Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
- Investigated Disease Process
A major depressive disorder, also referred to as depression, is a condition affecting 16.1 million adults in the United States each year (Anxiety and Depression Association of America, 2016). As a leading cause of disability in the world, depression is considered a common anxiety disorder that affects 1 in 13 adults globally (World Health Organization [WHO], 2016). The 2016 Florida Behavioral Risk Factor Surveillance System (BRFSS) state and county data report, which is used to estimate the prevalence of personal health behaviors that contribute to morbidity and mortality among adults in Florida, concluded that approximately 9.2% of adults in Miami Dade County suffer from depression, compared to a 11.3 % in the state of Florida. (Philip, 2016) The condition affects men and women alike; yet is most prevalent among women.
ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW
Major depression limits an individual’s ability to perform daily activities. Based on the Diagnostics and Statistical Manual of Mental Disorders (DSM-IV) (4th ed.), major depressive episodes occur for a period of two weeks or longer, reflects a change in a person’s daily functioning, and changes a person’s mood or loss of interest (National Institute of Mental Health, 2017).m Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
This paper will: (1) identify depression (the pathophysiology, standard of practice, and factors that contribute to a patient’s ability to manage depression); (2) analyze depression and how it affects patients, families, and populations (financial costs associated with depression for patients families, and the populations from diagnosis to treatment); and (3) promote best practices for managing depression in my current healthcare organization (including three strategies used to implement best practices for managing depression and the appropriate method of evaluating the implementation of each of the strategies).
A1. Pathophysiology of Depression
Unfortunately, the pathophysiology of depression has not been clearly defined. There appears to be a correlation between neurotransmitter availability, receptor regulation, and affective symptom sensitivity (Verdujin et al., 2015). Meta-analyses support the major depressive disorders are affected by specific pathophysiological mechanisms, such as inflammation, vitamin D, neurotrophic growth, and hypothalamic-pituitary-axis (Verdujin et al., 2015). Results suggests that an “upregulation of inflammation” in the brain may be associated with the development of depression (Moylan, Mae, Wray, & Beck, 2013). With a decrease in monoamines and an increase in tryptophan catabolites, the brain has difficulty withstanding the toxins presented. It was also suggested that hyperactivity of the hypothalamic-pituitary-axis may be another factor contributing to depressive disorders. When the neurogenesis is impaired and hippocampus volumes are reduced, there appears to be a malfunctioning of the glucocorticoid receptor (Verdijin et al., 2015). Based on the increases and decreases within the brain, it is presumed that recurring episodes can be determined via the cortisol levels.
Patients with depressive disorders may present with normal appearance or display physical symptoms which may vary including weight loss or gain and poor hygiene. Other symptoms of depression may be present, such as: psychomotor retardation, flattening or loss of reacting, and/or psychomotor restlessness or agitation (Olfson, Blanco, & Marcus, 2016).
A2. Standard of Practice
A variety of screening instruments, pharmacotherapy, psychotherapy, electroconvulsive therapy, and stimulation techniques are used for treating patients with depressive disorders (Olfson, Blanco, & Marcus, 2016). According to the Florida Agency for Health Care Administration (2015), questionnaires and rating scales are used as diagnostic assessment evaluation for clinical determination. Although many patients who suffer from depression will end up using a combination of therapies, it is not unusual to begin treatment exclusively with psychotherapy, as it is the least invasive. Ultimately treatments are chosen based on provider recommendation, patient preference, and symptom observations.
No laboratory studies are available at this time to diagnose depression; however, laboratory results are often used to exclude potential medical conditions that may present similar symptoms. All changes made to medication regimen are based on information provided in rating scales and questionnaires. These standards of practice are generic for Broward County and the state of Florida.
National standard of practice is very similar as it involves comprehensive assessment based on detailed history, physical examination and mental state examinations for proper establishment of diagnosis. Formulation of treatment plan involves deciding about treatment setting, medications and psychological treatments to be used. Treatment options for management of depression can be broadly be divided into antidepressants, electroconvulsive therapy (ECT) and psychosocial interventions. (Gautam, 2017)
A2a. Pharmacological Treatments
Evidenced-based pharmacologic therapies utilized in my community are similar to those used nationwide. If nonpharmacological treatments are available, PCPs should ask patients who are initiating depression treatment about preferences for medications or psychotherapy because the ability to address a patient’s treatment preference has been shown to be related to the likelihood of entering depression treatment and better treatment outcomes (Unutzer, 2012) Some forms of treatment drugs that have proven effectiveness include: selective serotonin reuptake inhibitors (SSRIs); serotonin/norepinephrine reuptake inhibitors (SNRIs); atypical antidepressants; tricyclic antidepressants; monoamine oxidase inhibitors; and St. John’s wort (Olfson, Blanco, & Marcus, 2016). All of these medications work by balancing neurotransmitters in the brain that affect both mood and emotions.
Inquiry of evidence was conducted at a local Mental Health / Rehab facility with the authorization from management. Physicians provided a prescribing report which displayed that the majority patients with the diagnosis of depression were prescribed SSRIs. Many reports and studies emphasize the fact that SSRIs are recommended as first line medication of choice because of the decreased side effect and their higher safety profiles. With use of medications it is important to provide patients with education about the side effects they may encounter such as gastrointestinal disturbances, increased appetite and weight gain, loss of sexual desire and other sexual problems such as erectile dysfunction and decreased orgasm, agitation, irritability and suicidal ideation. Special emphasis should be made to the adverse effects of stopping medications without the supervision of the prescribing physician.
Pharmacological treatments are not typically provided independently. Often times, patients are provided with consistent and faster results when medication is combined with psychotherapy. Patients with major depressive disorders who do not respond to drug therapies, have a high risk of suicide and medical morbidity or mortality, and need rapid antidepressant response, electroconvulsive therapy (ECT) is recommended. The Food and Drug Administration (FDA) has also approved the use of transcranial magnetic stimulation for treating major depression. For patients who have attempted and failed four medications or ECT treatments, the FDA has also approved the use of vagus nerve stimulation.
A2b. Clinical Guidelines
Assessment.
Management of depression involves comprehensive assessment based on detailed history, physical and mental state examinations. Obtaining history from all sources including family and or caregivers can be extremely helpful. These patients may present with a combination of symptoms of which include but are not limited to: loss of interest or pleasure, decreased energy, fatigue, reduced concentration and or attention, reduced self-esteem and or self-confidence, ideas of guilt and unworthiness, pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite(Blobel, 2015). Assessment should also focus on evaluation for physical illnesses known to play a role in the development of depression for example diabetes mellitus, thyroid disease or known malignancies. Previous surgical history and use of prescription medications and history of substance abuse should also be taken into consideration.
Diagnosis.
Patients are screened utilizing one or more of the following patient-reported instruments: Patient Health Questionnaire-9; Beck Depression Inventory or Beck Depression Inventory-II, Zung Self-Rating Depression Scale, or the center for Epidemiologic Studies-Depression Scale (Agency for Health Administration in Florida, 2015; Olfson, Blanco, & Marcus, 2016). The Hamilton Depression Rating Scale can also be performed by a professional to indicate depression severity. As previously stated no laboratory studies are available to diagnose depression. Laboratory results are often used to rule out medical diagnoses as a contributor to symptoms of depression.
Patient Education.
Education should be made readily available for the patient and all involved in their care by the prescribing provider. Providers should also refer patient’s information on agencies and organizations that also have resources available such as: The National Institute of Mental Health: Depression; Medline Plus, Depression and Bipolar Support Alliance (DBSA), and Families for Depression Awareness.
Education should include information on the different types of depression and risk factors for each. The signs and symptoms of depression and different ways to treat but most importantly information on crisis intervention. Education provided to patients should be provided in a format which is suitable for patient age, education level and specific depression diagnosis if applicable.
A2c. Standard Practice of Disease Management
In 2015 the Florida Medicaid drug therapy management program for behavioral health published the Florida best practice psychotherapeutic medication guidelines for adults. This guideline states a specific goal of beginning the process of symptomatic, syndromal, and functional recovery. The guideline addresses assessment and four different levels of treatment. Treatment options should be discussed with patient and initiation of monotherapy with SSRI’s. (Agency for Healthcare Administration State of Florida, 2015)
In Miami-Dade County, Florida practitioners in the community together with the CDC have been following documented approaches thru a series of promising practices. These are documented approaches to improving community health and quality of life. In the collaborative care for the management of depressive disorders a model is laid out where the responsibilities for providers is listed. Highlights include the routine screening for depression, the initiation of treatment and coordination of treatment amongst different providers. (The Community Guide)
The American Psychiatric Association (APA) supports the combination of psychotherapy and medications to treat patients with moderate to severe depression (2016). According to the National Institute of Mental Health (2017), 44% of individuals with depression receive treatments with medication and a health professional’s services; however, 37% of individuals are left untreated in the United States.
International rates are more alarming. There has been more than an 18% increase (approximately 300 million) in people worldwide who are diagnosed with depression (WHO, 2017a). Without the proper care, many of these individuals globally are not treated for depression and result in illness and disabilities. Evidence-based psychotherapeutic treatments, such as: interpersonal psychotherapy, cognitive-behavioral therapy; problem-solving therapy; and/or behavioral activation are the first line of treatment used when possible.
A3. Managed Disease Process
The goal in the treatment of depression is for the patient to achieve remission and/or to have complete relief of symptoms. Patients should be able to verbalize adequate coping skills for managing their depression as well as resources available to them in moments of crisis. The most important aspect would be for the patients reintegration to the community by returning to work, school and resuming previous functional and social abilities.
The characteristics of a patient with a managed depression disease process would include presenting with less labile moods, increased interest or pleasure with their activities, higher energy levels, improved concentration and attention span, an increase in self-esteem as well as self-confidence. These patients will not present with ideas of un-worthiness nor will they engage in acts of self-harm, suicide or harm to others. More regular sleep patterns and an increase in appetite are also good signs of a managed depression disease process.
There is a need to educate patients with depression on successful treatments of the condition. As patients become aware of their condition and understand the signs and symptoms to look out for, he/she may seek treatment earlier in the care of a relapse. Educating patients on the different treatments they are receiving, medication effects, side effects, and anticipated results is very important as it may play a vital role in a patient course of action.
Involving the patient, family and care providers in this critical process is imperative as it is not uncommon for symptoms to get worse before improvement is noted. Knowing what to expect and what needs to be reported increases the likely hood for treatment compliance and adherence. Access and transportation to all healthcare providers and services for regular follow up visits, medication and crisis management if need be.
A3a. Disparities
Many different types of disparities exist in healthcare on a national/local level and across all specialties. Racial disparities among community-dwelling elderly also exist in the United States (Akincigil. Olfson, Siegel, Zurlo, Wakup & Crystal, 2012). African Americans were less likely to receive a diagnosis and treatment for depression from a health care provider than Hispanic Whites (Akincigil, et al., 2012). A study conducted by Ankur Patel, M.D., with Penn State College of Medicine, concluded that there are significant racial/ethnic and economic disparities regarding mental health services. This conclusion was made after analyzing the race, age, payer, length of stay, average hospital cost, region and income of more than 450,000 hospitalizations during the 5-year period with a primary diagnosis of depression. “Depression is also known to be associated with difficulties in role transitions (e.g. low education, high teen child-bearing, marital disruption, unstable employment) and poor role functioning (e.g., low marital quality, low work performance, low earnings). (Gautam, 2017)
Most of these are also associated with poor access to stable insurance or funds to cover treatment and medication or alternative therapies for the disease process. WHO states that prevalence of depression varies by WHO region, from a low of 2.6% among males in the western pacific region to 5.9% among females in the African region. The differences in rates for depression across countries have been linked to cultural differences and/or the social effects that expression of the disorder may bring. In China for example the diagnosis of depression is made less frequently than in other Countries. One attribute has been, according to Xu Jun-Mian, M.D., the widespread access Traditional Chinese Medicine. (Jun-Mian, 1987)
A4. Managed Disease Factors
There are a variety of social, psychological, and biological factors that contribute to depression (WHO, 2017b). Managing of this disease is ongoing as patients can suffer from relapse in recovery. Life altering events, an increase in stress or even changes to daily routines are factors that contribute to the impaired management of the disease.
Financial resources are one of the factors that aid in managing this disease. Many times, treatment options require multi-disciplinary continuation of care, combination therapies along with polypharmacy. Some of these therapies may not be covered by healthcare insurance and having access to financial resources creates limitless opportunities for the treatment options.
A person who is depressed can suffer from a variety of other conditions which lead to or are the cause of the depression. Maintaining control of those diseases will contribute towards the successful management of depression. Patients need to be available to have access to their providers regularly for follow up and medication management. Having means of transportation and or plans in place to be compliant with appointments aids in management of depression.
Lastly patients need to be able to understand their condition and the treatment plans in order to manage it effectively. Treatment plans change with progression or regression of the disease therefore patient involvement of care plan contributes to disease management in a positive way.
A4a. Unmanaged Disease Factors
Depending on the stage of the illness, the frequency and severity of the symptoms will vary. It is important to assess reasons why access to care is compromised so that the underlying reason can be taken care of. Lack of financial resources can lead patients to problems with medication and therapy compliance. This can be a problem for patients who lack insurance. Those who are insured may also struggle with affording the co-payments or services that have been denied or are simply not covered by the insurance. Social service consults may prove to be useful as there are many communities that have resources in place for individuals without access to care or programs patients may qualify for that can ease the financial burden of care maintenance. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
It is important for providers to factor in circumstances that may prove challenging such as those who live in rural areas, have problems with mobility or co morbidities that require them to stay at home. Providers in conjunction with patient and or family should come up with a plan to facilitate access to adequate follow up care.
Teaching provided and communications have to be reinforced in a language and educational level that can be understood. Not having access to disease resources and crisis prevention contacts can be detrimental for patient and dangerous to those who surround them as well. Teaching and resources should also be provided to caregivers of patients with emphasis on crisis intervention.
A4ai. Unmanaged Disease Characteristics
A patient who has unmanaged depression, may experience one or more of the following: persistent sadness or anxiety, feelings of hopelessness, irritability, loss of interest and energy, difficulty concentrating or sleeping, and/or thoughts of suicide (National Institute of Mental Health, 2018).
- Patients, Families, and Populations
Depression affects patients, families and their communities on a daily basis. According to the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (2016), 7.6% of individuals 12 and over were identified with depression in 2012. Based on physician visits, 10.3% of patients indicated a prevalence of depression on their medical record. Unfortunately, there were a total of 42,773 suicide deaths in 2014 from individual’s who suffered from depression (CDC, 2016). These numbers affect families and communities across the country and the world. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
Patients
These individuals present with symptoms that affect everyone who comes in contact with them on a daily basis. The patient’s interpersonal and personal relationships also suffer due to the loss of interest and energy.
Families
For one they can be at risk for harming themselves or others around them. Because patients may lose interest in regular activities, they may no longer want to participate of play an active role as a part of the family. Special attention should be given to new mothers presenting with depression as they are at a much higher risk of harming themselves and or their newborns.
Populations
The difficulty concentrating or sleeping can become a challenge for them and affect performance in the workplace which in turn affects the community. Individuals with depression especially when unmanaged have an impact not only on their family but communities as a whole.
B1. Costs
Patient
For patients, the cost of depression can vary depending on the different types of treatments received. If a patient has medical insurance they may pay a reduced amount or simply co pays for therapy, medications and medical visits. Some insurances may not cover all medications or alternative therapies which increases the out of pocket expense.
Families
Families may feel the burden of the cost of depression in different ways. Because family structures and routines vary so much so can the actual costs. Things that may affect these costs are the age of patient with depression, the severity of the condition, need for medications and therapies, and insurance availability to name a few. For one monies will be used to pay for the patient treatments. Another way that families are impacted by the cost is directly related to the patient as many times they can become less productive at work or require caregivers to stay with the patient as well. One of the biggest factors would be the availability of medical insurance to help with offsetting some of the cost. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
Populations
Depression can lead to a variety of financial burdens for individuals and their families. Kessler (2012) identifies how depression can affect employment status, childbearing, marital timing and stability, education or lack thereof, parental and marital functioning, financial success, absences from work, comorbid disabilities, and suicidal instances. There are approximately 7% of employees in the United States that have been diagnosed with major depression (Kuhl, 2018). Among those who suffer from depression, it has been estimated that total economic burden has been $210.5 billion annually. Whether the financial cost has been directly or indirectly related to depression, an enormous amount of money is spent on providing care, treatment and interventions, and daily living of individuals suffered from depression.
- Best Practices Promoting
Mount Sinai Medical Center (MSMC) was established in 1949. Today, Mount Sinai is a 672-bed hospital with a number of satellite centers throughout Miami-Dade County. MSMC is the largest private independent not-for-profit teaching hospital in South Florida. The Primary Care Center at Mount Sinai Medical Center Family Medicine physicians provide primary care and comprehensive medical evaluations to adults and focus on disease prevention and health promotion. My plan is to promote best practice within the organization for the diagnosing and
treatment of depression. To begin with I feel it is important to empower providers with knowledge and equip them with the educational resources, evidence based information and skills needed to diagnose, treat, and provide care for patients suffering from depression. One way to do so will be via professional development seminars. These seminars will focus on the importance of routine outpatient screening for depression using a scale. Another practice to be implemented is to require primary care providers and clinics to document the initial and subsequent diagnosing scales. Lastly the importance of following up with patients and their caregivers, ensuring that they have the educational resources and are compliant with their plan of care. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
C1. Implementation Plan
- Professional developments on depression can be provided as a health care organization. Providers to attend these sessions include but are not limited to doctors, therapists, nurses, and case managers. In order to ensure all health care professionals within the organization have the knowledge about the identification and treatment practice, education will be provided detailing diagnosing tools and standards of care. The objective will be for attendees to verbalize the signs and symptoms of the disease, measurement tools used for diagnosing, treatment options, and managing effective care.
- The health care organization will incorporate a mandatory audit for the screening of depression. Scales such as the PHQ2/PHQ9, will become routine during examinations once information is input in Electronic Health Records (EHR) it will be easy to ensure screenings are being performed. Running reports to monitor the patients trends in the depression scoring and identifying patients who did not have the screening performed will allow providers to identify individuals who are at risk and assess the need for intervention. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
- Once diagnosed it is important to keep track of these patients to ensure that their plan of care is being followed and that the implementation is being executed. It is important to incorporate a systematic approach for identifying, diagnosing, educating patients, providing evidence-based treatments, and providing a close follow-up are used (Unutzer & Park, 2012). Patients who require adjustment of treatment plans, referrals to specialist, or adjunct therapy can be provided education and or resources needed that will maximize their rehabilitation potential. With a system in place to track progression and enforce follow up
C2. Evaluation Method
The effectiveness of the three strategies provided can be evaluated individually based on the following:
- A professional development workshops effectiveness can be evaluated by providing attendees with a pre-workshop questionnaire to assess their knowledge on symptoms and treatment of depression. A post-intervention workshop questionnaire will assess if the objectives of the workshop were met. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
- Mandatory screening for depression can be evaluated by having a checklist for health care providers to indicate that the patient has completed a screening annually. Another way providers can track mandatory screening of depression is by running reports thru EHR system that will alert which patients are missing the screen.
- To ensure effectiveness of tool to track progression and enforce follow up of disease, patient rating scales should be compared each visit to ensure the patient is responding appropriately to the treatments they are receiving. Auditing the charts of these patients to ensure that they are all receiving care and services that are required as well as reinforcing teaching and providing resources if applicable.
Conclusion
With over 300 million individually worldwide suffering from depression, it is important to diagnose, treat, and provide care for these individuals. Mental health disease, can often be overlooked and left untreated; however, research supports that severe cases of depression can lead to suicide. Therefore, it is important for healthcare organizations to understand the importance of providing evidence-based treatments and promoting best practices to ensure patients are receiving the necessary and appropriate care. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
References
Agency for Health Care Administration. (2015). Florida best practice psychotherapeutic
medication guidelines for adults. University of South Florida. Retrieved from
http://www.medicaidmentalhealth.org/_assets/file/Guidelines/Web_2015-
Psychotherapeutic%20Medication%20Guidelines%20for%20Adults_Final_Approved1.p
df
Akincigil, A., Olfson, M., Siegel, M., Zurlo, K.A., Wakup, J.T., & Crystal, S. (2012). Racial and
ethnic disparities in depression care in community-dwelling elderly in the United States.
American Journal of Public Health, 102(2), 319-328. doi:10.2105/AJPH.2011.300349
Anxiety and Depression Association of America. (2016). Facts and statistics. Retrieved from
https://adaa.org/about-adaa/press-room/facts-statistics#
Blobel, B. (2015). Psychologist in a PocketTowards Depression Screening on Mobile Phones . Proceedings of the 12th International Conference on Wearable Micro and Nano Technologies for Personalized Health. 211, p. 155. Amsterdam: IOS Press.
Centers for Disease Control and Prevention. (2016). Depression. National Center for Health Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
Statistics. Retrieved from https://www.cdc.gov/nchs/fastats/depression.htm
Conner, E. (2016, Mar 3/11/2018). Racial/Ethnic and Income Disparities in Depression Treatment. New York, NY, USA.
Gautam S, J. A. (2017, January). Clinical Practice Guidelines for the management of Depression. Indian Journal of Psychiatry , 59(5), 34-50.
Jun-Mian, X. (1987, June 1). Some Issues in the Diagnosis of Depression in China. Social and Community Psychiatry Section, 32(5), 368-370.
Kessler, R.C. (2012). Costs of depression. Psychiatric Clinical of North America, 35(1), 1-14.
doi:10.1016/j/psc.2011.11.005 Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
Kuhl, E.A. (2018). Quantifying the cost of depression. American Psychiatric Association: Center
for Workplace Mental Health. Retrieved from http://workplacementalhealth.org/Mental-
Health-Topics/Depression/Quantifying-the-Cost-of-Depression
Moylan S, Maes M, Wray NR, Berk M. The neuroprogressive nature of major depressive
disorder: pathways to disease evolution and resistance, and therapeutic implications.
Mol Psychiatry 2013; 18: 595–606.
National Institute of Mental Health. (2017). Major depression. Retrieved from
https://www.nimh.nih.gov/health/statistics/major-depression.shtml
National Institute of Mental Health. (2018). Depression. Retrieved from
https://www.nimh.nih.gov/health/topics/depression/index.shtml
Olfson, M., Blanco, C., & Marcus, S.C. (2016). Treatment of adult depression in the united
states. Journal of American Medical Association, 176(1), 1482-1491.
doi:10.1001/jamaintermed.2016.5057
Philip, C. M. (2016). 2016 Florida Behavioral Risk Factor Surveillance System (BRFSS) Data Report. State of Florida , Department of Health Public Health Research Section Epidemiology and Statistics. Celeste Philip, M.D., MPH.
The Community Guide. (n.d.). Mental Health and Mental Illness: Collaborative Care for the Management of Depressive Disorders. Retrieved March 27, 2018, from The Community Guide: https://www.thecommunityguide.org/findings/mental-health-and-mental-illness-collaborative-care-management-pedressive-disorders Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay
Unutzer, J., & Park, M. (2012). Strategies to improve the management of depression in primary
care. Primary Care, 39(2), 415-431. doi:10.1016/j.pop.2012.03.010
Verdujin, J., Milansechi, Y., Schoevers, R.A., van Hemert, A.M., Beekman, A.T., & Penninx,
B.W. (2015). Pathophysiology of major depressive disorder: Mechanisms involved in
etiology is not associated with clinical progression. Translational Psychiatry, 5(e649),
1-9. doi:10.1038/tp.2015.137
World Health Organization. (2017a). Depression: Let’s talk. Retrieved from
http://www.who.int/mental_health/management/depression/en/
World Health Organization. (2017b). Depression. Retrieved from
http://www.who.int/mediacentre/factsheets/fs369/en/ Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay