LORI CAPSTONE PP

1

Final Capstone Project Part I, II, III

Student’s name: Yaneisy Loriga

Instructor: Carmen Lazo

Course: MSN Capstone Project-DBX-DL01

Date: April 14, 2026

Introduction to the Practice Problem

Overview of Major Depressive Disorder

Major Depressive Disorder is one of such mental health disorders, a serious and widespread mental health disorder, which is typified with constant sadness, lack of interest in all activities, impaired functioning, and in severe cases, suicidal thoughts (Fisher et al., 2024). It impacts millions of adults globally and has an expansive influence on the quality of life, productivity, and a general outcome of health. Depression has been ranked among the leading causes of disability in the United States and the world health organization has announced them as one of the leading causes of burden of diseases in the world.

The treatment-resistant depression (TRD) is a partial version of the Major Depression Disorder and it is expressed when the patients fail to respond positively to two or more antidepressant medications (McIntyre et al., 2023). The given condition poses a significant issue in clinical practice because it is connected with a long-lasting disease, enhanced healthcare care, and a greater likelihood of the patient becoming hospitalized.

Importance of the Practice Problem.

The importance of treatment-resistant depression is that it is very prevalent, economically expensive, and affects patient outcomes (Lundberg et al., 2023). In the US, an estimated 7-10 percent of adults suffer depression every year, with almost a third of them coming with the treatment resistant variations. Depression cost to the economy is more than 300 billion a year in terms of health care cost, time lost cause of work and disability benefit. On a local level, in Miami-Dade County, the issue of mental health disorders is one of the most common morbidity factors, and underserved populations experience an extra barrier to care due to a lack of access to special treatment and socioeconomic differences.

The expenses of treating Treatment-resistant depression are far higher as compared to those of non-resistant where there is repetition of medication trials, more outpatient visits, and hospitalization. More complicated procedures like Transcranial Magnetic Stimulation (TMS) will open the possibility of lowering the expenses in the long-term by enhancing the results of the treatment process and lowering the rates of the relapse (Seewoo et al., 2022).

Purpose Statement

The aim of the proposed study is to determine the efficacy of Transcranial Magnetic Stimulation treatment in the minimization of depressive symptoms and enhancement of functional outcomes in a sample of adults with outpatient treatment-resistant Major Depressive Disorder in Miami-Dade County. The result that is proposed is quantifiable using validated depression scales including Patient Health Questionnaire-9 (PHQ-9), in 12 weeks of treatment. The project will prove that TMS is a safe and evidence-based approach to alternative continued pharmacologic management.

PICOT Question

Overview

The PICOT question used when developing this project consists of the following: “ In adults aged 21–65 diagnosed with treatment-resistant Major Depressive Disorder in an outpatient mental health clinic in Miami-Dade County (P), how does Transcranial Magnetic Stimulation (TMS) therapy (I), compared to continued pharmacologic management alone (C), affect depressive symptom reduction and functional improvement (O) over a 12-week treatment period (T)?” The question is designed to fill a very crucial gap in depression treatment, especially in cases when a person does not respond to the conventional methods of pharmacologic interventions (Seewoo et al., 2022).

Population (P)

The sample population will be comprised of adults with Major Depressive Disorder found in outpatient mental health clinics within Miami-Dade County whose treatments are resistant to treatment. This population is a vulnerable one because of being a chronic illness due to functional impairment and exposed to comorbid conditions.

Intervention (I)

The treatment method is the Transcranial Magnetic Stimulation which is a non-invasive treatment program that employs magnetic fields to stimulate the nerve cells in the brain. TMS is approved in depressed patients who failed to respond to the medication and is becoming more widespread in the outpatient medical facilities.

Comparison (C)

The comparison intervention is maintained pharmacologic management itself, which implies antidepressant drugs and periodic psychiatric follow-ups. Although medication is the treatment defense, a large portion of treatment-resistant depression patients will fail to have remission using pharmacologic therapies alone.

Outcome (O)

The main results are observed to be the lessening of symptoms of depression as well as enhancing of the functional status. The measurement of these will be done through standardized instruments like PHQ-9 and functional assessment scales. The aim of defining improvement is the clinically significant decrease in the scores of depressions and the enhanced capacity to engage with such daily activities.

Timeframe (T)

This project is planned to last 12 weeks in accordance with the common TMS treatment regimens and provide enough time to measure the clinical results.

At Risk Population and Environment.

The population size is another aspect that should be described. The target population consists of adults having treatment-resistant depression in Miami-Dade County, which is a diverse urban neighborhood with very high socioeconomic inequalities (Seewoo et al., 2022).

Social Determination of Health.

Poor mental health is caused by factors including low income, unemployment, low level of education and inaccessibility of health care services among others. The unequal access to healthcare in Miami-Dade County imbalances against the minority and underserved population unjustly scales the number of people with untreated or poorly managed depression.

Vulnerability and Risk Factors.

This group is susceptible because these issues associated with treatment-resistant depression such as chronic stress, trauma history, comorbidity, and insufficient access to mental health can trigger the aggravation of the symptoms, reduced life quality, and even the probability of their hospitalization. The necessity of the change is acute because the existing methods of treatment might not be sufficient to meet the needs of such a group of people. TMS and other evidence-based interventions provide a chance to enhance both results and discrepancies in care.

Evidence-Based Proposal

Proposed Intervention

The suggested intervention is to carry out a Transcranial Magnetic Stimulation therapy in outpatient mental health clinic environment to patients with treatment-resistant depression (Seewoo et al., 2022). TMS is confirmed by the accumulating evidence of its usefulness in decreasing the level of depressive symptoms and enhancing functional outcome.

Resources and Implementation.

The implementation of TMS is a procedure that requires solitary devices, schooling of medical staff and clinical pertinent guidelines. The choice of patients, educating them, and observing them throughout the treatment process is one of the areas where the advanced practice nurses (APNs) play a significant role. It is necessary to collaborate with psychiatrists and other mentally-focused professionals with the aim of seeking comprehensive care.

Feasibility

The fact that the option of this intervention is a possibility is explained by the increase in the access to TMS in outpatient facilities and non-invasive nature of the procedure. The initial costs may be high but in the long run, it will result to reduced healthcare utilization and improved patient outcomes hence its usefulness in the long run.

Timeline

The proposed plan will include the stages of patient recruitment, pre-interrogation, 12 weeks of the TMS application and the post interventions. The periodical follow-up appointment will be made to monitor the progress and respond to questions.

Theoretical Framework

Application of Nursing Theory.

Self-Care Deficit Nursing Theory by Orem will be used in this case. TMS is arguably considered in the framework of the treatment-resistant depression, as a means to increase the functional capacity and self-care activity of patients in question (Isik & Fredland, 2021).

Integration into Practice

The theory will be incorporated into the project with the focus on the patient-centered care, education, and empowerment. Nurses will play a critical role in assessing the needs of the patients, providing a helping hand, and promoting self-compliance with the treatment. These are directed towards the provision of improved clinical results as well as maximizing the competency of their patients in managing their condition.

Transcranial Magnetic Stimulation for Treatment-Resistant Depression

Synthesis of Current Evidence

Major Depressive Disorder is one of the most severe and common mental illness disorders. It is defined by continuous sadness, lack of interest in all activities in life, and failure to perform normal functioning, and even suicidal thoughts in a more severe form. It has a vast impact on millions of adults worldwide and is an extensive phenomenon that influences the quality of life, productivity, and overall health outcomes (Fiorillo et al., 2025). It affects millions of grown-ups in the universe and has very far-reaching impacts on life quality, output, and the overall outcome of health. Depression is one of the difficulties that most adults encounter whenever they attempt to respond to antidepressant treatments without taking the appropriate treatment regimen.

Several studies that were conducted properly come to the conclusion of a significant decrease in the severity of depression, as well as well-validated scales like Patient Health Questionnaire-9 (PHQ-9) and Hamilton Depression Rating Scale (HDRS) (Nwachukwu, 2025). Ilhan & Arikan (2025) also determined that TMS had a greater reduction in depressive symptoms and remission rate in patients, as compared to patients who received only sham (fake) TMS and pharmacologic treatment. On the same note, a systematic review and meta-analysis study, by Saelens et al., (2025) revealed that TMS was effective in enhancing the response and remission rate of TRD. The positive outcomes are unanimous, although variability of the studies exists in the specifics of TMS, such as frequency, intensity, and duration of stimulation. High-frequency TMS has been reported to produce better results compared to low-frequency TMS in some studies, whereas in some others, there are no differences in results (Saelens et al, 2025). Moreover, the short-term effects are predictable, but the long-term effects are somewhat unpredictable, and some patients may need booster treatments to maintain TMS effects. Hutton et al (2023). TMS access may also be made available in such areas as Miami-Dade County, where there are numerous underserved patients with deficient access to mental health care. Such practice change opens the door to novel treatment modalities and achieves population health and clinical goals.

Application to PICOT Question

My PICOT question is “In adults aged 21–65 diagnosed with treatment-resistant Major Depressive Disorder in an outpatient mental health clinic in Miami-Dade County (P), how does Transcranial Magnetic Stimulation (TMS) therapy (I), compared to continued pharmacologic management alone (C), affect depressive symptom reduction and functional improvement (O) over a 12-week treatment period (T)?”. Evidence supports the PICOT question, which seeks to compare whether or not TMS, along with pharmacotherapy, is more effective than pharmacotherapy alone at 12 weeks for the treatment of depressive symptoms and capacity for independent function. Most studies focused on adult participants (21-65 years) with a diagnosis of TRD, aligning well with the intended patient population in Miami-Dade County. The studies demonstrate that TMS results in greater improvement in depressive symptoms and increases functioning in various areas, including activities of daily living, social participation, and work. These measures directly align with the planned outcomes measured in the PICOT question, such as using the PHQ-9. Many studies also involve the use of TMS in an outpatient setting, increasing the likelihood of similar settings for implementation.

Evidence Supporting Practice Change

The evidence for practice change in the dissemination of TMS is robust, backed up by efficacy, impact, and effectiveness. TMS has been compared to medication-only treatment in many randomized controlled trials and reviews in patients with treatment-resistant depression (Saelens et al., 2025). TMS has a response rate of 50% to 60%, and a remission rate of 30% to 40%, which is comparable with medication alone in treatment-resistant depressed patients (Joseph et al., 2025).

In addition, TMS has shown increased functionality. Patients treated by TMS have better cognitive metrics, quality of life, and functionality. This is crucial as TRD is often associated with both persistent depressive symptoms and dysfunction (Hutton et al., 2023). By addressing symptoms and functioning, TMS takes a comprehensive approach. TM has few side effects as far as safety is concerned. As a non-pharmacological approach, TMS has fewer side effects particularly in comparison to the side effects that are normally experienced when taking a medication, such as weight gain, drowsiness, and sexual dysfunction. TMS is safe and results in enhanced adherence to treatment and reduced drop-outs.

The next factor to consider is cost. Though there is a cost for the equipment and training for TMS, there are studies describing the cost-benefit of TMS. These patients have trialed multiple medications, had many visits to the doctors, and potentially been hospitalized. The effectiveness and low rate of relapse with TMS result in cost savings for other medical and psychiatric care. Cost-benefit studies suggest TMS yields a cost-benefit over time, particularly for those with severe, chronic depression.

Nurses, Advanced Practice Nurses (APNs) in particular, play a critical role in TMS (Hutton et al., 2023). Studies highlight nurses' coordination of care, education, and monitoring of treatment response. Nurses are instrumental in assessing for TMS, educating patients about TMS, documenting treatment protocols, and assessing TMS with a range of outcome measures (Lozano et al., 2025). The presence of nurses enhances patient satisfaction and engagement and increases patient outcomes.

Need for Practice Change

It is necessary to alter because the current ways of treating depression and especially treatment-resistant depression are not effective. Not all patients become asymptomatic on medication, which causes persistent sickness, lower quality of life scores, and high risk of hospitalization (Okesanya et al., 2025). Moreover, the burden of depression on health care system is growing and it is obvious that more efficient and more sustainable methods are required. In some parts of the state such as Miami-Dade County, this problem is exacerbated by the socioeconomic status of the people and their access to specific forms of mental health treatment. Patients are prone to further sickness and distress until alternative interventions including TMS are considered.

Current State and Gaps in Care

The typical approach to depression treatment is medications, which fail in treating treatment-resistant depression. Psychotherapies and medication are broadly administered but they are inadequate to everyone. The restrictions to the implementation of TMS include the high cost, limited time and access, and the lack of training of providers (Lozano et al., 2025). However, increasing awareness, technological advances and evidence of the effectiveness of TMS are mitigating these obstacles and make TMS adoption easier.

The Advantages and The Disadvantages of TMS.

TM has a high level of benefits such as safety, effectiveness and side effect. Its advantages are that it is a choice when a patient is not responding to other interventions, and there is an increase in the symptoms and functioning of depression (Bhattacharya et al., 2022). Such drawbacks as the necessity of several treatments, high initial price, and the possible variation in the response time are present. Maintenance interventions might be required.

A Practice Change Proposal

One of the most serious mental disorders, which afflict adults worldwide, is Major Depressive Disorder. It becomes manifested in the form of continuous depression, lack of interest in the everyday life, dysfunction, and, in the most extreme version, suicidal thought. One further sub-diagnosis, within this broader diagnosis, is called treatment-resistant depression (TRD) where the patient fails to respond sufficiently to two or more attempts of using antidepressant medication. Approximately one-third of adults with depression in the United States have TRD, and the health care system presents more than 300 billion dollar per year expenses, wasted productivity and disability (Brooks, 2023). The necessity of an effective alternative can hardly be doubted in Miami-Dade County where the socioeconomic imbalance and the lack of accessibility to special mental health care only further complicate the issue. This project aims to test the effectiveness of Transcranial Magnetic Stimulation (TMS) as a treatment to minimize depressive symptoms and optimize functional outcomes of adults with TRD in an outpatient mental health clinic in Miami-Dade County.

Review of Literature

The evidence of the support of TMS in TRD is solid and consistent. Mollica et al., (2024) confirmed that TMS can significantly improve response and remission rates among patients with TRD, with response rates of 50-60% and remission rates of 30-40% being a more positive effect than placebo. In addition to relieving the symptoms, TMS also increases cognitive performance, quality of life, and functioning. Its side-effect profile is also far less than the pharmacologic treatment, as there is no weight gain, sedation/sexual dysfunction linked to its use, which contributes to the increase in treatment adherence (Mollica et al., 2024). Though the effects of TMS are not always long-term and some patients might require booster sessions, the evidence regarding this treatment is overwhelmingly positive, which is why this approach should also be part of the outpatient treatment of psychiatric patients (Minoo Sharbafshaaer et al., 2024).

Practice Change, Setting, and Implementation.

The change in practice suggested is the institutionalization of TMS treatment in an outpatient mental health clinic in Miami-Dade County. Currently, pharmacologic management has been the main method that the clinic has been utilizing, and there are a number of patients with TRD who are currently lacking adequate treatment. It represents a quality improvement project and will not involve an IRB approval or CITI training, since it does not involve direct human subjects’ research.

The implementation will be done in 12 weeks. During the first two weeks, the project head, who will be an Advanced Practice Nurse, will arrange the stakeholders, present the evidence of TMS, and obtain administrative and clinical buy-in. The third and fourth weeks will be allocated to staff education and training, consisting of TMS mechanisms, patient selection criteria, protocol standards, and documentation. The fifth and sixth weeks will involve procuring and installing equipment in a designated treatment room and finalizing a treatment protocol. The phase of active implementation will be done between weeks 6 and 12, whereby the able patients will be administered a course of TMS to be completed under five sessions a week during the first six weeks, with gradual tapering of the course. Patients will not cease to get current psychiatric care.

The obstacles that are likely to occur are staff resistance to change, disruption of the workflow, costly equipment, inconsistent insurance reimbursement, and patient-level obstacles such as transportation and time commitment to daily sessions. Strong nursing leadership, the increasing evidence base, the increasing insurance coverage of TMS, and the developed relations of the clinic with its patient community are the protective factors (Mallon et al., 2022).

Change Evaluation

The major assessment instrument is a PHQ-9, which will be given at baseline and weeks four, eight, and twelve. The improvement of at least five points over baseline is denoted as a clinically significant improvement, and less than five points are termed as remission (Moa Winninge et al., 2024). Secondary measures entail a functional assessment tool, which captures the variation in daily living, social participation, and occupational engagement. During the implementation process, measures will also be monitored, including the rates of session completion, dropout rates, adverse events, and protocol adherence.

Leadership and Stakeholders

Transformational and collaborative leadership will be used to inform this initiative. The project head will inspire the staff members by building a vision of equity and patient-centered care, establishing interdisciplinary relationships, being an analytical thinker about outcome data, and tirelessly championing resources and systemic change (Moa Winninge et al., 2024).

The stakeholders include the clinic administration, which gives the nod to the resources and other organizational support; psychiatrists and psychiatric nurse practitioner, who monitors the diagnoses and pharmacologic care; Advanced Practice Nurses, who facilitates the TMS program and monitor patient outcomes; TMS technician, who provides the sessions in a safe way; billing representative, who handles the reimbursement; and community advocate, who The proposal will be discussed during a formal stakeholder meeting including the clinical rationale, implementation plan, outcome framework and budget. It is estimated to cost 50,000-100,000 dollars in equipment, training, and setup, and the costs incurred in the long run are offset by the estimated savings in hospitalizations, emergencies, and trials and errors with medication.

Conclusions

The problem of Major Depressive Disorder is a huge healthcare problem that has become a challenge to people, society and even healthcare institutions and is becoming resistant to drugs. The proposed project demonstrates the opportunities of the Transcranial Magnetic Stimulation therapy as an effective intervention approach to improve the outcomes of this group. This project will enhance patient care by closing the gaps in available treatment options and combining the evidence-based practices that can result in the reduction of the cost involved in the healthcare services and the health equity. Nursing leadership and advocacy can be instrumental in bringing these changes and guaranteeing their success to ensure high-quality of care provided to patients.

Consistent findings exist with regard to the use of Transcranial Magnetic Stimulation in treatment-resistant depression. TMS provides superior functional and symptomatic results compared with pharmacologic therapy.

Not only is it a clinical diagnosis, but it is also the daily life of countless adults in Miami-Dade County who have tried medication after medication, with a slight or no effect whatsoever on the condition. It was in this regard and these facts that this venture has tried to do so. The first part identified the seriousness of the problem, specifically the clinical, economic, and social impairment of TRD in a vulnerable community, where there was an underserved population. The second section, the promptness of which was reached by existing literature, was that TMS is not an experimental hope, but an intervention that has been proven, approved by the FDA, and has high remission rates, improved functional outcomes, and a positive safety profile. Part three translated that evidence into an action plan, which was not only nurse-led but also had specific timelines, measures of outcomes that were based on PHQ-9, committed stakeholders, and a realistic budget. Putting together these three parts makes up a single argument: patients who have become treatment resistant to depression are entitled to more than it can give them in the current system, TMS is a move in the right direction, and it is accountable, caring, and evidence-based.

References

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