module 5 discussion

2

Module 4 Discussion

Jachai Littlejohn

St. Thomas University

NUR-670-AP3

Dr. Mesa

September 18, 2025

Creating a Search Strategy

Reliability of Evidence Using an Evidence Pyramid

Evidence-based practice requires clinicians to prioritize the strongest available evidence when making clinical decisions. The evidence pyramid visually ranks research by dependability, rigor, and bias reduction (Vatkar et al., 2025). At the base of the pyramid are background information, expert opinions, and case reports. Anecdotal evidence, lack of systematic approach, and prejudice restrict these source findings.

Moving upward, cohort studies and case-control studies provide more robust evidence by observing groups over time or retrospectively analyzing exposure and outcome relationships. These designs are nevertheless susceptible to confounding factors and lack randomization, which improves causal inference.

Higher on the pyramid are randomized controlled trials (RCTs). RCTs are the "gold standard" for intervention evaluation because randomization reduces bias and control groups strengthen causality results. RCTs have many advantages, but cost, effort, and generalizability might restrict them, particularly in rural regions with mental health needs.

At the very top of the pyramid lie systematic reviews and meta-analyses. These studies combine high-quality studies to assess an intervention's efficacy. Systematic reviews reduce random error and boost statistical power by pooling results across populations and situations. Cochrane systematic reviews and meta-analyses on telepsychiatry are the most credible for this PICO question, followed by RCTs on integrated care models.

The pyramid encourages physicians to seek the most credible data; however, in specialized or growing domains, such as integrated telepsychiatry, RCTs, quasi-experimental studies, and implementation research may still be needed.

Search Strategy for the Literature Review

Literature Review Search Strategy

The PICO question guiding this literature search is: In adults with mental illness residing in U.S. Mental Health Professional Shortage Areas (P), does offering integrated telepsychiatry services through primary care clinics (I), compared with usual care (limited in-person referral only) (C), increase treatment engagement and reduce symptom severity at 6 months (O)?

To answer this topic, numerous databases were searched to include psychiatric, nursing, medical, and multidisciplinary research. For biological and psychological evidence, PubMed/MEDLINE was examined, whereas CINAHL focused on nursing and allied health literature relevant to integrated care delivery. PsycINFO covers psychological and behavioral health research on patient engagement, stigma, and treatment adherence. Telepsychiatry intervention systematic reviews and meta-analyses with high evidence were sought in the Cochrane Library. Finally, Scopus was used to find multidisciplinary and policy relevant scalability and health systems research.

The search used a combination of keywords and controlled vocabulary tailored to each database. Search terms included "telepsychiatry AND integrated care," "rural mental health AND outcomes," and "primary care AND psychiatric services." Filters restricted findings to English-language, peer-reviewed human research from 2019 to 2025. These restrictions guaranteed that the research was recent, methodologically sound, and relevant to telepsychiatry, especially considering the fast growth of virtual care models during and after the COVID-19 epidemic.

Inclusion criteria required that studies be conducted in the U.S. healthcare system or in comparable high-income countries with similar telepsychiatry infrastructures. Interventions were limited to integrated telepsychiatry services in primary care or outpatient clinics for rural or underserved persons with mental illness. Comparisons required conventional treatment, usually in-person referral channels, and outcomes were confined to patient engagement indicators, including attendance, adherence, and follow-up, and validated mental symptom ratings. Randomized controlled trials, quasi-experimental studies, systematic reviews, and implementation research were acceptable. Studies on children or geriatric populations, unless findings were generalizable to adults, inpatient or emergency psychiatric settings, general telehealth treatments without psychiatric components, and grey literature or editorials without peer review were excluded.

The initial search retrieved hundreds of citations across the databases. Titles and abstracts were evaluated for relevance after duplicates were deleted, leaving 45 papers for full-text examination. The inclusion and exclusion criteria left 25 high-quality papers that directly influenced the PICO query. These included systematic reviews like O’Callaghan et al. (2021), on the efficacy and policy implications of telepsychiatry in rural healthcare delivery and randomized controlled trials like Sharma and Devan (2021) on how integrated telepsychiatry improves adherence and engagement compared to referral-only care. Implementation-focused studies like Yellowlees et al. (2020) showed that system-level shortages may quickly transfer psychiatric treatment to virtual modes. Adams et al. (2022) examined the changing role of psychiatric e-consultation and its ability to improve access in underserved areas, while Blease et al. (2020) examined physician perspectives on technology in psychiatry and its barriers and opportunities for telepsychiatry in primary care.

The final literature showed that integrated telepsychiatry models can improve engagement and symptom reduction in underserved populations, but implementation, provider adoption, and long-term sustainability are challenges. The retained research established a strong data basis that supports the PICO question and prepares to evaluate telepsychiatry as a solution to U.S. mental health professional shortages.

Literature Flow Diagram

References

Blease, C., Locher, C., Leon-Carlyle, M., & Doraiswamy, M. (2020). Artificial intelligence and the future of psychiatry: Qualitative findings from a global physician survey. DIGITAL HEALTH, 6, 205520762096835. https://doi.org/10.1177/2055207620968355

O’Callaghan, E. L., McAllister, L., & Wilson, L. (2021). Telepsychiatry in rural healthcare delivery: Systematic review and policy implications. Journal of Rural Health, 37(1), 220–230. https://doi.org/10.1111/jrh.12467

Sharma, G., & Devan, K. (2021). The effectiveness of telepsychiatry: thematic review. BJPsych Bulletin, 47(2), 1–8. https://doi.org/10.1192/bjb.2021.115

Thomas, Lim, C. T., & Huang, H. (2022). The Practice of Psychiatric E-Consultation: Current State and Future Directions. Harvard Review of Psychiatry. https://doi.org/10.1097/hrp.0000000000000338

Vatkar, A., Kale, S., Shyam, A., & Srivastava, S. (2025). Understanding the Levels of Evidence in Medical Research. Journal of Orthopaedic Case Reports, 15(5), 6–9. https://doi.org/10.13107/jocr.2025.v15.i05.5534

Yellowlees, P., Nakagawa, K., Pakyurek, M., Hanson, A., Elder, J., & Kales, H. C. (2020). Rapid Conversion of an Outpatient Psychiatric Clinic to a 100% Virtual Telepsychiatry Clinic in Response to COVID-19. Psychiatric Services, 71(7), 749–752. https://doi.org/10.1176/appi.ps.202000230

Records Identified Through Data Base Searching n = 300

Records Screened by Title or Abstract n = 250

Full-text articles assessed for eligibility n = 45

Duplicated Removed n = 50

Studies included in final synthesis n= 25

Records Excluded n = 205

Ful-text article excluded n = 20

Reasons : population mismatch, inpatient setting, lack of outcomes

Systematic Reviews and Meta Analysis

Cohort Studies

Case Control Studies

Expert Opinions

Randomized Controlled Trials

Case Series and Case Reports