Evidence Digest

A Focus on the Mental Health of Adults andOlder Adults

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of the evidence digest, a recurring columnin Worldviews, is to provide concise summaries of well-

designed/clinically important, recent studies along withimplications for practice, research, administration, and/orhealth policy. Articles highlighted in this column may in-clude quantitative and qualitative studies, systematic andintegrative reviews, as well as consensus statements by ex-pert panels. Along with relevant implications, the level ofevidence generated by the studies or reports highlighted inthis column (see Table 1) is included at the end of eachsummary so that readers can integrate the strength of evi-dence into their health care decisions.

Lerner D., Adler D.A., Chang H., Berndt E.R., Irish J.T.,Lapitsky L., Hood M.Y., Reed J. & Rogers W.H. (2004).The clinical and occupational correlates of work produc-tivity among employed patients with depression. Journalof Occupational and Environmental Medicine, 46(6 Suppl),S46–S55.

Purpose. The purposes of this study were to: (1) describethe impact of depression and specific depressive symptomson multiple dimensions of employee productivity, and (2)determine whether depression’s negative productivity im-pact is related to the type of work that employees perform.

Sample. The sample consisted of a total of 389 employ-ees who were recruited from primary care physician prac-tices in the northeast region of the United States. Two hun-dred forty-six of these employees were depressed and 143were healthy controls.

The refusal rate for study participation was 47%. Indi-viduals eligible for participation in the study were 18–62years of age who were working for pay at least 15 hours perweek. Persons who qualified for the depression group hada positive screen for dysthymia, major depression disorder(MDD), or both (i.e., double depression [DD]). Controlsubjects had to be free of depression symptoms (i.e., oneor fewer symptoms) and have none of the following ex-clusion criteria: (1) planning to retire within 2 years, (2)receiving disability or have an active claim, (3) actively

Copyright ©2005 Sigma Theta Tau International1545-102X1/05

abusing alcohol or drugs, (4) currently pregnant or deliv-ered a baby in the past 6 months, (5) diagnosed with bipolardisorder, (6) unable to speak and/or read English, and (7)diagnosed with a potentially serious disability or medicalcondition (e.g., arthritis, migraine). Subjects were mainlyfemale (88%) and White (90%).

Design. A descriptive, case control correlational studywas conducted.

Outcomes. The work-life quality (WLQ) questionnaire,a 25-item measure, was used to tap an individual’s abilityto perform a specific set of job demands related to: mentaland interpersonal demands, physical demands, time man-agement, and output demands.

Each of the four subscales indicates the percentage ofwork time in the past 2 weeks that a person’s physicaland/or emotional health problems interfered with his orher ability to perform each group of demands. The sum-mary score is known as the WLQ productivity loss index.Time lost from work was measured with two items thatasked employees how many full and half workdays weremissed in the past 2 weeks because of health or medicalcare. A ratio was calculated to measure productivity lostbecause of absences.

Findings. The findings indicated that employees whowere depressed were two to three times more likely to reportthat health problems interfered with their ability to meetjob demands than were employees who were not depressed.Productivity losses increased when employees had jobs thatnecessitated proficiency in decision-making and commu-nication (e.g., nurses, social workers, engineers, attorneys,and financial analysts) and/or frequent customer contact(e.g., salespeople, nurses, social workers, teachers). Em-ployees who reported that they were distractible and haddifficulty concentrating had poorer WLQ scores and pro-ductivity loss. Those reporting tiredness and sleepiness hadmore difficulty performing mental, mental-interpersonal,time, and output related tasks and missed more days ofwork.

Commentary. Although caution must be used in gen-eralizing these findings to diverse populations, as themajority of participants were White women and depres-sion is typically more prevalent in females, this study has

Worldviews on Evidence-Based Nursing �Second Quarter 2005 103

Evidence Digest

TABLE 1Rating system for the hierarchy of evidence (from Melnyk &Fineout-Overholt 2005)

� Level I: Evidence from a systematic review or meta-analysisof all relevant randomized controlled trials (RCTs),or evidence-based clinical practice guidelinesbased on systematic reviews of RCTs

� Level II: Evidence obtained from at least one well-designedRCT

� Level III: Evidence obtained from well-designed controlledtrials without randomization

� Level IV: Evidence from well-designed case-control andcohort studies

� Level V: Evidence from systematic reviews of descriptiveand qualitative studies

� Level VI: Evidence from a single descriptive or qualitativestudy

� Level VII: Evidence from the opinion of authorities and/orreports of expert committees

Modified from Guyatt & Rennie 2002; Harris et al. 2001.

very important clinical implications in that one in eightworking adults are clinically depressed and half of thesedepressed adults will experience a recurrence of theirdepression within 1 year of remission. Thus, it is criti-cal that routine screening of depression occur, both inprimary care sites as well as in workplace settings, sothat early identification and intervention can be imple-mented. Employers also should consider administeringthe work limitations questionnaire in order to identifyhealth and productivity improvement priorities for theiremployees.

Level of Evidence: IV.

Roth B. & Robbins D. (2004). Mindfulness-based stressreduction and health-related quality of life: Findings froma bilingual inner-city patient population. PsychosomaticMedicine, 66(1), 113–123.

Purpose. The purpose of this study was to determinethe effects of a mindfulness-based stress reduction (MBSR)program on the general health, health-related quality of life(QoL), sleep quality, and family harmony of Spanish- andEnglish-speaking medical patients at an inner-city healthcenter.

Sample. The sample consisted of 86 patients who werereferred to the MBSR program by their primary care ormental health providers. Most patients were coping withthe chronic stress associated with low socioeconomic sta-tus. Some also were experiencing acute psychosocial stress,such as bereavement; domestic violence; or the illness,death, or incarceration of a family member. The interven-

tion group was comprised of 68 adult patients: 48 Spanish-speaking and 20 English-speaking adults. Age range of theexperimental group was 26–82 years, with a mean of 51years. Eighty-two percent of the subjects were women. Fiftypercentage of the experimental group was receiving publicassistance, and the mean number of years of education was9.6. Sixty-six percent of patients in the intervention grouphad at least one medical and one mental health diagnoses.The comparison group consisted of 18 Spanish-speakingfemale adult patients who were 23–55 years, with a meanof 35.2 years. Sixty-seven percent of the comparison groupreported receiving public assistance. The number of yearsof schooling was 9.9. There were no significant differencesbetween the mean number of mental health or medicaldiagnoses between the two experimental and comparisongroups.

Design. Experimental; no random assignment. The com-parison group was comprised of patients who were referredto the MBSR program but who could not attend the MBSRsessions, due to reasons such as lack of transportation andlack of child care.

Intervention. Mindfulness-based stress reduction(MBSR) was an 8-week behavioral medicine course thatoffered the subjects training in mindfulness meditation,with the purpose of teaching individuals how they couldimprove their health and the quality of their lives. Thecourse met for 2 hours each week, and patients wereinstructed to spend 30–45 minutes per day, 6 days perweek, practicing meditation at home (e.g., awareness ofbreathing meditation; Hatha yoga). Forty-eight of theexperimental subjects took the course taught in Spanish,and 20 took the English version of the course.

Outcomes. At baseline and within 4 weeks following theMBSR course, all subjects completed the valid and reliableShort Form 36 (SF-36) that taps general health status andhealth-related QoL in the form of eight areas (e.g., gen-eral health, physical functioning, vitality, general mentalhealth), as well as two questions related to sleep qualityand family harmony in English or Spanish versions.

Findings. Sixty-eight percent of the experimental groupcompleted the MBSR course. The experimental groupshowed statistically significant improvement on five ofthe eight SF-36 measures. There were no differences be-tween the groups on sleep quality or family harmony items.

Commentary. Mindfulness-based stress reduction isbeing used frequently in the current health system, butthis strategy has not been systematically tested withinner-city, minority populations. Despite the fact that amajor limitation of this experimental study was the lackof random assignment to treatment and control groups

104 Second Quarter 2005 �Worldviews on Evidence-Based Nursing

Evidence Digest

that threatens the internal validity of the project (i.e.,the ability to say that the experimental intervention wasthe cause of improvement on the SF-36), the study isimportant in that it demonstrates that this type of inter-vention is feasible in a high-risk population of patientsat an inner-city health center. Replication of this studyusing a randomized controlled design is needed, withmore long-term follow up to determine the effects of theintervention over time. Caution should be used in gener-alizing these results to individuals of varied race/ethnicand socio-economic backgrounds.

Level of Evidence: III.

Yan H. & Sellick K. (2004). Symptoms, psychologicaldistress, social support, and quality of life of Chinese pa-tients newly diagnosed with gastrointestinal cancer. CancerNursing, 27(5), 389–399.

Purpose. The purposes of this study were to: (1) describesymptoms, psychological distress, social support, and qual-ity of life (QoL) of Chinese patients who were newly di-agnosed with gastrointestinal tract (GIT) cancer, and (b)identify the extent to which demographic, physical, andpsychosocial factors affect QoL.

Sample. The convenience sample was comprised of 146newly diagnosed GIT cancer patients who were recruitedfrom three major hospitals in Shanghai. Inclusion crite-ria for the study included: (1) first-time diagnosis of GITcancer in the past 6 months, (2) receiving treatment forGIT cancer in an outpatient clinic, (3) a life expectancyof at least 1–2 years, (4) 18 years of age or older, and(5) able to be interviewed. Individuals were excluded ifthey were receiving treatment for metastatic cancer orrecurrent cancer or had co-morbid chronic disease thatmight affect their perception of QoL. Of the 146 sub-jects, 76% were male and 92.5% were married, with anage range of 17–93 (mean of 55 years). The male-femaleratio was 3 to 1. The largest proportion of subjects hadcolorectal cancer, with the majority being in active cancertreatment.

Design.Descriptivecorrelational, cross-sectionaldesign.Outcomes. The Chinese versions of the Spielberger State

Anxiety Inventory and the Beck Depression Inventory-Short Form were used to assess anxiety and depression.Social support was measured with the Social Support Ques-tionnaire that was developed by the Mental Health Insti-tution of the Hunan Medical University in China. Health-related QoL was measured by the Cancer RehabilitationEvaluation System-Short Form (CARES-SF), and patients’perception of global QoL was answered on a visual ana-logue scale.

Findings. Subjects reported an average of 5 symptomsper patient, with 10% reporting 18 signs or symptoms. Themost common signs and symptoms reported were fatigue,pain, and weight loss. The four most distressing symp-toms were insomnia, the way that food tastes, hair loss,and fatigue. Depression was reported by 28% of the pa-tients, with younger patients (less than 40 years) experi-encing more depression than older patients (>70 years ofage). QoL was reported as moderate. Depression, systemdistress, and social support accounted for 44% of the totalvariance in health-related QoL. Perceived financial diffi-culty and symptom distress accounted for 20% of the totalvariance in global QoL. Patients saw their families as themost important source of support.

Commentary. Cancer is a major health problem in Chinathat affects more than 1.6 million people annually. Iden-tifying which patients are depressed, anxious, and per-ceiving a poor QoL is important in order to introduceinterventions to improve health outcomes and wouldbe important in China as well as across the globe. Stressand coping interventions as well as alternative therapiesmay be particularly useful intervention strategies. Thedevelopment and testing of interventions that are cul-turally sensitive and incorporate the needs and culturalvalues of individuals are urgently needed. The Chineseas well as some other cultures place an emphasis onfamily cohesion; therefore, targeting the family mem-bers with interventions for this population of patientsalso will be important.

Level of Evidence: VI.

Roose S.P., Sackeim H.A., Krishnan K.R., Pollock B.G.,Alexopoulos G., Lavretsky H., Katz I.R. & HakkarainenH. (2004). Antidepressant pharmacotherapy in the treat-ment of depression in the very old: A randomized, placebo-controlled trial. American Journal of Psychiatry, 161(11),2050–2059.

Purpose. This study’s purpose was to test the efficacy ofan antidepressant medication (i.e., citalopram) in compar-ison to a placebo in the treatment of patients 75 years orolder with unipolar depression.

Sample. The sample consisted of 174 patients who wererecruited through radio and newspaper advertisementsand/or through referral from physicians. Inclusion criteriaincluded: (1) age 75 years or older, not living in a residen-tial setting, (2) unipolar depression, single or recurrent, butwithout psychosis, (3) a depression score of greater thanor equal to 20 on the Hamilton depression scale, and (4)willing to consent to participate in the study. Fifty-eight

Worldviews on Evidence-Based Nursing �Second Quarter 2005 105

Evidence Digest

percentage of the subjects were women with a mean age of79.6 years.

Design. A multi-site, double-blind randomized con-trolled trial (RCT) was used at 15 clinical sites.

Treatment. At the end of a placebo week, subjects wererandomly assigned to receive either 20 mg per day of citalo-pram or a placebo.

Outcomes. Key measures completed by participants in-cluded the Hamilton depression scale, the Montgomery-Asberg Depression Rating Scale, the Beck Depression In-ventory, the Clinical Global Impression of severity, the Anx-iety Rating Scale, and the Center for Epidemiologic StudiesDepression Scale (CES-D Scale).

Findings. Twenty-nine of the patients did not finish the8-week trial, which left 145 patients completing the study.There was not a main treatment effect for the citalopram,but there was a treatment effect for site (i.e., there wasmarked variability in how subjects responded to both themedication and the placebo across sites, with medicationresponse ranging from 18% to 82% and placebo rangingfrom 16% to 80% across sites).

Commentary. The design used in this study (i.e., double-blind RCT) is the strongest one for establishing causality.Findings indicated that medication was not more effec-tive than placebo in the treatment of depression in thissample of very old adults. This study supports trialsthat have been conducted with other age groups (e.g.,teenagers), which have supported that antidepressantsalone are usually not effective in treating depres-sion. A combination of cognitive-behavior therapy

with antidepressant use is typically most effective intreating moderate to severe depression. Given that indi-viduals over 65 years of age are the most rapidly growingsegment of the population and they experience a highlevel of depression, it is important to provide routinescreening and effective treatments to prevent suicideand other negative outcomes. Since antidepressants areso commonly prescribed in primary care practice, thefindings from this study again reinforce that it is impor-tant for treatment to be individualized and that patientsreceiving antidepressants should also receive cognitive-behavior therapy or other types of psychological inter-ventions. In addition, there is an urgent need for furtherstudies that evaluate the efficacy of antidepressant treat-ments for the very old.

Level of Evidence: II.

ReferencesGuyatt G. & Rennie D. (2002). Users’ guides to the medical

literature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M., et al. (2001). Current methods ofthe U.S. Preventive Services Task Force: A review of theprocess. American Journal of Preventive Medicine, 20(3Suppl), 21–35.

Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. A guide tobest practice. Philadelphia: Lippincott Williams &Wilkins.

106 Second Quarter 2005 �Worldviews on Evidence-Based Nursing