Using evidence to inform clinical

decision making.

ASSESSMENT TWO: SUBMISSION TEMPLATE

Please complete the following the activities by filling in the spaces below and
submitting this as your assignment in Turnitin. This is a word document so you can
add space as needed.

You are a community mental health nurse in Sydney. In a recent review of referrals to your
service it was noted that there has been a large number of clients referred for treatment of
depression. The treatment provided by your service for these clients is antidepressant
medication. Some of your patients, however, are not keen to take antidepressant medications
for different reasons. You are aware that in other mental health services psychological
interventions such as cognitive behavioural therapy (CBT) are offered as an alternative or
adjunct to medication. Your team is open to change and it is decided to search for evidence of
the most optimal care for these clients

PART 1: DEVELOPMENT OF PICO AND SEARCH PLAN

1. Use the following categories to help define your problem and what you are looking at in
simple terms
PICO: Patient/Problem, Intervention, Comparison, and Outcome.
(remember to use your readings to help you if you are unsure)
Patient/Problem: Depression
Intervention: Cognitive Behaviour Therapy
Comparison: Anti-depressants
Outcome: Reduce depression

2. Now use these terms from the question above to create your PICO research question so
that you have a clear purpose for your search:
In (P) depression does (I) cognitive behaviour therapy compared with (C) anti-depressants
reduce (O) depression?

3. What type of clinical question do you think this PICO answers?

Therapeutic Etiology Diagnositic Prevention Prognosis
Others

4. The table below will help you to think of the other terms that you might also like to look up
when searching for evidence to help you answer your question this is part of basic planning
for a research search.

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 We ask you to look up alternative terms because sometimes articles from different countries and health
systems call things different names for example, in Australia we sometimes us the term community
nurses, but in the UK they often talk about district nurses if you only searched under district nurse
youd miss all the articles which happened to a different term you would be missing some of the picture!

Population Intervention Comparison Outcome

(not commonly used in (not commonly used in
actual database search actual database search
strategy) strategy)
What is your What is your What is your What is youre
population? Main intervention? Main comparison? Main outcome? Main
search term: search term: search term: search term:

Depression Cognitive behaviour Anti-depressants Reduce depression

therapy
What other terms What other terms What other terms
might have been What other terms might have been might have been
used? might have been used? used?
Alternative search used? Alternative search Alternative search
terms: Alternative search terms: terms:
terms:
-Depress* -CBT -Anti-depressive -Treat
-Dysthymia -Cognitive behavio* agents -Control
-Dysthymic Disorder -cognitive therapy - Antidepress*
-Counselling or -Atypical
counseling antidepressants
-Behavio* therapy -Monoamine oxidase
inhibitors

5. Is there a particular group of people that you want to look at? List here any inclusion
criteria you might use to refine your search if you have too many papers:

Gender: ALL Age Range: No

Publication Dates: Last 10 years for RCT Language: English

6. What kind of study do you think would best answer your question? Select here which type
of article you might want to access. You can also use these to refine your search if you have a
lot of papers.
Systematic Review Qualitative Study
Randomized Controlled Trial (RCT) Economic Evaluation
Cohort Study Clinical Practice Guidelines
Case-control Study/Case Series

Systematic Search Strategy Worksheet

7. Now that you have decided on WHAT you will be searching, you need to put down a plan of
HOW you will search for your articles. This helps you and others to see how you got your
evidence and how you made sure you got the best evidence to help you decide on your
clinical action.
Using the PICO terms in your table, enter each term in a row (group them together under the PICO
categories).
The next step is to combine similar terms using OR so that you have all the papers on the same topic
together

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 The final step is to find papers which only talk about both the population AND the intervention. To do this
you use AND in the database.
Key terms:
1 Depression
2 Depress*
3 Dysthymia
4 Dysthymic disorder
5 Cognitive behaviour therapy
6 CBT
7 Counseling, counselling
8 Cognitive therapy
9 Behavio* therapy
1 Antidepressants, anti-depressants
0
1 Anti-depressive Agents
1
1 Antidepress*
2
1 Atypical antidepressants (second generation, tricyclics)
3
1 _1 OR 2 OR_3 OR_4
4
1 5 OR 6 OR 7OR 8 0R 9
5
1 10 OR 11 OR 12 OR 13
6
1 14 AND 15 AND 16
7
OR = combine alternate terms for the same topic to get as many potential papers
as possible!
AND = combine the groups of topics to get papers which cover ALL the terms!

PART 2: EVIDENCE OF APPLICATION OF PLAN IN DATABASE SEARCHES AND

ABSTRACTS
1. Place the screenshots/screengrabs/digital pictures of your two (2) database
here. Please ensure your screenshots provide all steps of your search and are clear
enough to be legible these must be READABLE!!

Database search 1- Medline search showing evidence for randomised control trial

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Database search 2- Cochrane library search showing evidence for systematic
review

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2. Place the abstract of your selected Randomised Controlled Trial here. Please add
this as a screenshot, do not retype this yourself.
Title- Effect of Cognitive Therapy With Antidepressant Medications vs Antidepressants Alone
on the Rate of Recovery in Major Depressive Disorder: A Randomized Clinical Trial (Hollon et
al. 2014).

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3. Place the abstract of your selected Systematic Review here. Please add this as a
screenshot, do not retype this yourself.
Title- Psychological therapies versus antidepressant medication, alone and in
combination for depression in children and adolescents (Cox et al. 2014).

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PART 3: APPRAISAL OF YOUR TWO ARTICLES Randomised controlled trial

Randomised Controlled
Trial Appraisal Tool

Section A: Are the results of the review valid?

Screening Questions

1. Did the trial address a clearly focused issue?

Yes No Cant tell
Justify your answer:
Yes. The study was carried out to determine effects of cognitive therapy with
antidepressant medications vs antidepressants alone on the rate of recovery in
depression
HINT: An issue can be focused In terms of
The population studied
The intervention given
The comparator given
The outcomes considered
2. Was the assignment of patients to treatments randomised?
Yes No Cant tell
Justify your answer:

Yes. The participants were randomised using a randomisation schedule generated by

the project statistician (mentioned inside the article under procedures.)

HINT: Consider
How was this carried out?
Was the allocation sequence concealed from

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3. Were all of the patients who entered the trial properly accounted for at
its conclusion?
Yes No Cant tell
Justify your answer:

Yes- The longitudinal Interval Follow-up Evaluation (LIFE) was used to provide
retrospective assessments of diagnostic status across time. The article also includes a
detailed flow diagram to indicate the number of patients left at each stage of the trial
including the reasons for dropping patients.

HINT: Consider
Was the trial stopped early?
Were patients analysed in the groups to which they were randomised?

Detailed questions

4. Were patients, health workers and study personnel blind to treatment?

Yes No Cant tell
Justify your answer:
Yes.
The health interviewers were blind to the type of treatment that the patients received,
however the patients were not blinded.
- This may be due to the fact that patients were able to tell when CBT was being
offered.

HINT: Think about

Patients?
Health workers?
Study personnel?

5. Were the groups similar at the start of the trial?

Yes No Cant tell
Justify your answer:

Yes, a grading criterion was used to measure the extent of the depression. DSM-IV
major depressive either chronic (episode duration 2 years) or recurrent (with an
episode in the past 3 years if only the second episode).
- 17 item Hamilton Rating Scale for Depression (HRSD) score of 14 or more
- Over the age of 18, English speaking and have the ability to give informed
consent
HINT: Look at
Other factors that might affect the outcome such as age,
sex, social class
researchers and patients?

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6. Aside from the experimental intervention were the groups treated
equally?
Yes No Cant tell
Justify your answer:

Yes as there is no mention of any special treatments in the article.

Section B: What are the results?

7. How large was the treatment effect?
Justify your answer:

The main outcome measured was blind evaluations of recovery with a modified
version of the 17-item Hamilton Rating Scale for depression and the Longitudinal
Interval Follow up Evaluation. The primary outcome is clearly specified as it states
what they measured to see how well cognitive therapy with antidepressant
medication was working.

HINT: Consider
What outcomes were measured?
Is the primary outcome clearly specified?
What results were found for each outcome?

8. How precise was the estimate of the treatment effect?

Justify your answer:

Combined treatment enhanced the rate of recovery vs treatment with ADM alone
(72.6% vs 62.5%;t 451= 2.45;P= .01; hazard ratio [HR], 1.33; 95% CI, 1.06-1.68). The
confidence interval here is 95%, meaning that there is a 95% chance that the CI
calculated contain the true population mean.

HINT: Consider
What are the confidence limits?

Section C: Will the results help locally?

9. Can the results be applied in your context? (or to the local population?)
Yes No Cant tell
Justify your answer:
According to the trial cognitive therapy combined with anti-depressant medication
enhances the rates of recovery from major depressive disorders relative to anti-
depressants alone. This means that people will benefit from a combined treatment
approach if they have a major depressive disorder, but provided no conclusion as to
what will happen to people with other forms of depression like melancholia, psychotic
depression and antenatal depression.
Yes the results can be applied to most of the local population as there is no significant
difference between major depressive disorder or depression (Beyond Blue 2015).
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HINT: Consider whether
Do you think that the patients covered by the trial
are similar enough to the patients to whom you will
apply this?, if not how to they differ?

10. Were all clinically important outcomes considered?

Yes No Cant tell
Justify your answer:

Yes important outcomes were considered, however, information on other types of

depression would be informative.

HINT: Consider
Is there other information you would like to have seen?
If not, does this affect the decision?

11. Are the benefits worth the harms and costs? Yes Cant tell No
Justify your answer:

The benefits are definitively worth the costs, as it improves recovery and also reduces
the frequency of adverse events. Adverse effects of anti-depression medication is the
reason most people stop taking regular medication (Remick 1988), and combination of
treatment with CBT will improve recovery (Wilson 2014).

HINT: Consider: Even if this is not addressed by the review, what do you think?

PART 3: APPRAISAL OF YOUR TWO ARTICLES Systematic review

Systematic Review
Appraisal Tool

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Section A: Are the results of the review valid?
Screening Questions

1. Did the review address a clearly focused issue?

Yes No Cant tell
Justify your answer:
Yes Psychological therapies versus antidepressant medication, alone and in
combination for depression in children and adolescents. Although the population
studied was limited to adolescents, as there is no set age for depression and its
treatment, this particular paper will answer my PICO question. If depression is left
untreated in children and adolescents it is likely to recur in adulthood.

HINT: An issue can be focused In terms of

The population studied
The intervention given
The outcomes considered
2. Did the authors look for the right type of papers?
Yes No Cant tell
Justify your answer:

Yes- The author searched the Cochrane Depression, Anxiety and Neurosis Groups
Specialised Register that contains RCTs from Central, Medline, Embase and PsycINFO
with dates from 1950-1967 to 2014.
Looking at the articles and its selection criteria (types of studies, interventions,
participants and outcome measures) the authors focused on the review question.

HINT: The best sort of studies would

Address the reviews question
Have an appropriate study design (usually RCTs for papers evaluating interventions)

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Detailed questions

3. Do you think the important, relevant studies were included?

Yes No Cant tell
Justify your answer:

Yes all relevant studies were included.

- The databases used were Cochrane Depression, Anxiety and Neurosis Review
Group's Specialised Register (CCDANCTR) to 11 June 2014. The register contains
reports of relevant randomised controlled trials (RCTs) from the Cochrane
Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date),
EMBASE (1974 to date), and PsycINFO (1967 to date).
- Reference lists of all trials were checked to identify additional published or
unpublished research. Authors of all included studies and recognised experts in
the field were contacted to ensure no study was missed. Non English studies
were included in the study

Based on analysis of the reference list I can confidently state that the studies used
were relevant to this particular systematic review.
HINT: Look for
Which bibliographic databases were used
Follow up from reference lists
Personal contact with experts
Search for unpublished as well as published studies
Search for non-English language studies
4. Did the reviews authors do enough to assess the quality of the included
studies?
Yes No Cant tell
Justify your answer:
At least three review authors independently conducted the screening process of titles and abstracts. The same
review authors assessed full articles for adherence to selection criteria.

References had to pass the following simple criteria.

It had to be a RCT.
Include participants with a diagnosis of a depressive disorder using DSM or ICD criteria (as diagnosed by a
clinician).
At a minimum, compare an antidepressant medication with a psychological therapy.
A risk of bias assessment tool based on Chapter 8 of the Cochrane Handbook for Systematic Reviews of
Interventions (Higgins 2011) was also used.

HINT: The authors need to consider the rigour of the studies they have identified. Lack of rigour may
affect the studies results.

5. If the results of the review have been combined, was it reasonable to do

so?
Yes No Cant tell
Justify your answer:

Two review authors independently selected studies, extracted data and assessed the
quality of the studies. They applied a random effects meta-analysis, using the odds
ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe
continuous outcomes when the same measures were used, and standard mean
difference (SMD) when outcomes were measured on different scales.
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A random effects analysis assumes that parameters underlying studies follow some
distribution while a fixed effect model assumes that a single parameter value is
common to all studies(Higgins, Thompson & Spiegelhalter 2009).
The results of all the studies are clearly displayed. The display of results shows studies
that had similar results, those that had contradictory and are clearly discussed.
HINT: Consider whether
The results were similar from study to study
The results of all the included studies are clearly displayed
The results of the different studies are similar
The reasons for any variations in results are discussed

Section B: What are the results?

6. What are the overall results of the review?
Justify your answer:

There is very limited evidence upon which to base conclusions about the relative
effectiveness of psychological interventions, antidepressant medication and a
combination of these interventions. On the basis of the available evidence, the
effectiveness of these interventions for treating depressive disorders in children and
adolescents cannot be established. When comparing the multiple objectives for these
studies numerical values given are comparative with other studies but do not indicate
an overall value.
HINT: Consider
If you are clear about the reviews bottom line results
What these are (numerically if appropriate)
How were the results expressed (NNT, odds ratio etc)

7. How precise was the estimate of the treatment effect?

Justify your answer:

As the study did not reach a conclusion confidence intervals are not given, however,
all the RCTs analysed were at 95% confidence interval. In my case this shows that the
conclusion the authors achieved is accurate and not a result of skewed studies.
HINT: Look at the confidence intervals, if given

Section C: Will the results help locally?

8. Can the results be applied to the local population?

Yes No Cant tell
Justify your answer:

Yes. Even though this study used children and adolescents, depression can affect any
age. Based on scenario 1 there is no mention of the age group the clinic specifically
treats. Using this article I can say that psychological intervention on their own or in
adjunct to medication may not work effectively in children and adolescents and
therefore adults. The medication used between adults and adolescents is the same,
the pharmacology of most anti-depressants is similar but the doses are different.

HINT: Consider whether

The patients covered by the review could be sufficiently different to your population to cause
concern
Your local setting is likely to differ much from that of the review

9. Were all important outcomes considered?

Yes No Cant tell
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Justify your answer:

All-important outcomes were considered by this review.

HINT: Consider
Is there other information you would like to have seen?
10. Are the benefits worth the harms and costs?
Yes No Cant tell
Justify your answer:

No.
As psychological intervention does not treat depression that well, implementing it in
the clinic and be costly and can create adverse effects. More research is needed in
psychological interventions for treating depression in children and adolescents.
In regards to treatment of adults and elderly using CBT, I personally cannot see much
difference in effectiveness of treatment when compared to the adolescents.
HINT: Consider
Even if this is not addressed by the review, what do you think?

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PART 4: SYNTHESISING THE EVIDENCE (10 marks)
Finally, write a 400 word summary of the evidence that the two articles provide. You need to
summarise the important information that relates to your clinical question, and write this in
simple language as if you were explaining the rationale for your clinical decision making to a
patient within your care

The purpose of this research was to find out if psychological interventions such as cognitive
behavioural therapy (CBT) when offered as an alternative or adjunct to medication is effective
in treating depression.

Based on a clinical trial that was carried out on 452 participants for 42 months, to determine if
cognitive therapy combined with anti-depressant medication, or anti-depressants on its own,
was effective in treating major depressive disorder (Hollon et al. 2014). They found that
cognitive therapy in combination with anti-depressant medication enhanced the rates of
recovery from major depressive disorder relative to anti-depressants alone. (72.6% vs 62.5%;
t 451= 2.45; P= .01; hazard ratio [HR], 1.33; 95% CI, 1.06-1.68). Patients who received the
combined therapy reported less severe adverse effects. Major depressive disorder is the same
as depression as only the time of onset of the negative symptoms separates the mild from
major (Belmaker & Agam 2008). The clinical trial showed us that using cognitive behavioural
therapy is effective in treating depression only if used in conjunction with the medication
answering the PICO question but it is too early to draw a conclusion.

A systematic review was carried out by Cox et al. (2014) to evaluate the effectiveness of
psychological therapies and antidepressant medication, alone and in combination, for the
treatment of depressive disorder in children and adolescents. It comprised of 11 studies, and
1307 participants. Although the research focused on children and adolescents, research
evidence shows that if depression is not treated effectively at this stage it can recur at an
adult age (Hazell 2007), (Castiglia 2000) and therefore this article was chosen to answer the
research question. The type of medications used between adolescents and adults are also the
same. The review found that there was limited evidence about the relative effectiveness of
psychological interventions, antidepressant medication and a combination of these
interventions to treat depressive disorders, therefore no conclusion was reached.

Treating depression with anti-depressants has proven effectiveness, but treatment with CBT
has contradictory effectiveness. A combination therapy may benefit some individuals and
improve recovery. Based on the available evidence CBT can be tried on certain patients
especially adolescents or a combination of CBT and anti-depressants, and stopped when the
patients wish to. Further research needs to be carried out on the effectiveness of cognitive
behavioural therapy. In conclusion for people with depression cognitive behaviour therapy
may reduce depression when compared to anti-depressants.

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 References
Belmaker, R.H. & Agam, G. 2008, 'Major depressive disorder', N Engl J Med, vol. 358, no. 1, pp.
55-68.
Beyond Blue 2015, Types of Depression, Beyond Blue Organisation, Australia, viewed 5th
September 2015, <https://www.beyondblue.org.au/the-facts/depression/types-of-
depression>.
Castiglia, P.T. 2000, 'Depression in adolescents', J Pediatr Health Care, vol. 14, no. 4, pp. 180-
2.
Cox, G.R., Callahan, P., Churchill, R., Hunot, V., Merry, S.N., Parker, A.G. & Hetrick, S.E. 2014,
'Psychological therapies versus antidepressant medication, alone and in combination
for depression in children and adolescents', Cochrane Database Syst Rev, vol. 11, p.
CD008324.
Hazell, P. 2007, 'Depression in adolescents', BMJ, vol. 335, no. 7611, pp. 106-7.
Higgins , J., Green S, 2011, Cochrane Handbook for Systematic Reviews of Interventions
Version 5.1.0, The Cochrane Collaboration, viewed 5th September 2015,
<www.cochrane-handbook.org. >.
Higgins, J.P., Thompson, S.G. & Spiegelhalter, D.J. 2009, 'A re-evaluation of random-effects
meta-analysis', J R Stat Soc Ser A Stat Soc, vol. 172, no. 1, pp. 137-59.
Hollon, S.D., DeRubeis, R.J., Fawcett, J., Amsterdam, J.D., Shelton, R.C., Zajecka, J., Young, P.R.
& Gallop, R. 2014, 'Effect of cognitive therapy with antidepressant medications vs
antidepressants alone on the rate of recovery in major depressive disorder: a
randomized clinical trial', JAMA Psychiatry, vol. 71, no. 10, pp. 1157-64.
Remick, R.A. 1988, 'Anticholinergic side effects of tricyclic antidepressants and their
management', Progress in Neuro-Psychopharmacology and Biological Psychiatry, vol.
12, no. 23, pp. 225-31.
Wilson, P.J. 2014, 'The case for CBT over antidepressants', Med J Aust, vol. 200, no. 8, p. 460.

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