DUNIA-CAPSTONE 3

Evidence-Based Literature Review Supporting the Practice Change 1

Evidence-Based Literature Review Supporting the Practice Change

Evidence-Based Literature Review Supporting the Practice Change

Student’s name: Dunia Barrueta

Florida National University

Instructor: Dr. Carmen Lazo, DNP, MSN, APRN-BC, APN

Course: Capstone Project

Date: July 27, 2026

Current State of the Problem

Depression is one of the most prevalent conditions treated by primary care, and a leading cause of disability worldwide. Depression is frequently not recognized in routine clinical assessments and is not adequately treated, which results in late diagnosis and treatment of the disorder, despite having available validated screening tools and evidence-based treatments for depression. People with physical complaints who are being cared for by a Primary Health Care provider may not manifest psychological signs and symptoms, and standardized screening is important to identify those needing further evaluation. The proposed change in practice consists of rolling out a Patient Health Questionnaire-9 (PHQ-9) depression screening protocol, a nurse practitioner (NP) referral and follow-up protocol for adults who are treated in primary care clinics across Miami-Dade County, Florida. The goal is to enhance the identification of depression and the number of behavioral health referrals completed within six months compared to the current system of inconsistent screening and provider discretion.

Evidence Supporting Standardized Depression Screening

Existing literature remains robust in that the standardization of depression screening promotes the detection of symptoms of depression in primary care. Garcia et al. (2022) determined that universal screening for depression led to greater parity in depression detection across various adult patients. These results demonstrate that standardized screening helps to minimize the effects of provider judgment and will help to decrease disparities among racial and ethnic groups and by socioeconomic status. The results of these findings are significant for Miami-Dade County, Florida, due to its diverse population of Japanese-speaking residents as well as its being a culturally and linguistically diverse county. When administered in a universally standardized manner, the PHQ-9 is an evidence-based assessment for every eligible patient, rather than allowing for diagnoses to fall through the cracks. But, as also pointed out by Garcia et al., screening alone would not be helpful if positive results are not promptly assessed, referred, and treated, and as such, there is a need for structured follow-up of the proposed intervention.

Integrated Mental Health Care and Quality Improvement

There are several studies that further support the integration of mental health services in Primary care. Isaacs & Mitchell (2024) found that elements of integrated care models include collaborative effort among members of the medical care and behavioral health team, clinical pathways, leadership support, and communication between primary care and behavioral health providers. Through their review, they found that integrated care (IC) provides better access to mental health care and less fragmentation of care. Knight et al. (2022) reported similar results when they looked at quality improvement collaboratives in general practice. They discovered that organizational commitment, ongoing monitoring, provider education, and leadership are needed to achieve sustainable improvement of clinical outcomes.

There are a number of consistent findings that integrated approaches to care are effective in managing depression, but divergent findings on how these approaches are implemented. Although both studies highlighted the critical importance of organizational readiness and different approaches to ensuring quality, Isaacs and Mitchell (2024) went further in emphasizing the importance of integrating other disciplines into the team and ensuring organizational readiness. Knight et al. (2022) focused mainly on methods for quality improvement, which included collaborative learning, quality audit and feedback, and monitoring performance. Both reviews, however, found that leadership of standardized processes and the tracking of outcomes are effective in supporting the success of evidence-based interventions over time.

Evidence Supporting Nurse Practitioner-Led Care

NPCs are also well-positioned to facilitate better patient engagement and health care coordination, backed by evidence. Baglini et al. (2024) tested a nurse practitioner-led telemedicine referral bridge for enhancing attendance at a psychiatric first visit. Issues about transport, poor scheduling, referral protocol, financial constraints, or fear and confusion are all factors related to patients missing behavioral health appointments. Appropriate follow-up by a nurse helped to increase the completion rate in the study, which gave next-patient education, cared for patients, and maintained regular communication.

Leadership is more important for nurse practitioners than behavioral health coordination. A nurse practitioner (NP) collaborative CHM was assessed in a randomized controlled trial with heart failure (HF) patients by Chen et al. (2025). While the group was not identical to adult patients with depression, the results of this study showed that collaborative care led by a nurse had significant positive outcomes for patients regarding medical costs, functional status, nurse lectures regarding self-management, and fewer rehospitalizations. The implications of these findings are that when patient education, patient monitoring, trans-disciplinary team collaboration, and continuity of care are realized, chronic disease management is enhanced through coordinated NP leadership. Improved long-term disease management is appropriate for depression care; this is because depression is often accompanied by chronic diseases like cardiovascular disease, diabetes, and hypertension.

Application of Evidence to the Proposed Practice Change

There is further evidence supporting nurse-led depression interventions from a systematic review and meta-analysis conducted by Cranstoun et al. (2024), which explored nurse-led psychological intervention for adult cancer patients who are depressed. Interventions delivered by nurses were found to significantly alleviate depressive symptoms and enhance emotional well-being and patient engagement. Results presented in this study, although undertaken with oncology samples, support the role of an evidence-based nurse to effectively provide mental health interventions in addition to ongoing clinical care. Likewise, Babu et al. (2025) found that nurse depression management in primary care promotes depression symptom tracking, adherence to depression treatment, patient education, and continuity of care. They noted that nurses have a unique opportunity to offer continuous assessment, remind patients of treatment plans, facilitate multidisciplinary management, and assess patients for other services that address behavioral and mental health. These studies, combined, indicate that NP's can be expanded beyond screening for depression, and should manage the depression as a whole.

The evidence also illustrates the value of quality improvement work being undertaken in a structured way when working towards change in practice. According to Knight et al. (2022), quality improvement collaboratives are effective in increasing implementation success when they set measurable targets and give providers frequent feedback about their performance and encourage a team-based approach to implementation. Implications to the proposed project: If the proposed project is to be implemented, it is important to monitor screening compliance, completion of the PHQ-9, behavioral health referrals, and attendance of the intervention throughout the 6-month intervention period.

Strengths, Limitations, and Controversies in the Evidence

Despite the overwhelming evidence for depression screening and collaborative care, there are also a few concerns and challenges to standardized screening. One question that has come up is whether or not to try screening everyone for depression if resources for behavioral health are not available. Increased screening may lead to a higher volume of patients needing treatment and thereby strain already limited BH services, albeit this may not happen, as the past couple of years have demonstrated and Garcia et al. (2022) recognized. Likewise, Isaacs and Mitchell (2024) found workforce deficiencies and lack of communication amongst others as insurmountable challenges in the delivery of integrated mental healthcare. These findings show that screening is not enough and underscore the importance of coordinated care, referral systems and administrative support. Another restriction is with regard to the population studied. Cranstoun et al. (2024) directed their attention towards adults with cancer, for instance, and Chen et al. (2025), towards heart failure patients. While these populations vary from the suggested evidence-based adult primary care population, the value of nurse-led collaborative care links to depression management, further supporting the justification for nurse-led approaches with this other population.

Currently, the evidence is supportive for requiring standardized depression screening of patients, nurse practitioner-led depression referral and/or follow-up, as both are a response to multiple gaps in the current evidence. Although screening for depression began to gain ground in primary care, its use remained inconsistent, screening was poorly integrated into behavioral health, and the processes for depression screening, diagnosis, and referral were not well connected. Standardized screening enables a consistent approach to identifying patients for extra screening, and using a nurse-led follow-up service increases referral completion, engagement with patients and continuity of care. The intervention is also consistent with evidence-based practices for delivery of integrated healthcare and quality improvement practices that promote long-term sustainability.

Justification for the Proposed Practice Change

This practice change is expected to yield greater depression identification, higher rate of behavioral health referrals completed, earlier initiation of treatment, better integration of primary care and mental health, and better patient outcomes. Other clinical benefits may include decreased use of the emergency department, better control of associated chronic conditions, decreased health service costs, and better quality of life. Staff education, a change to electronic health records, standardization of a referral pathway and administrative support are required for implementation.

Summary of the Evidence

In sum, the literature is supportive of the effectiveness of standardized depression screening via nurse practitioner-led collaborative care. The studies examined confirmed the following common findings: improved depression identification is related to standardized screening tools; screening along with coordinated follow-up has a higher level of success; improved implementation is associated with leadership, quality improvement strategies, and interdisciplinary collaboration. There are some differences of opinion on the methods used to implement the practices and the populations studied, but the overall studies strongly suggest that a practice change is warranted for adult primary care patients in Miami-Dade County.

References

Babu, R., Juthamamee, S., Sahu, P., & Pangandaman, H. K. (2025). Nurse-Led Interventions for Patients with Depression in Primary Care: Aligned with SDG.  Vascular and Endovascular Review,  8(5s), 75-84. https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16895

Baglini, K., Bruns, D. P., & Hill, J. R. (2024). Telemedicine as a Referral Bridge: A Nurse Practitioner–Led Intervention to Increase Initial Psychiatric Appointment Attendance.  The Journal for Nurse Practitioners,  20(7), 105068. https://doi.org/10.1016/j.nurpra.2024.105068

Chen, C. W., Wang, T. J., Liu, C. Y., Chuang, Y. H., Su, C. C., & Wu, S. F. V. (2025). Effectiveness of a nurse practitioner-led collaborative health care model on self-care, functional status, rehospitalization and medical costs in heart failure patients: A randomized controlled trial.  International journal of nursing studies,  162, 104980. https://doi.org/10.1016/j.ijnurstu.2024.104815

Cranstoun, D., Baliousis, M., Merdian, H. L., & Rennoldson, M. (2024). Nurse-led psychological interventions for depression in adult cancer patients: A systematic review and meta-analysis of randomized controlled trials.  Journal of Pain and Symptom Management,  68(1), e21-e35. https://doi.org/10.1016/j.jpainsymman.2024.03.028

Garcia, M. E., Hinton, L., Neuhaus, J., Feldman, M., Livaudais-Toman, J., & Karliner, L. S. (2022). Equitability of depression screening after implementation of general adult screening in primary care.  JAMA Network Open,  5(8), e2227658. https://doi.org/10.1001/jamanetworkopen.2022.27658

Isaacs, A. N., & Mitchell, E. K. (2024). Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review.  International Journal of Mental Health Systems,  18(1), 5. https://doi.org/10.1186/s13033-024-00625-x

Knight, A. W., Tam, C. W. M., Dennis, S., Fraser, J., & Pond, D. (2022). The role of quality improvement collaboratives in general practice: a qualitative systematic review.  BMJ Open Quality,  11(2). https://doi.org/10.1136/bmjoq-2021-001800

Parish, A. L., Gillis, B., & Anthamatten, A. (2023). Pharmacotherapy for depression and anxiety in the primary care setting.  The Journal for Nurse Practitioners,  19(4), 104556.https://doi.org/10.1016/j.nurpra.2023.104556

Roberts, A., Corathers, S., Rapaport, R., Rompicherla, S., Majidi, S., Rioles, N., ... & Malik, F. S. (2024). Depression Rates in Youth With Type 1 Diabetes During the COVID-19 Pandemic: Data From the T1D Exchange Quality Improvement Collaborative.  Clinical Diabetes,  42(4), 532-539. https://doi.org/10.2337/cd24-0004

Sarakbi, D., Groll, D., Tranmer, J., & Sears, K. (2022). Achieving quality integrated care for adolescent depression: a scoping review.  Journal of Primary Care & Community Health,  13, 21501319221131684. https://journals.sagepub.com/doi/full/10.1177/21501319221131684