NUR 670

1. Response for Libia

Abstract

Perimenopausal women frequently experience anxiety and depressive symptoms associated with fluctuating hormone levels and neurotransmitter disruptions. The purpose of this literature review was to evaluate the evidence supporting the use of hormone replacement therapy (HRT) combined with psychiatric treatment compared with psychiatric treatment alone for reducing anxiety and depressive symptoms over six months in perimenopausal women. An evidence pyramid was used to assess the reliability of available research, and a systematic literature search was conducted across multiple databases. The findings demonstrate that higher levels of evidence, including systematic reviews, meta-analyses, and randomized controlled trials, provide the strongest support for clinical decision-making, while lower levels of evidence offer valuable contextual information but are more susceptible to bias (Vatkar et al., 2025).

Comparison of Evidence Using the Evidence Pyramid

An evidence pyramid ranks study designs based on their potential for bias and overall data reliability (Vatkar et al., 2025). When evaluating how combined HRT and psychiatric care affects perimenopausal mood disorders, different layers of the pyramid yield varying degrees of scientific authority. At the highest level of the pyramid are systematic reviews and meta-analyses, which provide the most reliable evidence for clinical decision-making. They are the most dependable because they synthesize findings from multiple high- quality studies and reduce the influence of single-study bias (Blunt, 2026). According to Li et al. (2026), a recent comprehensive meta- analysis verified that estrogen-based therapies actively reduce depressive symptom severity during perimenopause.

Below systematic reviews are randomized controlled trials (RCTs), which are considered the gold standard for evaluating treatment effectiveness (Vatkar et al., 2025). Their reliability level is high since

randomization prevents selection bias, but strict inclusion criteria sometimes make it hard to generalize results to everyday patients with complex comorbidities, and their findings may be limited by sample size, study duration, and participant characteristics. Several RCTs investigating estrogen therapy and depressive symptoms in perimenopausal women demonstrate improvements in mood and anxiety symptoms, particularly among women experiencing hormonally related mood disturbances (Sharma et al., 2023).

Observational studies, including cohort and case-control studies, occupy the middle of the evidence pyramid (Blunt, 2026). These studies contribute valuable information regarding associations between hormonal changes during perimenopause and the development of mood symptoms; however, they cannot establish causality due to the potential influence of confounding variables. At the lower levels of the pyramid are expert opinions, narrative reviews, and clinical experience. While these sources may provide useful clinical insight, they are more vulnerable to bias and should not be used independently to guide treatment decisions (Vatkar et al., 2025). Therefore, the highest level of reliability for this PICO question comes from systematic reviews, meta- analyses, and RCTs evaluating hormone therapy and psychiatric interventions.

Literature Review Search Strategy

For this literature review, the search was deployed across PubMed/ MEDLINE, CINAHL, PsycINFO, Cochrane Library, and Google Scholar, capturing peer-reviewed, English-language literature. These databases were selected because they provide extensive coverage of nursing, psychiatric, psychological, and medical research relevant to perimenopausal mental health. The search strategy was built by systematically translating each component of the PICO question into a combination of controlled vocabulary, specifically Medical Subject Headings (MeSH), and highly targeted keywords (Hosseini et al., 2024). To capture the precise population, keywords like "climacteric", "menopause transition", and "midlife women" were paired alongside the core MeSH term "perimenopause". The

intervention layer was constructed using terms such as "hormone replacement therapy", "estrogen", "estradiol", and the abbreviation "HRT". To address the comparative psychiatric arm, the search incorporated the MeSH term "antidepressive agents" alongside keywords like "SSRIs", "SNRIs", "psychotherapy", and "psychiatric treatment". Finally, the clinical outcomes were targeted using the terms "depression", "anxiety", "mood swings", and "symptom reduction".

These distinct conceptual blocks were bridged using Boolean operators. Within each individual category, terms were expanded using the "OR" operator to capture every possible linguistic variation (Dekkers et al., 2022). The broad categories were then locked together using the "AND" operator to ensure that every retrieved article explicitly featured all components of the clinical inquiry. The resulting master string— (Perimenopause OR "Menopause transition" OR "Climacteric") AND (Hormone Replacement Therapy OR Estrogen OR Estradiol OR HRT) AND (Antidepressants OR SSRI OR Psychotherapy OR "Psychiatric treatment") AND (Depression OR Anxiety OR "Symptom reduction") — served as the filter to isolate relevant research.

Inclusion criteria consisted of peer-reviewed studies published in English, studies involving perimenopausal women, research evaluating hormone therapy and mental health outcomes, and studies published within the previous five years. Exclusion criteria included studies focused exclusively on postmenopausal women, articles examining only vasomotor symptoms without psychological outcomes, non-peer- reviewed publications, editorials, opinion papers, and studies unrelated to anxiety or depression.

The search initially identified 86 records. After removal of duplicates and application of inclusion and exclusion criteria, 62 studies underwent title and abstract screening. Twenty-five full-text articles were assessed for eligibility, and 10 studies met all criteria for inclusion in the final review. A PRISMA-style literature flow diagram was developed to illustrate the identification, screening, eligibility, and inclusion process. This systematic approach enhanced the transparency,

reproducibility, and credibility of the literature review while ensuring that the highest-quality evidence available was used to answer the clinical question.

2. Response for Leydiana

Creating a Search Strategy.

Abstract.

Evidence-based practice allows psychiatric-mental health nurses to make clinical decisions using timely research evidence. This literature review aimed to rank sources based on reliability using the evidence pyramid and explain our search strategy to complete a literature review on continuity of psychiatric care with barriers to transportation and caregiver support for older adults. The evidence pyramid was utilized to understand how strong of evidence there was for our research question. Systematic reviews and meta-analysis proved to provide the highest level of evidence. A literature search was completed on PubMed, CINAHAL Complete, PsycINFO, Cochrane Library, and Google Scholar. Keywords consisted of older adults, geriatric mental health, transportation barriers, caregiver support, continuity of care, social isolation, mental health services utilization. Articles were included if they were peer-reviewed and published from 20 21-20 26 and included adults ages 65 years or older. After title and abstract screening with assessment of eligibility, 20 articles were included in our final review. Our results showed that transportation barriers, caregiver burden, social isolation, and decreased access to health care have negative effects on continuity of psychiatric care and mental health outcomes in older adults. Our thorough search allowed us to find current and high-quality evidence that could be used in psychiatric nursing practice.

Key words: evidence-base practice, older adult, continuity of care, transportation barriers, caregiver support, psychiatric mental health nursing.

Compare the reliability of evidence-based research using and evidence pyramid.

Evidence-based practice is essential to psychiatric-mental health nursing because it allows providers to make clinical decisions based on the best available evidence. The evidence pyramid is one strategy utilized to grade research evidence (Melnyk & Fineout-Overholt, 2023). Studies that rank high on the pyramid provide stronger evidence than those on lower levels.

Systematic reviews sit at the top of the pyramid and synthesize research studies to provide large overviews of evidence about certain topics. In addition to proving stronger evidence for decision-making, these studies attempt to remove bias (Melnyk & Fineout-Overholt, 2023). Randomized trials are placed beneath systematic reviews and are highly effective forms of research because people are assigned to intervention and control groups.

Studies that provide moderate evidence include cohort studies, case control studies, and qualitative studies. Cohort and case-control studies are utilized when randomized trials are not ethical or possible. Qualitative studies can highlight patient perceptions about certain barriers to care but are limited by lack of generalizability. Expert opinion and background information provide the least amount of evidence because they do not typically provide scientific data. However, they can be helpful when making clinical decisions.

Systematic reviews, cohort studies, and peer-reviewed research about healthcare access, continuity of care, caregiver support, transportation barriers, and mental health outcomes among older adults were used. These studies were utilized because they provided the highest level of evidence available regarding the selected topic. Social isolation, transportation barriers, caregiver burden, and poor healthcare access

among older adults lead to poor mental health outcomes and lack of continuity in care (Choi et al., 2022; Yang et al., 2023).

Describe the search strategy used to conduct the literatures review for your PICO question.

Multiple databases were utilized to identify evidence about continuity of psychiatric care among older adults: PubMed, CINAHL Complete, PsycINFO, Cochrane Library, and Google Scholar. These databases were specifically chosen because they allow users to search through nursing, psychiatric, medical, and behavioral health literature that has been peer-reviewed.

Search terms included older adults, geriatric mental health, transportation barriers, caregiver support, continuity of care, psychiatric appointment adherence, social isolation, care coordination, and mental health service utilization. Keywords were paired using Boolean operators (AND, OR) to increase relevancy. (“older adults” AND “mental health access”), (“transportation barriers” AND “psychiatric care”), and (“caregiver support” AND “continuity of care”).

Certain inclusion and exclusion criteria were used to increase the quality of literature found. Articles had to be peer reviewed and published between 2021 and 2026, written in English, and involve participants who were aged 65 years and older. Studies had to examine one or more of the following topics: mental health service utilization, barriers to healthcare access, transportation barriers, informal caregiver support and involvement, social support, care coordination, and continuity of care.

Exclusion criteria included articles published before 2021, research involving pediatric populations, articles not written in English, editorials/opinion pieces, and articles that did not focus on healthcare access or continuation of psychiatric care. Studies were also excluded if they were only conducted in inpatient settings. Research studies were excluded if they focused solely on inpatient settings because the

literature search was meant to identify studies related to outpatient psychiatric care.

To illustrate the search and screening process, a literature flow diagram was generated. The search resulted in 145 articles across all databases. Duplicate records were removed, leaving 120 articles screened by title and abstract. Abstracts were screened based on inclusion criteria and 80 articles were excluded. Forty articles were assessed by full text review and 20 articles were excluded after further evaluation. 20 studies were included in our final literature review. We believe our systematic search provided evidence that is up-to-date, relevant and can be applied to psychiatric nursing practice with older adults facing barriers accessing mental health care.