EMRs. This would also assist the registered nurse as case manager, which is the role supported as most effective in integrating primary healthcare and mental healthcare in current research. Mental health patients are being lost in the United States healthcare system because registered nurses are not involved in patient care at the primary care level to the degree that they could be and should be.
The role of registered nurse in bridging the gap between what is considered classic disease management processes such as diabetes mellitus and hypertension, and mental health processes such as depression and anxiety, when it has been studied, shows repeatedly that patients respond with comfort and ease to the registered nurses at their primary care physician’s practices which increases their success in treating the symptoms of their disease processes. Registered nurses are an extremely important key to a patient’s care. No other healthcare team member treats patients as an entire human being the way registered nurses are trained to do. Registered nurses address not only a patient’s physical symptoms, but also a patient’s mental, emotional, spiritual and environmental symptoms, as well. Because of this, registered nurses are poised at an excellent vantage point to understand a patient’s complete care needs, which makes them especially qualified to intervene on multiple levels to ensure a patient is receiving needed therapies to maximize quality and quantity of life.
Research was reviewed from four articles found utilizing the Cumulative Index of Nursing and Allied Health Literature (CINAHL) through EBSCOhost. Limitations set for the searches included utilizing EBSCO-CINAHL Plus with Full-Text as well as setting search parameters for the past five years only and searching keywords which included nursing education, nursing, depression, mental health, suicide, machine learning, mindfulness and primary care. All articles were published in the English language. All articles were reviewed and analyzed utilizing Avila University’s Nursing Department Literature Review Protocol for each of four types of research studies including quantitative, qualitative, mixed method and meta-analysis. The quantitative and mixed method samples were obtained randomly. The qualitative method sample was obtained purposively. The meta-analysis was a review of six randomized controlled trials. The quantitative and mixed methods articles utilized longitudinal data collection. The qualitative study utilized cross-sectional data collection. The sample sizes ranged from 5 patients to 696 patients.
The first article reviewed was a quantitative study, “Collaborative nurse-led self-management support for primary care patients with anxiety depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study)” authored by Thomas Zimmerman, Egina Puschmann, Hendrik van den Bussche, Birgitt Wiese, Annette Ernst, Sarah Porzelt, Anne Daubmann and Martin Scherer. This study was published in 2016 and took place in Hamburg, Germany in twenty general practitioners’ practices with a total of 220 patient participants. The patients that participated in the study were chosen by, “a biometrician (AD), not involved in field work” (Zimmerman, Puschmann, van den Bussche, Wiese, Ernst, Porzelt, Daubmann, Scherer). The sample was obtained utilizing certain eligibility criteria including “a) age: 18-65 years old, b) literacy (German), c) fully able to give consent, d) sufficient auditory and visual capabilities, e) currently not in psychotherapeutic treatment, f) Patient Health Questionnaire (PHQ) scoring 5 points or higher” (Zimmerman, et al.). Patients were divided 1:1 to either participate in nurse-led care or routine care. Nurse-led care involved case management and counselling techniques to encourage patients to lead their care plan through self-management. By the end of the study patients who were in the nurse-led intervention group reported increased self-efficacy as measured by several different scales, including the General self-efficacy scale (GSE scale), PHQ, EQ-5D quality of life and the Freiburg questionnaire of coping with illness (FQCI). Data collection was longitudinal. The main barrier to implementing this type of intervention across the board in Germany is lack of economic resources and lack of education of healthcare professionals related to what a registered nurse is capable of in the primary care setting.
The second article reviewed was a qualitative study, “Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions” authored by Lisa A. D. Webster, David Ekers and Carolyn A. Chew-Graham. This study was published in 2016 and took place in the North of England with ten clinicians—five general practitioners (GPs), three practice nurses (PNs), one health assistant and one mental health specialist and five patients (four of which completed the interview). “Recruitment of clinicians…was by personal invitation from the research team to those participating practices who took part in the service development project. The invitation was made after two months of working within the collaborative care framework in order to explore the implementation of the intervention within the practice” (Webster, Ekers, Chew-Graham). The recruitment of patients to participate was also by invitation, which was sent about two months after the patients had received the intervention with an offer for a “love to shop voucher” (Webster, et al) for those willing to give their time for an interview. Demographics of the patient sample were predominately female diabetics with some form of arthritis or back pain in addition to being depressed. Demographics of the clinician sample were also predominately female. Practice sizes ranged from 4,402—25,386. Data collection was cross-sectional and was completed utilizing semi-structured interviews which were face-to-face for clinicians and via phone for patients. The results of this study also support the integration of mental health services in the primary care setting, but with one important caveat: tending appropriately to the mental healthcare of the registered nurses who are the leaders in providing and coordinating that level of patient care.
The third article reviewed was a mixed methods study authored by Brenda Reiss-Brennan, “Mental health integration: Normalizing team care.” This study was published in 2014 and focuses on nine primary care clinics of Intermountain Healthcare in Salt Lake City, Utah. Three clinics from each phase of mental health integration were included: potential, adoption and routinized. Even though this study utilized a mixed methods approach, it is primarily a qualitative study. The sample included both clinicians and patients. Fifty clinical staff were selected for balance among team members including physicians, clinic managers, nurse care managers, mental health specialists and medical support staff. Patients were randomly selected who had received care for depression from their primary care provider (PCP) in the previous twelve months, for a total of 59. This study tested the effectiveness based on objective and subjective criteria of mental health integration (MHI) which is “a team-based approach where complementary roles include the patient and family and are operationalized at the clinic improving both physician and staff communication” (Reiss-Brennan). MHI is a standardized approach to incorporating mental healthcare into the primary care setting. The data collected was longitudinal and was collected via self-report, observation and interview. Again, the data collected, which included a decrease in emergency department visits and patient-reported decrease in mental illness symptomatology, as well as positive provider reported reactions to MHI, support implementation of mental healthcare via the primary care setting.
The fourth and final article analyzed was a meta-analysis authored by Kathleen Barrett and Yu-Ping Chang, “Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care.” The study was published in 2016 and reviewed a total of six articles with a total of 696 participants. Four electronic databases were searched including CINAHL, Medline, PsycInfo and Google scholar. Key words included in the search were as follows: chronic pain, depression, depressive disorders, behavioral interventions and primary care. Limitations set on the search included articles published during the years 1995 to 2015, available in English, original randomized controlled trials (RCT), adult population and studies that contained a behavioral health intervention. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. The patients in the study had an average age of 45, with 316 men and 380 women. Three of the six studies were conducted in the United States, two in Australia and one in England. All study participants had at least two of the three diagnoses (depression, chronic pain and substance used disorder) during the time of the study. Two of the six studies were conducted strictly in primary care. The results of this meta-analysis showed, again, that integrating behavioral healthcare in the primary care setting had a positive impact on patient care through decreased mental illness symptomatology.
The changes that need to happen to better serve our country’s mental health patient population revolve around nurse-led mental health integration of primary care. The resources it would take to influence the people who could make this change are tremendous. The changes that need to be made to standardize mental health integration have already been successfully implemented by Intermountain Healthcare in Salt Lake City, Utah. To make these changes across the country there will need to be a change in healthcare law. This begins with one EMR that acts as an umbrella for all EMRs. There needs to be a way for each of the many pieces of the care puzzle to fit together so that each piece of a patient’s records from different providers can be viewed by each of the team members on the patient’s care team. This would also allow application of machine learning algorithms to accurately predict suicidality in patients. In some cases, before the patient is aware of the imminent danger facing them. “In an effort to contribute to the development of one such method, we applied machine learning (ML) to electronic health record (EHR) data. Our major findings included the following: (a) This method produced more accurate prediction of suicide attempts than traditional methods, with notable lead time (up to 2 years) prior to attempts; (b) model performance steadily improved as the suicide attempt became more imminent; (c)model performance was similar for single and repeat attempters; and (d) predictor importance within algorithms shifted over time” (Walsh, Ribeiro, Franklin).
The changes that are needed are possible, but only with the help of big money to lobby lawmakers in the community on a local, state and federal level. To find funding for this type of initiative nurses would need to contact major non-profit organizations that study mental illness such as the American Foundation for Suicide Prevention (AFSP), the National Alliance for Mental Illness (NAMI) and perhaps the countless of other small non-profits started by parents, family members and friends of those who have died of suicide. Bringing these voices together as one voice would provide the power needed to move legislation. This is the tip of the iceberg and would eventually lead to a massive healthcare system reformation. The first step, though, is to have one medical record that unites them all. Ideally this medical record would be fluid enough to communicate with most of the EMRs already in existence.
So many lives are lost every day to suicide. If the resources were in place to address mental illness where it meets primary care, it is certain that the number of sons, daughters, husbands, wives, ex-husbands, ex-wives, mothers, fathers, brothers, sisters, cousins, aunts, uncles, friends, neighbors and other community members that we lose to suicide would drastically decrease. The evidence uncovered in this research review supports this without a shadow of a doubt. “Most patients with behavioral health needs use the primary care office as their main source of care, and given the nation’s shortage or behavioral health providers, this may be the only setting in which behavioral health problems can be broadly recognized and treated” (Crowley, Kirschner). Bottom line is there is a huge need for nurses in primary care who are able and willing to implement changes once they are legislated either as part of health care law or part of their health care entity’s updated care standards at the place where primary care nursing and mental health nursing meet.
Ashman, J. J., Rui, P., & Okeyode, T., (2017). Characteristics of office-based physician visits 2014. National Center for Health Statistics Data Brief (no 292). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db292.htm
Barrett, K., & Chang, Y. (2016). Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care. Journal of Nursing Scholarship,48(4), 345-353. doi:10.1111/jnu.12213
Cherry, D., Albert, M., & McCaig, L. F., (2018). Mental health-related physician office visits by adults aged 18 and over: United States, 2012–2014. National Center for Health Statistics Data Brief (no 311). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db311.htm
Crowley, R. A., & Kirschner, N., (2015). The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: Executive summary of an American college of physicians position paper. Annals of Internal Medicine,163(4), 298. doi:10.7326/m15-0510
National Center for Health Statistics., (2016). Depression. Retrieved from https://www.cdc.gov/nchs/fastats/depression.html
Office of the Associate Director for Communications., (2018). Vital Signs: Suicide rising across the US, more than a mental health concern. Retrieved from https://www.cdc.gov/vitalsigns/suicide/index.html
Reiss-Brennan, B., (2014). Mental health integration: Normalizing team care. Journal of Primary Care & Community Health, 5(1), 55-60. doi:10.11/2150131913508983
Walsh, C. G., Ribeiro, J. D., & Franklin, J. C., (2017). Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science,5(3), 457-469. doi:10.1177/2167702617691560
Webster, L. A. D., Ekers, D., & Chew-Graham, C. A. (2016). Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions. BMC Nursing,15(1). doi:10.1186/s12912-016-0190-2
Zimmermann, T., Puschmann, E., Bussche, H. V., Wiese, B., Ernst, A., Porzelt, S., Daubmann, A., Scherer, M. (2016). Collaborative nurse-led self-management support for primary care patients with anxiety, depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study). International Journal of Nursing Studies,63, 101-111. doi:10.1016/j.ijnurstu.2016.08.007