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Worldwide, major depressive disorder (MDD) is expected to be the leading cause of disability by 2030 (Malhi & Mann, 2018). Guidelines for MDD treatment recommend psychotherapy at all levels (McQuaid et al., 2022; Qaseem et al., 2016). However, clients in rural areas of the United States experience significant barriers to obtaining in-person psychotherapy (Gale et al., 2019). Self-management (SM) strategies are now a standard of care for chronic health treatment (Frantz et al., 2021) and, therefore, these interventions may provide an alternative option for clients with MDD without access to in-person psychotherapy.
The purpose of the current article is to describe the implementation and evaluation of a pilot project that integrated the use of digitally delivered cognitive-behavioral therapy (dCBT) as a SM program for clients with MDD at a community mental health center in rural Eastern United States. The interventions were implemented during routine psychiatric telehealth appointments by a psychiatric advanced practice nurse (APN). The advantage of implementing the program within the current workflow is that other APNs can use this approach to improve client outcomes.
Background
MDD is a serious health problem. Up to 30% of adults with MDD experience suicidal ideation (Schneider et al., 2020), and MDD accounts for 59% to 87% of all suicides (Cai et al., 2021). Furthermore, suicide rates in rural areas of the United States are 55% higher than in urban areas (Gale et al., 2019). When not fatal, MDD can be extremely disabling, with 88% of adults reporting difficulty with work, home, and social activities (Brody et al., 2018). Clients with recurrent disease may spend more than 20% of their life with MDD symptoms (Cuijpers, 2017). Early access to evidence-based interventions is imperative, as increased duration of MDD episode is associated with increased suicide risk and poorer treatment outcomes (Kraus et al., 2019).
The benefit of psychotherapy in the treatment for MDD is well-established, with at least 350 randomized control trials (RCTs) demonstrating the efficacy of many psychotherapeutic approaches (Cuijpers, 2017). Although combined psychotherapy and medications is most effective, when used alone, psychotherapy is more effective than pharmacotherapy, especially in the long-term when clients stop...