Theory of Patient Advocacy: Vitamin D and Depression Allison Mills, BSN, RN University of Central Florida.

Theory of Patient Advocacy:Vitamin D and Depression

Allison Mills, BSN, RNUniversity of Central Florida

No longer is vitamin D merely in the spotlight for Rickets. No longer is depression simply viewed as a set of symptoms. There is now evidence that inflammation has a role in depression (Raison et al., 2006), while vitamin D has anti-inflammatory properties (Antai-Otong, 2014). The overall health complications and impacts of vitamin D deficiency are currently being examined. This research includes vitamin D and its impact on the brain in depression. Although, research of the specific relationship is currently inconclusive, one study shows that by treating a vitamin D deficiency, some patients with depressive disorder experience less symptoms (Khoraminya et al., 2012). With the prevalence rate of vitamin D deficiency close to 42% (Forrest & Stuhldreher, 2011) and depression rates affecting 11.23% of the western world’s population (Samaan et al., 2014) clearly this is significant to health care professionals.

Is vitamin D a light in the darkness of Depression?

BACKGROUND AND HISTORY:

PROBLEM:

Since the correlation between depression, the immune system, and vitamin D deficiency comes from newer research, there seems to be a lack of provider attention, to translate the findings into practice. This could cause vitamin D deficiency (and the damaging effects of inflammation) to be under diagnosed and thus untreated. Without identification, providers may not be prescribing patients the most effective treatments for the best patient outcomes.

Is vitamin D a light in the darkness of Depression?

Role of the Nurse Leader: Pushing for better care

▪ This problem should be a concern to nursing professionals since nursing is focused on a holistic care model, with a desire to give patients the best care available.

▪ Since depression affects a patient’s wellbeing as a whole person, it is important to diagnose and treat patients accurately and timely, with vitamin D as a consideration.

▪ So, if nurses/practitioners are to holistically support patients in reaching their greatest potential as healthy beings, then it is in their best interest for nursing and other disciplines to address this problem.

▪ The concept of patient advocacy is made up of a “series of specific actions for preserving, representing and/or safeguarding patients’ rights, best interests and values in the healthcare system,” (Bu & Jezewski, 2006, p104).

▪ Nurses, as patient advocates, are called to have patients’ best interests; Thus, nursing professionals are called to advocate for research regarding vitamin D deficiency to produce standards of care, education, and implementation of desired/necessary changes. This will in turn shape the healthcare system to produce better patient outcomes and, hopefully, healthier, happier patients.

Advocacy

Discussion of Alternative solutions:▪ Research:

▪ Barriers and gaps: To explore reasons as to why prescribers do or do not prescribe testing for supplementation, on a consistent basis or even on a risk factor basis.

▪ Practice standards: Further research needs to be done to standardize the practice, vitamin D level criteria and treatment according to those levels, since various doses of supplementation are available (Leedahl et al., 2013).

▪ Educate: ▪ Prescribers: to identify deficiencies and those at risk; to identify those who do not respond fully to typical

antidepressant therapies; and, for a better understanding of the benefits of diagnosis and consequences for the patient of a missed diagnosis (Forrest & Stuhldreher, 2011; Antai-Otong, 2014).

▪ Patients: educate on diet, lifestyle, sun exposure and other interventions to improve vitamin D deficiency and depression, especially those with identifiable risk factors (Forrest & Stuhldreher, 2011). Providing treatment options and education is a primary part of treatment planning (Antai-Otong, 2014, p231).

▪ Act (as patient advocates): ▪ Practitioners should be encouraged to take proactive measures and test for vitamin D deficiencies in those

patients with risk factors. Even though there is still inconclusive evidence regarding the relationship between vitamin D deficiency and depression, practitioners can still feel confident in correcting a lone deficiency, focusing on vitamin D’s known effects on bone health (Berk et al., 2008).

Using the Theory of Patient Advocacy (Bu & Jezewski, 2006), it is possible for more patients to be diagnosed and treated for vitamin D deficiency. In some patients, this would sequentially

decrease the symptoms of depression (Khoraminya et al., 2014) and possibly other diseases of inflammation, decreasing costs in the healthcare system (Jiménez & Mills, 2012).

Application of Theory as a Selected Solution: Patient Advocacy theory

▪ Antecedents: Identifies the cause of the need for advocacy such as health disparities, busy hospital environments, vulnerability of patient (population, risks, condition, situation/environment), with a risk of patient rights being jeopardized.

▪ Three Core Attributes (or Action)

▪ Safeguarding patient autonomy (providing information for informed decisions)

▪ Acting on behalf of the patient (those vulnerable, unable to communicate)

▪ Championing social justice for provisional care ( change in system or policy)

▪ Consequences: The Outcome

▪ Negative: ▪ Nurse: Insubordination, moral distress/dilemma, career distress, can lead to legal action

▪ Positive: ▪ Patient: empowered patients, rights preserved, improved quality of life

▪ Desirable change in policy or system; Improved healthcare delivery

Why? Because nurses advocate for what's right for our patients.

Rationale:

▪ Act (as patient advocates) on behalf of the patient and safeguard patient autonomy: ▪ Practitioners should be encouraged to take proactive measures and test for vitamin D deficiencies in

those patients with risk factors and those unable to communicate feelings/symptoms. Even though there is still inconclusive evidence regarding the relationship between vitamin D deficiency and depression, practitioners can still feel confident in discussing and correcting a deficiency, focusing on vitamin D’s known effects on bone health (Berk et al., 2008).

▪ Research to champion social justice for provisional care: ▪ Barriers and gaps: Researching and learning of such barriers could provide basic knowledge of

previously unidentified problems and access to a solution through awareness, leading to resolve with education and the transition of practice and system changes.

▪ Practice standards: Without specific guidelines, doctors/practitioners may be reluctant to address the deficiency; Also, establishing standards of practice should addressing practice barriers, and thus treatment inconsistencies, especially in populations identified as vulnerable and at risk (Leedahl et al., 2013).

▪ Education to safe guard patients: ▪ Prescribers: to identify deficiencies and those at risk; to identify those who do not respond fully to

typical antidepressant therapies; and, for a better understanding of the benefits of diagnosis and consequences for the patient of a missed diagnosis (Antai-Otong, 2014).

▪ Patients: By providing information, the patient is allowed to make informed decisions about their care, treatment and their body. This will give the patient control and a sense of empowerment (Bu & Jezewski, 2006).

Implementation Plan and Steps▪ First steps: Nurses to advocate for further research as previously discussed;

In the mean time, nursing professionals are to be educated on what is known and are to act proactively (i.e., educate patients, suggest or order a vitamin D level (depending on scope of practice)

▪ Second Steps: Educate healthcare professionals through advertised seminars; create and offer free continuing education module/s on the topic of Vitamin D deficiency solely first and, post conclusive research, how it affects other disorders, such as depression; educate other professionals through own network either via word of mouth or social media.

▪ Third step: Implementing practice change through translation of research findings▪ Agency for Healthcare Research and Quality (AHRQ) has two models/processes specifically for

translating research into practice

▪ http://www.ahrq.gov/research/findings/factsheets/translating/

▪ Fourth Step: Reevaluate through research. Perform a post education assessment questioning practitioners how often/consistently vitamin D deficiency is tested in their practice; post treatment questionnaire asking patients about their improvements.

Plan for evaluation: Vitamin D deficiencyResearch

▪ Later reassessing research: Is there conclusive evidence stating relationship between vitamin D and depression pathophysiology?

▪ Review continuing education attendance

▪ Official standards of care implemented across the board, especially in vulnerable populations?

▪ Research pre and post education (follow up 1-2 years): vitamin D testing and treatment frequencies

▪ Review lab orders/results for levels increased and deficiencies decreased; as well as patient report of decrease in depressive symptoms

▪ With increased testing and diagnosis, is there an increased prevalence?

▪ Research patients response to treatment and current symptoms in general, if any.

Enlightening Supplemental Resources:

▪ If interested in more information, linked below is a 20 min interview with psychiatrist, Dr. Colin Ross, MD: “Vitamin D, Health & Disease: Deficiency, Toxicity, Depression, Mental Health” http://youtu.be/Dx_qnm8cjvk

▪ Resource for patients and practitioners: http://www.vitamindcouncil.org/

Changing practice could start right here!

References▪ Agency for Healthcare Research and Quality (AHRQ) (2014). Translating research into practice. Retrieved from

http://www.ahrq.gov/research/findings/factsheets/translating/

▪ Antai-Otong, D. (2014). Vitamin D: An anti-inflammatory treatment option for depression? M.W. Roman (Ed.). Issues in Mental Health Nursing, 35(3), 227-234

▪ Arvold, D., Odean, M., & Dornfeld, M. (2009). Correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomized controlled trial. Endocrine Practice, 15(3), 203-211.

▪ Berk, M., Jacka, F., Williams, L., NG, F., Dodd, S., & Pasco, J. (2008). Is this D vitamin to worry about? Vitamin D insufficiency in an inpatient sample. Australian & New Zealand Journal of Psychiatry, 42(10), 874-878.

▪ Berk, M., Sanders, K. M., Pasco, J. A., Jacka, F. N., Williams, L. J., Hayles, A. L., and Dodd, S. (2007). Vitamin D deficiency may play a role in depression. Medical Hypotheses, 69(6), 1316-1319.

▪ Bu, X., & Jezewski, M. (2007). Developing a mid-range theory of patient advocacy through concept analysis. Journal of Advanced Nursing, 57(1), 101-110.

▪ Forrest, K. Z., & Stuhldreher, W. L. (2011). Prevalence and correlates of vitamin D deficiency in US adults. Nutrition Research, 31(1), 48-54.

▪ Jiménez, J. A., & Mills, P. J. (2012). Neuroimmune mechanisms of depression in heart failure. Q. Yan (Ed.). Methods in Molecular Biology, 934, 165-182.

▪ Khoraminya, N., Tehrani-Doost, M., Jazayeri, S., Hosseini, A., Djazayery, A. (2012). Therapeutic effects of vitamin D as adjunctive therapy to fluoxetine in patients with major depressive disorder. Australian & New Zealand Journal of Psychiatry, 47(3), 271-275.

▪ Leedahl, D., Cunningham, J., Drake, M., Mundis, C., King, S., Frye, M., & Lapid, M. (2013). Hypovitaminosis D in psychiatric inpatients: Clinical correlation with depressive symptoms, cognitive impairment, and prescribing practices. Psychosomatics, 54(3), 257-262.

▪ National Research Council. (2011). Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academies Press.

▪ Raison, C., Capuron, L., & Miller, A. (2006). Cytokines sing the blues: inflammation and the pathogenesis of depression. Trends in Immunology, 27(1), 24-31.

▪ Rutledge, T., Reis, V., Linke, S., Greenberg, B., & Mills, P. (2006). Depression in heart failure: A meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. Journal of the American College of Cardiology, 48(8), 1527-1537.

▪ Samaan, Z., Anglin, R., Li, G., & Thabane, L. (2014). What is the role of vitamin D in depression? Psychiatric Times, 31(4), 1-3.