Depression and CBT: A Collaborative Approach

Chapter One

Introduction

Depression is a common mental health disorder that affects millions of people globally (World Health Organization (WHO) 2018). Individuals suffering from the disorder will experience periods of low mood, which can be life-threatening at their most severe. Distress can have a particularly negative impact on a person's life because it can cause feelings of inadequacy and hopelessness, feeling empty, having no pleasure in life, and, perhaps most concerning, suicidal ideation (Rotenstein et al., 2016). Fortunately, several interventions and strategies for managing and treating symptoms have emerged over the last century. Cognitive Behavioral Therapy is the most commonly applied. CBT is a psychotherapeutic treatment that has helped individuals to be able to identify and change disruptive thoughts that have a negative influence on their behavior. Statistical analysis from multiple scientific studies has proven the effectiveness of CBT in the treatment of older adults (Kishita and Laidlaw, 2017). Evidence has demonstrated that CBT is effective when delivered in different forms such as self-help, computerized, and telephone formats. The increasing access to psychological therapists (IAPT) initiative rolled out in 2008 under the UK National Health Service has ensured a significant increase in patients' access to cognitive therapy services within health care (Köhler et al., 2017). In recent years, cognitive-behavioral Therapy (CBT) has grown in popularity as a psychotherapeutic strategy for effectively managing mental health disorders (NICE 2018). Depression is one of the most compelling indications for CBT because the core psychopathology of depression, cognitive biases, and negative schemata are cognitive (Belzung et al., 2015). CBT is an evidence-based intervention that focuses on talking Therapy. It is based on the idea of investigating how their perceptions of events influence people's emotions and behaviors. Integrating research knowledge to enhance therapeutic interventions, utilizing clinical skills, and recognizing the insights that people can contribute to their wellbeing are all elements of evidence-based practice (Kishita and Laidlaw, 2017). As a result, nurses and patients must collaborate to develop shared goals for mood management and identify thoughts that may propagate problems (Rotenstein et al. 2016). As a result, nurses work in accordance with the Nursing and Midwifery Council's (NMC) Code (2015), recognizing the contribution that individuals can make to their own wellbeing. In England and Wales, the Working to improve Access to Psychological Therapies (IAPT) initiative (2008) achieved success in doubling the NHS's budget for talking therapies, thereby raising public access to psychotherapeutic approaches and the number of mental health experts trained to deliver such therapies (Kishita and Laidlaw, 2017). Furthermore, the Department of Health (2017) stated in a recent mandate that people in need of mental health care should have timely access to evidence-based services, such as better access to psychological treatments.

Possible effects of pre-tests on cognitive-behavioral Therapy significantly affected the overall quality of life (Morin et al., 2009). Evidence has proved that CBT is effective when delivered in different forms such as self-help, computerized, and telephone formats. From the research that has been conducted in the past, evidence suggests that CBT is cost-effective (Schutte-Rhodin et al., 2008). Improving access to CBT would likely improve the outcomes and saves on the overall cost. However, future research is warranted to evaluate the related economic impacts of CBT administration in older adults. The causes for this disorder vary from one individual to another, and there is no specific cause. The Centres for disease control and prevention estimate that 8.1 percent of American adults who have more than 20 years have had depression (WHO 2017). Depression is experienced in different ways and may negatively impact an individual’s day-to-day work schedule. It may also influence productivity in business and influence relationships between workmates. (DeRubeis et al. 2008). Depression has varied signs and symptoms depending on the sex and age of these individuals (Negele et al., 2015). Men may experience mood swings, hopelessness, sadness, loss of interest, and reduced sexual desire. In contrast, women, on the other hand, may experience symptoms such as irritability, sadness, loss of interest in activities such as social involvements, sleep disorders, and fatigue. Although the causes of depression vary with different individuals, there are several known possible causes of depression Statistics show that about 21% of people who suffer from depression have a substance use problem (DeRubeis et al., 2008). Many factors have influenced depression in older adults, although health care providers have found it difficult to determine the exact causes of depression in these adults. There are no designated tests to diagnose depression; health care providers have made diagnoses basing on the symptoms displayed by these patients (Sinyor, Schaffer & Levitt, 2016). In older adults, depression has been considered as a common problem but not a part of growing old. The confusion caused by this disorder in older adults may look like Alzheimer’s disease; hence care needs to be exercised when handling such patients. Many factors have influenced depression in older adults, although health care providers have found it difficult to determine the exact causes of depression in these adults (Schlögelhofer et al.,2018). There are no designated tests to diagnose depression; health care providers have made diagnoses basing on the symptoms displayed by these patients. Cognitive-behavioral therapy is a popular and empirical form of treatment for mental health disorders. These mental disorders are presented in two forms known as major depressive and persistent depressive disorders (NICE 2018). CBT is a psychotherapeutic treatment that has helped individuals identify and change disruptive thoughts that negatively influence their behavior. Statistical analysis from multiple scientific studies has proven the effectiveness of CBT in the treatment of older adults (Kishita and Laidlaw 2017). These mental health difficulties such as anxiety and depression have affected a wide range of populations of older adults. This form of Therapy has focused on changing the negative thoughts that could worsen an individual’s thoughts, leading to depression. The increasing access to psychological therapists (IAPT) initiative rolled out in 2008 under the UK National Health Service has ensured a significant increase in patients' access to cognitive therapy services within health care systems (Turner and Swearer, 2010). The main goal of this form of treatment is to teach people that they cannot control all the events happening in the world but can control their minds and how they perceive these events. CBT is becoming increasingly used in recent years by health professionals as it has proven effective in treating depression in older adults. As a result of solid support for its effectiveness, CBT has been widely adopted as the most efficient form of physiotherapy (Lepping et al., 2017). This form of treatment is considered short-term is effective to individuals and families. It is a highly structured and interactive form of Therapy characterized by many different principles that have recognized multiple relationships between thoughts, behaviors, and emotions.

Research has widely shown that specific habits in an individual are associated with the mental disorder they are suffering from (Rief et al., 2018). Frequent practice and application of adaptive behavior in CBT have helped to change these patterns of human behavior. Writing about these experiences and the whole experiment process by patients is an effective form and part of behavioral Therapy in older adults (Schlögelhofer et al.,2018). This helps them increase their awareness of their thinking patterns. Cognitive change strategies are also incorporated in the complete remission of the symptoms by teaching patients to improve their attention to identify negative thoughts as soon as they start occurring (Reavell et al., 2018). Hence cognitive Therapy and behavioral Therapy are effective in treating depression in older adults, and a have a significant effect than clinical treatment outcomes. This form of therapy treatment first emerged in the 1960s by Aaron Beck, who discovered that different forms of thoughts in human beings significantly contributed to emotional problems (Thoma, Pilecki & McKay 2015). During his time as a psychiatrist at the University of Pennsylvania, Dr. Beck studied and practiced psychoanalysis and carried out various tests and experiments on concepts of depression (Schlögelhofer et al.,2018). The fundamental concepts of his research proved that depressed patients experienced negative thoughts that arose spontaneously, which he named automatic thoughts. According to his findings, the patient’s thoughts were centered on three aspects: the world, the future, and about themselves (Chanda and Grossberg 2013). By helping these patients deal with their thoughts, Dr. Beck realized that they could think more about real facts and behave normally after the Therapy. The long-lasting change could only be attained if the patients focused more on changing their underlying thoughts about things they perceived, which he named Cognitive Therapy (Thoma, Pilecki & McKay 2015). Nowadays, it is widely known as Cognitive Behavioural Therapy, which has been studied and proved effective in treating depression.

Aim

The main goal of this study is to determine the effectiveness of Cognitive behavioral therapy treatment in older adults who are suffering from severe depression. This study also focuses on CBT goals in each session, considered unique based on circumstances and thoughts that led to an individual being depressed. Another purpose of this study is to help clients re-think their perspectives and patterns, allowing them to control their behavior solely. This is important as it ensures that these clients can solve this problem if it occurs again without professional help.

Overview of dissertation

The first chapter of this dissertation briefly summarized the topic of this paper and discussed cognitive behavioral therapy and how effective it is in reducing depressive symptoms in older adults. The second chapter will define a literature review and outline the search strategy to find eight relevant articles. The chosen articles will then be reviewed and critically analyzed. The third chapter discusses the literature review and recommendations for nursing practice. These recommendations will be derived from the reviewed literature to identify how nurses can improve the quality of care they provide to service users. Chapter 4 will offer a conclusion to the points raised throughout the dissertation.

CHAPTER TWO

Introduction of literature review

Bolderston (2018) defines a literature review as an informative, critical summary of a specific topic. It can identify what is known about a particular subject and is especially useful in identifying literature gaps to help formulate questions that require additional research (Parahoo 2014). Essentially, literature reviews help us better understand a subject (Winchester and Salji 2016). They are especially valuable tools for nurses because they provide evidence for research, which can help improve and perfect the current quality of nursing care. Smith and Noble (2015) This literature review will highlight the search strategy used to locate the selected articles. It will then critically examine these articles, focus on themes identified to make practical guidelines.

Search strategy

An initial search was conducted using CINAHL, Scopus, and Medline to identify relevant literature for this review. The databases were used to gain access to a wide range of literature in the field of psychiatric nursing (Ecker & Skelly 2010). The search terms used to find this literature was ‘nurse*, ‘cognitive behavioral therapy*,' ‘depression*,' and ‘depression.' To broaden the search and compensate for variations in terminology, Boolean operators and truncations were used, which in theory meant that a more significant number of articles would emerge (Ecker and Skelly 2010). To narrow the search even further, date parameters were used so that only articles published between 2008 and 2019 would appear. This time frame was chosen to ensure that the research gathered was recent. Furthermore, only articles in English were considered when using the advanced search (Thoma, Pilecki & McKay 2015). Although the search was refined to only include reports produced in the United Kingdom, this significantly reduced the number of articles not included in the final search criteria. However, efforts were made to find research conducted in Westernised countries with healthcare systems similar to the UK so that any recommendations could be meaningfully applied to UK practice (Ecker and Skelly 2010). This search yielded 56 articles, six of which were considered fit for this review after reviewing each summary to ascertain which were most suitable. The articles chosen were a mix of exploratory and descriptive research articles, that is, research that produced either statistical data or descriptive, non-numeric data (Parahoo 2014). These articles were critiqued using Holland and Rees' critiquing framework (2010). The framework aided in identifying the articles' strengths and weaknesses.

Literature review

Preventing major depression

A recent randomized trial in depressed older adults done by Arch and Craske (2008) indicated that a preventive internet-based intervention made up of the aggregation of problem-solving and behavioral activation has notable impacts in patients with subthreshold depression. The level of depressive symptoms following the intervention was significantly lower in the treatment group as opposed to the enhanced care-as-usual control group (Arch and Craske 2008). The most important thing was that after a follow-up for one year, the number of elderly persons who developed significant depressive symptoms was significantly lower in the treatment group than in the control group (Belzung et al., 2015). The finding concurs with past research indicating that brief psychological interventions in individuals with threshold depression can prevent significant depression at follow-up. In a meta-analysis consisting of 17 randomized trials in subthreshold depression done by Start-up, Jackson, and Bendix ( 2004), it was found that the rate of incidence was reduced significantly in the patients who received preventive interventions such as CBT as opposed to those who did not. In a similar study conducted by Kolher et al. in 2017 on the effectiveness of cognitive-behavioral therapy and pharmacotherapy in inpatient treatment of depressive disorders, Additional CBT was administered to 206 successively registered acute hospitalized patients with unipolar clinical depression (Kohler et al. in 2017). This joint treatment was then contrasted to mental health primary care (clinical management) in an inpatient unit. After hospital treatment, 105 of the 206 patients received symptom-focused CBT in addition to medical Therapy (Jayasekara et al., 2016). All patients received the Hamilton Rating Scale for Depression, the Beck Depression Inventory (BDI), the Dysfunctional Attitude Scale, the Clinical Global Impression Scale, and the Global Assessment of Functioning. Patients who received additional CBT experienced a significantly more significant reduction in depressive symptoms than those who received only inpatient primary care. Furthermore, remission rates in the combined treatment group were significantly higher (HAMD 72 % to 51 %) than in the primary care only group (Miloseva, Milosev & Rihter, 2016). Naturalistic design flaws and inconsistent pharmacological treatment are examples of design flaws. The findings show that adding cognitive-behavioral treatment to depressive disorders improves outcomes significantly more than the standard procedure in acute psychiatric treatment. Treatment strategies must accompany medication. Only 33% of patients in the Sequenced Treatment Alternatives to Relieve Depression trial met remission criteria after the first antidepressant treatment step and 50% after the second (Jayasekara et al., 2016). The strict criteria for inclusion of randomized controlled trials frequently result in under-representation of their patient populations. Their findings must be supplemented with findings from clinical studies to provide an accurate picture of the effectiveness of treatment.

Identifying the maladaptive beliefs, including losses and transitions

In a study conducted by Chand and his associates on how Cognitive-Behavioural Therapy works for depressed older adults, 106 studies were selected as sample representation. These samples were able to address older adults as the two subgroups in the literature (Chand & Grossberg, 2015). They were able to show that Cognitive-Behavioural Therapy was equally as effective as other treatment methods like life-review therapy or interpersonal Therapy (Miloseva, Milosev & Rihter, 2016). In general, effect sizes for Cognitive-Behavioural Therapy as treatment in elderly adults suffering from depression were shown to be in the medium-large range. Even though there is evidence for Cognitive-Behavioural Therapy efficacy, there may be a necessity for some accommodations within Cognitive-Behavioural Therapy to provide the older adults the whole therapeutic benefit. Overally, Chand and Grossberg (2015) propose the administration of the material at a slower rate, given that the speed of processing reduces as people enter into adulthood. Suppose therapists can limit the number of new ideas that they introduce in each session. In that case, it is likely that this will make treatment time longer but will help in the mastering of new cognitive and behavioral techniques for the patients. A recent review of Metadata analyses of Butler, Chapman, Forman, and Beck (2016) on the effect of CBT in emotional distress identified 16 quantitative reviews on populations with different emotional disorders. A total of 332 clinical trials that covered more than 16 different disorders were used in conducting this study (Butler et al., 2016). This study review proved that CBT was efficient in treating emotional distress from the studies compared to the response rates on the samples under study. Similar research by Kennerly, Kirk, and Westbrook (2017) also developed their thoughts of Therapy around the behavioral aspects where they observed stimuli caused by different environmental factors and the resultant impacts on a person’s thoughts. The three were able to show efficacy for treating emotional disorders and centered their Therapy within sensible ecological factors that could trigger them (Kennerly, Kirk & Westbrook, 2017). The early approach of this aspect was focused on understanding the significant contribution of the negative behavior of human being to the stimulating factors within the environment. Schlogelhofer and his associates (2018) carried out similar research on clinical study results from a randomized control trial of cognitive behavior in patients with partially remitted depressive disorder. This study is among the first to examine the clinical benefits of cognitive therapy in this patient population (Schlogelhofer et al., 2018). A single-blind, randomized control design was used for this study. Ninety people with partially remitted major depression were randomly assigned to cognitive behavioural guided self-help plus psycho pharmacotherapy (n = 49) or psychopharmacotherapy alone (n = 41). Over a 3-week run-in period and a 6-week treatment period, they were clinically assessed at regular intervals with ratings of depressive symptoms and stress-coping strategies (Ansari & Grossberg, 2016). After six weeks, an intention-to-treat analysis (n = 90) revealed that patients who received cognitive behavioral guided self-help in addition to psycho pharmacotherapy did not have significantly lower scores on the Hamilton Rating Scale of Depression (17-item version; HRSD-17) or the Beck Depression Inventory (BDI) compared to patients who received psycho pharmacotherapy alone (Chand & Grossberg, 2015). There were significant differences between the two groups at the end of treatment in terms of the BDI but not the HRSD-17 when negative stress-coping strategies were taken into account. After a 6-week intervention, guided self-help did not result in a significant reduction in symptom severity in patients with partially remitted depressive disorder (Waltman, Creed & Beck, 2016). However, the intervention reduces negative stress-coping strategies. A study by Sinyor, Schaffer and Levitt in 2016 focused on the sequenced treatment alternatives to relieve depression (STAR*D) trial. STAR*D trial is the world's largest pragmatic trial ever conducted to investigate the treatment of severe depression. STAR*D, which cost $35 million over six years, sought to test the efficacy of both medication and behavioral therapeutic interventions and determine whether specific treatments are more optimal after one or more failed trials (Sinyor, Schaffera & Levitt, 2016). The analysis included patients (n = 2876) who sought treatment for depression in either a psychiatric or family practice setting. Patients in the four levels of STAR*D were randomly assigned to various treatment monotherapies, combinations, or augmentation strategies. According to the Hamilton Depression Rating Scale, the primary outcome was remission (Köhler. et al., 2017). Secondary outcomes included clinician and patient self-report measures of response and various measures of patients' level of function and quality of life.

Remission rates for treatment levels 1 to 2 and 3 to 4 ranged from 18% to 30% and 7% to 25%, respectively. There was no difference in effectiveness between any treatments (Jayasekara et al., 2016). Patients who had longer index episodes, more concurrent psychiatric or general medical disorders, and lower baseline function measures were less likely to achieve remission. There were no significant differences in outcomes between patients treated in primary care versus those treated in specialist care, nor were there significant differences in depression rating scores obtained through clinician ratings versus self-report (Sinyor, Schaffera & Levitt, 2016). The STAR*D trial findings shed important light on the efficacy of current treatment strategies for patients suffering from depression. In his work, Benjamin et al. (2015) focused on the idea that Acute and longer-term outcomes in depressed outpatients require one or several treatment steps. The participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial are described in this report, and the acute and long-term treatment outcomes associated with each of four successive steps are compared. One (N=3,671) to four (N=123) successive acute treatment steps were administered to a broadly representative adult outpatient sample with nonpsychotic major depressive disorder (Benjamin et al., 2015). Those who did not achieve remission or were unable to tolerate a treatment step were encouraged to proceed to the next. Those who receive an acceptable benefit, preferably symptom remission, from any particular step may be eligible for a 12-month naturalistic follow-up period. Self-Report Quick Inventory of Depressive Symptomatology For the first, second, third, and fourth acute treatment steps, remission rates were 36.8 percent, 30.6 percent, 13.7 percent, and 13.0 percent, respectively. Overall, the cumulative remission rate was 67% (Ansari & Grossberg, 2016). Those who required more treatment steps had a higher rate of relapse during the naturalistic follow-up phase. Furthermore, after the first three treatment steps, participants who were in remission at follow-up entry had lower relapse rates than those who were not. Lower acute remission rates and elevated relapse rates during the follow-up phase are expected when more treatment steps are required (Waltman, Creed & Beck, 2016). There is a need for research to determine the best multistep treatment sequences for individual patients and the improvement of more broadly treatment options.

Research design

This refers to the overall strategy used in research to address the research question effectively. This has widely been referred to as a blueprint that has been used to inform this research. Collection, measurements, and data analysis are the blueprints informing the research process (Boaz et al., 2018). The type of research design used depends on the research question. The primary function of research designs is to ensure that the evidence obtained enables s researcher to address the problem under research with logic. Properly designed blueprints can avoid issues and mistakes that researchers commit. These research processes used different case studies and descriptive designs to manipulate the collected data into the final output that presented the research decision. Case studies have provided an in-depth understanding s of a particular study (Dannels, 2018). In fields with large volumes of work, case studies are used to narrow down the broad fields. Case studies have been used in this research to test the effectiveness of theories and models that have been applied in this research (Boaz et al., 2018). This design was beneficial to this research as it enabled different methods and relied on other data sources to investigate the problem under study. In comparison of social and economic factors, scientists have used these research methods, in particular, to design and examine real-life scenarios and provide a basic framework for application into real-life happenings (Tobi & Kampen, 2018). Metadata analysis is another research design used in this research; this method has evaluated and summarised results from different individual studies enhancing the researcher’s interest and ability (Boaz et al., 2018). Using synoptic reasoning, these research design analysis procedures have summarised existing knowledge and develop an in-depth understanding of the research question. Analysis differences among studies conducted by different researchers increases the data precision and the estimated effects. Metadata analysis in research effectively determines the research gaps, which has been useful in clarifying policies and programs (Dannels, 2018). New hypothesis and new research problems can be generated from analysing that from deterrent sources. Descriptive research design was also used in these research in order to provide answers to questions of who, what, when and how variables in research have been associated with the main topic of study. Information about the current status of a phenomena is obtained though descriptive research.

CHAPTER THREE

Discussion

In patients with partially remitted major depression, cognitive behavioral guided self-help did not significantly improve depressive symptoms as measured by the Hamilton Rating Scale of Depression (17-item version; HRSD-17) (Schlogelhofer et al., 2018). Reduced negative stress-coping strategies improved for those assigned to cognitive behavioral guided self-help, significantly improving Beck Depression Inventory but not HRSD-17. These findings imply that cognitive-behavioral guided self-help may help manage negative stress-coping strategies. From the above review, it is evident that cognitive-behavioral therapy effectively treats depression in older adults. This form of treatment is readily available to use in older adults (Belzung et al., 2015). This review has adopted the integrated approach of cognition and behavioral aspects from recent researchers. The speed and response of cognitive factors in older adults slows with time, although this slow development in these older adults can be solved up with exercise and other interventions that keep them active. A review of literature from different scholars deduce that CBT effectively administers therapy to older adults suffering from depression (Miloseva, Milosev & Rihter, 2016). Learning and memory become slowly inhibited as a person grows old, which is an indicator of why anxiety disorders and depression is common in older adults. Relevance evidence has been able to prove that an individual’s working memory decline with age. These limitations influence the pace and learning of these individual and hence need to slow down while administering CBT. Unconditioned stimuli precede the conditioned stimulus, which determines fear in human beings. Exposure to these two types of stimulus to an individual reaches a point in time to get a similar response to a conditioned stimulus. Physical changes within the human body were also considered to be conditioned responses. According to Canadian statistics on anxiety disorders, 2.6% of men and 3.4% of women were diagnosed with a social anxiety disorder (Waltman, Creed & Beck, 2016). The number of females with anxiety disorder was higher than the number of male patients suffering from the same condition. A person’s thoughts, image, and belief systems were influenced by physical environmental factors (Early and Glady, 2017). The environment determines the psychological responses of a person they relate with. CBT has been researched from a psychotherapy perspective and no other form is effective than CBT. Recent studies by Kennelly and his associates in 2017 have urged that and have challenged the CBT prominence among programs and practitioners, claiming that the studies conducted on the subject matter are weak and lack evidence (Kennelly et al., 2017). Treatment demand for the clients heightened with time, this form of treatment was administered using different plans and strategies to enhance effectiveness. He suggested that group therapy and individual therapy administration be used to treat emotional disorders to ensure efficacy (Jou, 2016). Jou was more focused on group therapy as his study was able to deduce that group therapies were more effective forms of Therapy than use of medicines. According to him, there are some forms of adult depressions that do not require medications but require cognitive behavioral treatment administered in groups.

Emotional change in adults is an essential therapeutic work in individuals. New experiences in these people are likely to trigger previous life experiences that are a mix of negative thoughts that may hinder their minds and, hence depression (Ansari & Grossberg, 2016). Research has been able to deduce that there are new ways of thinking about emotional experience in adults and how to remedy the situation. Emotional-related cognitions in adults became more relevant in their adults than how they were while young (Jou 2016). The study also deduce that maturity affected the CBT models whereby the speed of these conversations was scheduled to change. Slower conversations would give these individuals an understanding of the instructive guidance in place. This will enable them to adapt to different cognitive levels of different clients and the work done (Ansari & Grossberg, 2016). Therapeutic environments should ensure that the clients are making progress and learning. For real progress to be made, clients are assigned to perform individual therapy sessions. Aside from using simpler languages in these sessions, the trainer needs to ask their clients to repeat or recite what they have learned in session to ensure that they are fully aware. Ellis, Cushing, and Germain (2015) emphasize that CBT is effective in treating stress in older patients. In his work, he points out those specific protocols for CBT have been developed to address this issue of emotional distress. These particular treatment protocols have shown differences in the treatments used even though they share the same core model (Ellis, Cushing & Germain, 2015). This model in psychiatry has an overall goal which is to ensure that the use of therapeutic treatment procedures reduces the symptoms manifesting in these patients When determining the optimal number of CBT sessions for patients with mental health issues, the number of sessions required can vary depending on the illness. In terms of depression treatment, Delgadillo et al. (2014) stated that 4 to 6 sessions would suffice to alleviate depressive symptoms. He conducted a study on the idea that cognitive factors maintain mental disorders and psychological distress. His study deduces that adaptive cognitive behavior has greatly contributed to keeping problems emotional and distress (Delgadillo et al., 2014). Beck's model, these adaptive techniques include beliefs, schemas about an individual, the world, and the future. Emphasis was majorly on the thoughts of an individual that gave rise to automatic thoughts on particular situations and how the therapeutic strategies have changed maladaptive cognitions. Since the clients in question are old, the trainer needs to ensure their clients take notes to aid in memory and enhance the effectiveness of the CBT in older people. Having a positive attitude in Therapy ensures that the clients recover on time (Reavell et al., 2018). Therapy with these individuals may involve rediscovering new skills with your clients rather than teaching them new methods. However, some forms of Therapy require that the therapist not entirely depend on the clients' reasoning and problem-solving abilities (Webb et al., 2017). At times the therapist is needed to lead the sessions rather than handing over instructions which only expect the client to apply them.

Emotional changes with maturity require the design of cognitive interventions as these changes may problems. Research has also deduced that emotional triggers and changes in older adults are likely to be shaped by the surrounding environmental factors. Harsh and unstable environments act emotionally as triggers that may induce instability and stress (Chand & Grossberg, 2015). It has been proven that effective cognitive Therapy in older adults improves life by elongating the life span of these individuals. Without CBT in adults living with depression, death is likely to occur as their minds would shutter. It was established that there are various alternatives ways to treat people with depression, which gave rise to more and better treatment plans. To ensure that the main goal is attained, the patient and the doctors should actively participate in the therapy session to ensure collaboration. Hence, a combination of a variety of cognitive behaviour and techniques that are significantly emotion-oriented stress cognitive factors and behavioural techniques are recognized for enhancing emotional disorder treatment (Hundt, 201ns. Beck began observing his patients and their negative thoughts on their behavior and hence developed this model of Therapy to help p in depression treatments (Reavell et al., 2018). Over time, he observed that this new plan effectively reduced emotional disorder symptoms and advocated for its use. CBT treatment demand for the clients heightened with time, this form of treatment was administered using different plans and strategies to enhance effectiveness. He suggested that group therapy and individual therapy administration be used to treat emotional disorders to ensure efficacy. Chapman was more focused on group therapy as his study could deduce that group therapies were more effective forms of Therapy that use medicines (Knoll & MacLennan, 2017). According to him, some forms of adult depressions do not require medications but require cognitive behavioral treatment administered in groups. It was established that there is no distinguished difference in the outcomes of using individually administered CBT and supported CBT. These results were obtained after a Meta-analysis of data was compared between the individually performed Therapy and supportive care therapy, which showed no statistical difference after the treatment was administered (Reavell et al., 2018). It was deduced that the results of these techniques were consistent with the results of the therapy and anxiety disorder exposure. These scholars believe that new research is needed to explore this relatively new area in anxiety disorders. The condition is more common in Canada, which has a large population of the elderly group within the society. Their age group structure is mainly comprised of the elderly in society (Knoll & MacLennan, 2017). In a mental health survey in Canada conducted in 2014, social anxiety was considered a mental disorder and was included in its study. Cognitive behavioral therapy has helped individuals determine change and disturbing patterns that negatively influence their emotions (Findlay, Arim, Brown & Larson, 2020). His study focused on changing the negative aspects of the mind that caused emotional difficulties and anxiety. These thoughts are identified through different patterns and the focus shifted on strategies in place to overcome them. This form of Therapy encompassed an arrangement of approaches and techniques to address the thoughts and emotional changes people faced.

CBT treatment demand for the clients heightened with time; this treatment was administered using different plans and strategies to enhance effectiveness. He suggested that group therapy and individual therapy administration be used to treat emotional disorders to ensure efficacy (Reavell et al., 2018). Jou was more focused on group therapy as his study could deduce that group therapies were more effective forms of Therapy that use medicines. According to him, some states of adult depressions do not require medications but require cognitive-behavioral treatment administered in groups Arch and Craske (2008) focused on how the theory expanded to incorporate more than the two therapeutic aspects becoming more flexible and had the power to address many mental issues and disorders resulting from depression. CBT integrated with other therapy models to produce desired results (Knoll & MacLennan, 2017). All anxiety disorders were recommended this kind of Therapy, becoming the most studied treatment modality. Clients can decentralize themselves marks the first step of envisioning other related environmental perspectives and developing healthy and positive thoughts.

Ethical considerations

Various factors are considered when carrying out the research process. These are deemed ethical considerations and should be handled to ensure that your research project is not affected (Fiesler 2019). This research was carefully done and ensured all interactions were harmless to the researcher and the environment. Data collected was mainly from primary sources. These reduced the interaction between the survey group and the researcher, which declined psychological harm. Secondary sources of data ensure ethical considerations in research are upheld. Financial harm was reduced as face to face interviews may prompt an employer to reveal strategic competition to their enemies who might cost them their jobs.

Recommendation for practice

This chapter focuses on discussing the recommendations within nursing practice widely supported by the literature reviewed in chapter two. These recommendations have been stated with the sole purpose of improving nursing practice to enhance the overall health care of individuals. It also addresses how these recommendations can further be applied in health care to yield positive influence in the near future. Scholars have documented findings over time indicated that there is a need for improved healthcare to enhance efficiency and cover the identified gaps in research (Department of Health 2020). In addressing patients’ needs and safety, system efficiency and improvement in quality are required. Traditional practice has been relied on overtime by medical practitioners, and as it stands, redesigning for reliable and cost-effective systems of health care is needed. Continuous upgrade in the health care systems enhances efficiency and improvement in the health care system. The main themes identified for recommendation in the literature review are as follows.

Nurses’ role in preventing major depression

There is a general suggestion that practitioners can play a vital role in preventing major depression by referring patients with subthreshold depression to brief preventive psychological interventions or providing those interventions by themselves. Another research by Van Zoonenet al (2014) focused on psychosocial interventions focused on perinatal depression, which shows that preventive interventions are effective. Looking past psychotherapy in general and concentrating on particular treatment modalities and how efficient they are for treating depression, cognitive behavioral Therapy has shown to be efficacious. In theory, this is sensible (Chand and Grossberg 2015). Cognitive-Behavioural Therapy is designed to assist patients in regulating emotion, increasing activity, and work towards an optimal level of functioning both optimistically and realistically. This has been proven to fit well with the requirements of the adult population. Older adult population may get stuck as they focus on all the things they were enjoying while young and which they are not able to do due to old age. This is maladaptive thinking that Cognitive-Behavioural Therapy can address since its main focus is on solving problems fitting within the current topic. It is essential to check the challenges with demand and supply in line with the wider nursing workforce in Wales. New roles are growing within the NHS and professional, and skill mixes are evolving; hence retaining staff is vital in raising the immediate impact on the psychological wellbeing of elderly adults with depression (NHS 2020). For mental health service providers in Wales to deliver such mental health services, it is essential to have a well-prepared, developed, and supported workforce. The key thing to achieving this is education and training. This will ensure that they have the right attitudes and values needed for dealing with depressed patients.

Identifying the maladaptive beliefs, including losses and transitions

Laidlaw et al. (2008) showed that for many elderly patients, losses and transitions characterize the later years of their lives. According to Laidlaw et al. (2008), the failures and transitions can trigger thoughts of unresolved relationships, missed opportunities, and reflection on unachieved goals. Cognitive-Behavioural Therapy for elderly populations should focus on the meaning the patient gives to these losses and transitions. For instance, depressed elderly adults could view their retirement as a loss of self-worth as they become less productive (Laidlaw 2008). Cognitive-Behavioural Therapy can help patients identify ways of thinking about the situation that will enable them to adapt to these losses and transitions. When applying Cognitive-Behavioural Therapy with elderly population, it is vital to keep in mind features that define the elderly population. Laidlaw et al (2008) developed a model which clinicians could use to develop a more appropriate conceptualization of elderly population with a focus on major events and associated cognitions related to physical health, interactions with younger generations, and changes in role investments (Chand & Grossberg 2015). Its emphasis was on the need to explore beliefs about aging viewed through socio-cultural lens of each patient and examine cognitions in the context of the time period in which the individuals have lived. Another critical aspect of Cognitive-Behavioural Therapy is that it concentrates on the current problem without the necessity to go back to past life events. When the Therapy begins, the therapists help the patients set goals for treatment and monitor progress along with the sessions (Chand & Grossberg 2015). The cognitive element of this technique identifies the maladaptive beliefs of the patient about themselves, after which the therapists challenge these beliefs to replace them with more adaptive ones. To determine the beliefs, the first step involves exploration n of the patient’s automatic thoughts, which refers to the first thoughts an individual has after some events (Department of Health 2020). This session involves asking the patient to recount latest negative events. After this, they are supposed to describe the first thought that they experienced following the event. Patterns normally come up as a patient tends to think in same way when faced with a different situation. A significant part of sustained recovery from depression can cope with or avoid relapse risk factors (Chand and Grossberg 2015). Recovery can imply an individual controlling their lives and living in meaningful ways, instead of returning to the level of functioning they were in before depression. Even though depression is a chronic condition that can occur severally throughout an individual’s life, this does not mean a state of consistent powerlessness and suffering but, instead, a journey that includes successes and setbacks (Scottish Recovery Network, NHS Education for Scotland 2007). This will reduce the number of formal admissions in the country. In 2016, statistics showed that there were 1730 formal admissions to hospital and 1606 average daily available beds for mentally ill patients in Wales (Royles and Powel 2014).

Training and Memory Aids

Chand and Grossberg (2015) also propose the use of memory aids like handouts and session recordings that the patients can take with them to assist them in making reviews between sessions. Additionally, Chand and Grossberg (2015) also propose multimodal training. Visual demonstrations and modeling, as opposed to only verbal interventions, can make Cognitive-Behavioural Therapy more effective for the elderly population. In addition, to serve older adults, particularly those coping with physical ailments and post-stroke, Broomfield et al. (2011) suggest a necessity for an augmented Cognitive-Behavioural Therapy intervention that should include grief work to assist the elderly population in accepting their present physical state and roles. Any impairment resulting from physical ailments usually leaves patients grieving the kind of people they used to be and the things they used to do while they were young and which they cannot do at their old age (RCN 2020). By incorporating grief work into the traditional Cognitive-Behavioural Therapy, patients can work through this kind of grief as they restructure their sense of self. Cognitive-Behavioural Therapy is a structured psychotherapeutic approach built on a collaborative relationship between the psychotherapist and the patient (Chand and Grossberg 2015). One of the significant aspects of Cognitive-Behavioural Therapy is psychoeducation. A patient needs to be taught about stress and its reduction strategies. In this process, therapists of the patients with information relating to the treatment process and also about their situations. It is also vital for a therapist to educate the patient on some techniques of stress management for coping with stressful conditions in a more effective way (Care quality commissions 2020). This includes strategies on specific relaxation methods like exercise that require breathing deeply and progressive muscle relaxation that can be used by the patient on their own when they feel that they are in distress.

CHAPTER FOUR

Conclusion

From the above discussion, it is evident that the application of Cognitive Behavioural Therapy is effective in treating depression in older adults. Patients with these conditions have undertaken Therapy, either individually directed or clinical directed by their physicians. CBT works by training an individual’s mind to let go off negative thoughts and replace them with positive thoughts. Individuals' thoughts are mostly centered on three aspects: thoughts about themselves, the world, the future, and how events can happen. However, it is advisable to incorporate group-directed therapy sessions for patients as they enable them to open up and share the innermost feelings that trigger negative thoughts. Patients' health projected in digital versions has kept patient-centered records. It has ensured that the evidence and the treatment history of patients have been taken into account when treating patients with depression. Quality improvement is directly related to the service that has been delivered to patients. Improved health care systems have enhanced safety, cost-effectiveness, and efficiency in health care provision in these individuals. These recommendations were drawn from the critiques of the literature reviews that were cited to enhance efficiency in the research conducted competencies. The generation of new ideas in nursing would be improved by applying these new methods recommended in chapter three. However, these studies have also been criticized for several issues that the former researchers failed to capture. The idea of the use of medicines was not adequately covered by these researchers in their literature review, which gave rise to a research proposal that found out that Therapy can be used along with medications and lifestyle improvements to ensure the effectiveness of treating depression.

Reference

Angiras, A., 2020. Counselling in an Ancient Hindu text: A case for CBT in the Sri Madbhagavad Gita focusing on Arjuna's distress. The European Journal of Social &Behavioural Sciences, 28(2), pp.3170-3177.

Arch, J.J. and Craske, M.G., 2008. Acceptance and commitment therapy and cognitive behavioral Therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical psychology: Science and practice, 15(4), pp.263-279.

Bingham, S.A., 1991. Limitations of the various methods for collecting dietary intake data. A Beck, A.T., 1970. Cognitive Therapy: Nature and relation to behavior therapy. Behavior therapy,

Bolderston, A. 2008. Writing an Effective Literature Review.Journal of Medical Imaging and Radiation Sciences39(2), pp. 86-92.

Buntrock, C., Ebert, D.D., Lehr, D., Smit, F., Riper, H., Berking, M. and Cuijpers, P., 2016. Effect of a web-based guided self-help intervention for prevention of major depression in adults with subthreshold depression: a randomized clinical trial. Jama, 315(17), pp.1854-1863.

DeLuca, J. B., Mullins, M. M., Lyles, C. M., Crepaz, N., Kay, L., &Thadiparthi, S. (2008). Developing a comprehensive search strategy for evidence based systematic reviews. Evidence based library and information practice, 3(1), 3-32.

DeRubeis, R. et al. 2008. Cognitive Therapy versus medication for depression: treatment outcomes and neural mechanisms.Nature Reviews Neuroscience9(10), pp. 788-796.

DiMauro, J., Domingues, J., Fernandez, G., &Tolin, D. F. (2013). Long-term effectiveness of CBT for anxiety disorders in an adult outpatient clinic sample: A follow-up study. Behaviour research and Therapy, 51(2), 82-86.

Fiesler, C., 2019. Ethical Considerations for Research Involving (Speculative) Public Data. Proceedings of the ACM on Human-Computer Interaction, 3(GROUP), pp.1-13.

Floyd M, Scogin F, McKendree-Smith NL, Floyd DL, Rokke PD. Cognitive Therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults. BehavModif. 2004; 28: 297-318. 26.

Gallagher, M., McLeod, H.J. and McMillan, T.M., 2019. A systematic review of recommended modifications of CBT for people with cognitive impairments following brain injury. Neuropsychological rehabilitation, 29(1), pp.1-21.

Hundt, N.E., Amspoker, A.B., Kraus-Schuman, C., Cully, J.A., Rhoades, H., Kunik, M.E. and Stanley, M.A., 2014. Predictors of CBT outcome in older adults with GAD. Journal of anxiety disorders, 28(8), pp.845-850.

Jayasekara, R., Procter, N., Harrison, J., Skelton, K., Hampel, S., Draper, R., & Deuter, K. (2016). Cognitive behavioural Therapy for older adults with depression: a review. Journal of mental health, 24(3), 168-171.

Kamilaris, A., Kartakoullis, A. and Prenafeta-Boldú, F.X., 2017. A review on the practice of big data analysis in agriculture. Computers and Electronics in Agriculture, 143, pp.23-37.

Knoll, A. D., & MacLennan, R. N. (2017). Prevalence and correlates of depression in Canada: Findings from the Canadian Community Health Survey. Canadian Psychology/psychologie canadienne, 58(2), 116.

Köhler, S., Hoffmann, S., Unger, T., Steinacher, B., Dierstein, N., & Fydrich, T. (2017). Effectiveness of cognitive–behavioural Therapy plus pharmacotherapy in inpatient treatment of depressive disorders. Clinical psychology & psychotherapy, 20(2), 97-106.

Laidlaw K, Davidson K, Toner H, Jackson G, Clark S, Law J, et al. A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression. Int J Geriatr Psychiatry. 2008; 23: 843-850.

Lepping, P., Whittington, R., Sambhi, R.S., Lane, S., Poole, R., Leucht, S., Cuijpers, P., McCabe, R. and Waheed, W., 2017. Clinical relevance of findings in trials of CBT for depression. European Psychiatry, 45, pp.207-211.

O’Connor, E., Senger, C.A., Henninger, M.L., Coppola, E. and Gaynes, B.N., 2019. Interventions to prevent perinatal depression: evidence report and systematic review for the US Preventive Services Task Force. Jama, 321(6), pp.588-601.

Pattnaik, A., 2018. Assessing the implementation strength of family planning programs in malawi: methods for collecting data, creating composite scores, and linking to key outcomes (Doctoral dissertation, Johns Hopkins University).

Reavell, J., Hopkinson, M., Clarkesmith, D. and Lane, D.A., 2018. Effectiveness of cognitive behavioral Therapy for depression and anxiety in patients with cardiovascular disease: a systematic review and meta-analysis. Psychosomatic Medicine, 80(8), pp.742-753.

Reavell, J., Hopkinson, M., Clarkesmith, D., & Lane, D. A. (2018). Effectiveness of cognitive behavioral Therapy for depression and anxiety in patients with cardiovascular disease: a systematic review and meta-analysis. Psychosomatic medicine, 80(8), 742-753.

Rief, W., Bleichhardt, G., Dannehl, K., Euteneuer, F. and Wambach, K., 2018. Comparing the efficacy of CBASP with two versions of CBT for depression in a routine care center: a randomized clinical trial. Psychotherapy and psychosomatics, 87(3), pp.164-178.

Royles, E. and Powel, D.H., 2014. Commissioners and the Ombudsman and the infrastructure of Welsh Governance: lessons from Wales and lessons for Wales: Policy Briefing Report.

Rutberg, S. and Bouikidis, C.D., 2018. Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research. Nephrology Nursing Journal, 45(2), pp.209-213.

Schlögelhofer, M., Willinger, U., Wiesegger, G., Eder, H., Priesch, M., Itzlinger, U., ... & Aschauer, H. (2018). Clinical study results from a randomized controlled trial of cognitive behavioural guided self‐help in patients with partially remitted depressive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 87(2), 178-190.

Smith, J. and Noble, H. 2015. Reviewing the literature: Table1.Evidence Based Nursing19(1), pp. 2-3.Schindler, A., Hiller, W. and Witthöft, M., 2013. What predicts outcome, response, and drop-out in CBT of depressive adults? A naturalistic study. Behavioural and Cognitive Psychotherapy, 41(3), p.365.

Stikkelbroek, Y., Vink, G., Nauta, M.H., Bottelier, M.A., Vet, L.J., Lont, C.M., van Baar, A.L. and Bodden, D.H., 2020. Effectiveness and moderators of individual cognitive behavioural Therapy versus treatment as usual in clinically depressed adolescents: a randomized controlled trial. Scientific Reports, 10(1), pp.1-13.

Sweetman, A., Putland, S., Lack, L., McEvoy, R.D., Adams, R., Grunstein, R., Stocks, N., Kaambwa, B., Van Ryswyk, E., Gordon, C. and Vakulin, A., 2020. The effect of cognitive behavioural Therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Medicine Reviews, p.101404.

Thompson LW, Coon DW, Gallagher-Thompson D, Sommer BR, Koin D. Comparison of desipramine and cognitive/behavioral Therapy in the treatment of elderly outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry. 2001; 9: 225-240.

van Zoonen, K., Buntrock, C., Ebert, D.D., Smit, F., Reynolds III, C.F., Beekman, A.T. and Cuijpers, P., 2014. Preventing the onset of major depressive disorder: a meta-analytic review of psychological interventions. International journal of epidemiology, 43(2), pp.318-329.

Waltman, S. H., Creed, T. A., & Beck, A. T. (2016). Are the effects of cognitive behavior therapy for depression falling? Review and critique of the evidence. Clinical Psychology: Science and Practice, 23(2), 113.

Wolpe, J. and Lang, P.J., 1974. A fear survey schedule for use in behaviour therapy. Behaviour modification procedure: A sourcebook, pp.228-232.