Student Name

Capella University

NURSE-FPX-4905 A2

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Submission Date

A Practicum Analysis: Healthcare Process Issue

An adverse effect has become a serious healthcare issue – the lack of response to antidepressant medications – among adults who seek treatment at a Mayo Clinic location, which has an impact on depression management overall. Antidepressants have also been used successfully as a first-line treatment option in major depression; however, most of those taking antidepressants are unable to take and adhere to them. This poor adherence leads to lack of response to treatment, and to less overall improvement of symptoms. The non-adherence to antidepressants worsens depression symptomology, raises the risk of relapse and recurrence of depression, can avoid hospitalizations, and leads to increased health care costs. This paper will address the healthcare process question: why are antidepressants not being taken as prescribed by the doctor? The patient behaviors related to antidepressant adherence will be addressed, as well as the application of nurse-led education and follow-up for intervention.

Description of the Practicum Site

I am doing my practicum time at a community-based ambulatory health care facility. Mayo Clinic in the United States (US) provides services that involve the psychiatric evaluation of adults and the provision of psychotropic medications to adults with psychiatric disorders, particularly dementia patients. The clinic plays an important role in enhancing accessibility and aiding in long-term maintenance treatment by the systematic follow-up of chronic psychiatric conditions and treatment on an individual basis, according to the study reported. Directed at out-patient management, the clinic’s area of focus is regularly scheduled follow-up (not acute or emergent). The patient population is generally 25+ years old and are typically diagnosed with major depressive disorder (MDD), are prescribed an antidepressant to help manage their MDD, receive periodic follow up with MDD for routine follow up.  The majority of patients require full nursing care, rehabilitation, and drugs, as well as help in carrying out their daily activities and behavioral issues caused by dementia. On a subsequent appointment, the MDD checks on medication, signs of depression, Medication compliance, side effects, and effectiveness of treatment so far and provides therapeutic assistance if necessary. The facility has roughly 350 full-time healthcare workers: a psychiatrist, a psychiatric nurse practitioner, a registered nurse, a medical assistant, a behavioral health counselor, as well as administrative support. These providers are more likely to launch a multi-disciplinary approach to deliver the best, client-centered, evidence-based behavioral health care to aid depression management and ensure continuity of care for individuals prescribed an antidepressant.

Clinical and Operational Decisions at the Practicum Site

In my setting, the clinical and operational interventions I was interested in improving for adherence to antidepressants were aimed at: quickening the initiation of antidepressants, maintaining adherence, and decreasing attrition. Identifying patients who were not taking their medications, giving follow-up education and medication adherence assessments to each patient based on their individual problems, scheduling weekly contact with high-risk patients with my nurse preceptor, and documenting the medication adherence assessments and my nursing interventions in the EHR down to patients’ concerns for changes in the treatment plan as needed, were all included in clinical decisions made Basis for prescribing was the psychiatric prescriber’s, but I also contributed in supporting the clinical decision making as part of my clinical assessment and documentation. This has been supported in previous research, which found that having more follow-up visits (including nurse-led) and having work done as a team with other professionals was shown to improve adherence to taking medication, quality of care, fewer hospitalizations, and better management of depression that resulted in better depression outcomes (fewer relapses and improved quality of life). The severity of depression was determined by the Patient Health Questionnaire-9 (PHQ-9), and adherence to medication was a key quality indicator of this patient population. The clinical decision-making and outcomes were consistent with safe and evidence-based decisions that will likely lead to better depression management in the long run in this facility.

Antidepressant Non-Adherence and Patient Outcomes

The problem with which I have worked at the Practicum site involves a failure of adult outpatient clients who are depressed to take antidepressants. Many adults taking a prescribed antidepressant or serotonin-norepinephrine reuptake inhibitor (SNRI) may not be able to take their medication as directed as a group, which negatively impacts the effectiveness of their medication, symptom severity, and risk of relapse or hospitalization. This issue would be suitable for an intervention by Nurse-led Quality improvement. The interventions include a registered nurse (RN) to screen for medication adherence, patient teaching, and a weekly telephone call visit with an RN to document in the EHR and ongoing work with the interdisciplinary team.

Presently, it has been noticed that the population generally fails to adhere to the treatment with antidepressants. Unni found that 42.9% and 46.2% of the population, in the USA and five European countries, respectively, were non-adherent. Their study concluded that the more common reasons cited for non-adherence were forgetfulness and concerns about medications. In a similar study, Chanie found another non-adherence rate of 32.9% among adults with depression, and listed the major factors associated with low adherence, such as being a woman, having low education levels, not working, length of treatment, and having severe side effects of the treatment. Lack of adherence also was found to be negatively associated with increased health care costs, relapse rate, emergency room visits, and hospitalizations, Gutirrez-Abejn also found. Results support the need for an interdisciplinary approach with a nurse-led intervention to enhance adherence to medications.

Analysis of Impact on Quality, Safety, and Cost

When patients are not taking their antidepressant medication, it is detrimental not only to the patient’s treatment, but also to the healthcare system. Failure to take medication (or adhere to a treatment regimen) was a factor that led to treatment failure, slowed drug healing, and lowered rates of drug remission; ultimately affecting the quality of care and drug outcomes. It was revealed that poor adherence to depression medication leads to poor depression outcomes, in addition to maintaining depression symptoms (Infante-Ventura et al., 2025). In addition, in terms of safety, non-adherence with medication is associated with more relapses, antidepressant withdrawal symptoms, emergency room visits, and hospitalization. It was concluded that poor adherence to antidepressants leads to poorer clinical outcomes and to significantly higher costs – research suggests that the cost of not taking antidepressants (alone) accounted for more than 13% of all antidepressant spending per year. Any interventions that involve interacting with health care providers to discuss medication adherence, such as by a nurse, providing individualized education to patients, and ensuring structured follow-up care should be explored to maximize medication adherence, patient safety, reduce health care costs, and optimize long-term patient outcomes in adults with depression.

Causes and Root Cause of the Problem

There were multiple factors that led adult subjects with depression not to take antidepressant drugs. Some of these factors were non-compliance with medications, not completing treatment because of side effects of medications, and not showing improvement of symptoms within a reasonable period of time. Parents’ forgetfulness in giving medicines and concerns about the medicines were found to be the most common causes of non-adherence, researchers said. Having low levels of health literacy, unemployment, and side effects were linked to a higher risk for non-adherence. Further, polypharmacy, multiple roles and functions played by prescribers have an effect on adherence. Other factors that affected adherence were the lack of follow-up care, medication cost, and fragmented care. This can be addressed by a thorough review of adherence, nurse-led assessment, and specific education of the patients with planned and structured follow-up.

Practicum Hours

This time was spent at Mayo Clinic completing my 10 practicum hours, under my preceptor’s supervision. During the first hour, clinic orientation was conducted, and the workflow, the patients to be seen in the clinic, and the aim of this project were discussed. During the second hour, there was an opportunity to observe a few of the follow-up psychiatry appointments and observe the practice of screening for depression symptoms and adherence to medication with a PHQ-9 (Patient Health Questionnaire-9). During the third hour, I assisted in acknowledging some patients who were not taking their antidepressant drugs as prescribed and talked about typical challenges of taking antidepressants. During the fourth hour, I was able to educate patients individually about their medications and adherence as well as some common side effects of their medications. During the fifth hour, medication management visits were shadowed, and a learning opportunity was provided about collaboration amongst disciplines in the care of the patient. During the 6th hour, I practiced taking a medication adherence screening and a nurse intervening in the EHR. During the 7th hour, I helped to determine patients’ needs for a weekly nurse-led follow-up visit. During the 8th hour, many more times, I gave a great deal of emphasis to patient education on the importance of medications and future visits. During the ninth hour, I did a review of patient PHQ-9 scores and spoke to my preceptor about their change in response to treatment and their progress. At the end of the 10th hour, I discussed the experience of being in the practicum and how the Nurse-Led Education, follow-up, and interdisciplinary care may affect the success of adherence to medications, patients’ safety, and overall treatment outcomes with the adults presenting with Major Depressive Disorder.

Conclusion

Good adherence is still a large challenge in the treatment of depression in the clinic environment of Mayo. During the practicum experience, both patient factors, treatment factors, and system factors have been reinforced to understand how these factors affect adherence. The most compelling evidence to date for nurse-led interventions that can overcome the barriers is through adherence screening, individual patient education, and follow-up care for patients in an organized manner. Implementation of the evidence-based strategies highlighted in this experience into the management of major depressive disorder (MDD) can enhance medication adherence, medication safety, quality, and resource efficiency and ultimately improve outcomes.