MayJune 2021 Volume 39 Number 3 111Nursing Economic$

May/June 2021 | Volume 39 Number 3 111
Nursing Economic$
Developing a well-prepared and geographically
distributed mental health
workforce is a crucial goal of
healthcare workforce planning
initiatives and contributes to
health systems’ ability to
improve population health
(Beck et al., 2020). Before the
SARS COV-2 global pandemic,
sharp increases in suicide,
substance abuse, opioid crises,
gun violence, and severe
depression among young
people were increasing
demands on mental and
behavioral health professionals,
including nurses (Substance
Abuse and Mental Health
Services Administration, 2020).
However, the growing demand
for behavioral health services,
let alone treating the 44 million
American adults who have a
diagnosable mental health
condition, is being met by a
potential shortage of
professionals, which the Health
Resources and Services

Administration (2016) projects
will worsen to as many as
250,000 workers by 2025.
Access to mental health care is
crucial given the societal
upheaval brought about by the
SARS COV-2 global pandemic.
To address the growing
demand for mental health
services, many communities and
healthcare systems are exploring
novel ways to integrate mental
health treatment into primary
care delivery, for example, using
the Collaborative Care Model
(Vanderlip et al., 2016). Nurses
often contact people living with
mental or behavioral health
conditions while being treated
for physical and medical
conditions in both community
and hospital settings. A recent
focus on mental health care,
particularly in outpatient
settings, has been an emphasis
in team-based models,
telehealth, and integration of
mental health and primary care
with contributions from
physicians, nurses, social
workers, peer support, and
community health workers – all
of which can be beneficial
relative to more traditional and

often siloed models of mental
health treatment (Reiss-Brennan
et al., 2016).
Characteristics of Registered Nurses
and Nurse Practitioners Providing
Outpatient Mental Health Care
David I. Auerbach
Max C. Yates
Douglas O. Staiger
Peter I. Buerhaus
The growing demand for mental
health services, together with
current and increasing shortages
of mental health professionals
and increasing adoption of
integrated models of care
delivery, suggest nurses will
become increasingly needed to
provide mental health services.
Analysis of a national survey
finds registered nurses and
nurse practitioners working in
outpatient mental health settings
are older than those in other
settings. Most would benefit
from additional training. Provision
of team-based care was
associated with higher job
satisfaction.

May/June 2021 | Volume 39 Number 3112
The growing demand for
mental health services, together
with current and increasing
shortages of mental health
professionals and increasing
adoption of integrated models
of care delivery, suggest nurses
will become increasingly needed
in providing mental health
services. Registered nurses (RNs)
who provide mental health
services help establish a
patient’s diagnosis, develop a
plan of care, coordinate
services, and evaluate treatment
effectiveness, among other
activities. Nurse practitioners
(NPs) who provide psychiatric
and mental health care often
lead care delivery teams,
prescribe medications
(Alexander & Schnell, 2020),
including buprenorphine
(Barnett et al., 2019; Spetz et al.,
2019), provide psychotherapy,
and coordinate care with other
providers.
Prior research based on the
National Sample Survey of
Registered Nurses (NSSRN),
arguably the most comprehen -
sive, detailed representative
survey of RNs available, found

the mental health nursing
workforce is relatively older,
female, and White compared to
other nurses (Hanrahan &
Gerolamo, 2004; Hanrahan
2009). However, data used in
these studies came from the
2000 and 2004 waves of the
NSSRN when integration
models, use of telehealth, and
other contemporary mental
healthcare features were not in
use and, therefore, not assessed
in these surveys. In this data
brief, the recently released 2018
NSSRN is used to update and
describe key demographic
attributes of RNs and NPs
providing outpatient mental
health services and
characteristics of their practice.
Data and Methods
Data for the study come
from the 2018 NSSRN, a
comprehensive survey of RNs
developed and administered by
the U.S. Health Resources and
Services Administration with
assistance from the U.S. Census
Bureau. The survey assessed the
number of RNs in the United
States and contains questions
regarding RNs’ educational

background, employment
setting, job position, salary,
geographic distribution, social
and demographic characteristics,
job satisfaction, and other
information. The NSSRN has
been fielded every 4 years from
1977 to 2008 and again in 2018
when most questions related to
surveyed RNs’ status as of
December 31, 2017. The 2018
NSSRN heavily oversampled
NPs, with surveys mailed to
approximately 50,000 (roughly 1
in 4) NPs, and obtained a 50%
response rate. This data brief
focuses on RNs and NPs
working in outpatient mental
healthcare settings and, in some
cases, compares their
characteristics with the overall
RN and NP workforce.
A descriptive analysis was
conducted of key survey
questions pertaining to
individual and practice
characteristics. Frequencies,
means, and RNs’ and NPs’
perceptions of their use of
teamwork and telehealth, job
satisfaction, and educational
content that would help them
do their jobs better were
reported. The samples of mental

health RNs and NPs were
weighted using weights
provided by the NSSRN. All
analyses were performed using
Stata version 16.
Results
As shown in Table 1, 100
RN and 734 NP respondents to
the survey working in outpatient
mental health settings were
identified. These nurses
represent just under 15,000 RNs
(0.6% of the RN workforce) and
5,776 NPs (2.7% of the NP
workforce). RNs working in
outpatient mental health are
considerably older than other
RNs, with just under 10% under
age 35 compared to 22% of all
other RNs, and nearly half are
50 and over. These RNs are
more likely to be non-White
and have lower earnings than
other RNs, despite being older.
NPs working in outpatient
mental health settings are also
older than other NPs, with more
than half over 50 compared to
37.5% of all other NPs. A similar
fraction is non-White, more are
male, and earnings are slightly
higher than other NPs.
Team-Based Care

The extent to which
outpatient mental health RNs
and NPs practice team-based
care, which is a critical aspect of
many prominent and innovative
mental healthcare models, was
explored.
The majority of RN and NP
respondents indicated they
Nursing Economic$
Nursing Economic$
Table 1.
Number and Characteristics of Mental Health RNs and NPs in
the United States, 2018
Outpatient Mental
Health RNs (n=100)
All other RNs
(n=22,962)
Outpatient Mental
Health NPs
(n=734)
All other NPs

(n=20,781)
Number (weighted) 14,995 2,708,393 5,776 204,230
Age Group
Under 35 9.9% 22.4% 12.1% 17.2%
35-49 42.6% 36.8% 36.9% 45.3%
50+ 47.5% 40.8% 51.0% 37.5%
Non-White 39.1% 28.3% 26.1% 25.3%
White 60.9% 71.7% 73.9% 74.7%
Female 88.7% 89.4% 86.1% 89.8%
Male 11.3% 10.6% 13.9% 10.2%
Annual Earnings $67,292 $75,077 $111,685 $106,435
Figure 1.
Extent to Which RNs and NPs Practice Team-Based Care
100%
90%
80%
70%
60%
50%
40%
30%

20%
10%
0
Outpatient mental
health RNs
All other RNs Outpatient mental
health NPs
All other NPs
A great extent Somewhat Very little Not at all N/A
8%
17%
69%
6%
21%
64%
11%
29%
57%
9%
27%

59%
5% 5%0 3%
1% 3%
2% 3%
practice team-based care (see
Figure 1). A solid majority (69%)
of outpatient mental health RNs
practiced team-based care to a
great extent, slightly higher than
the percentage for all other RNs
(64%) and higher than the rate
of outpatient mental health NPs
(57%).
There are many forms of
team-based care training.
Different types of team-based
care training RNs and NPs
reported receiving are shown in
Figure 2. More than half of all
RNs and NPs received informal
on-the-job training in team-
based care, and fewer than 1 in
5 have not received any
training. RNs were more likely
to have received formal on-the-
job training and educational
videos, while NPs were more

likely to have received training
during their educational
program. RNs and NPs working
in outpatient mental health
settings were no more likely to
receive team-based care
training, despite the fact both
types of nurses in these settings
were more likely to practice
team-based care than other RNs.
The association between
team-based care in the
workplace and RNs’ and NPs’
job satisfaction ratings was
examined. Although questions
are asked independently of each
other in different sections of the
questionnaire (e.g., satisfaction
is not explicitly linked to team-
based care), and many factors
influence satisfaction, an
observed relationship could
provide suggestive evidence that
and NPs find a team-based
environment more satisfying.
The combined responses of RNs
and NPs are shown in Figure 3
and reveal nurses practicing
team-based care either
somewhat or to a great extent
are overwhelmingly satisfied
with their jobs. More than 90%

of those practicing team-based
care to a great extent agreed
they are extremely or
moderately satisfied; 85% of
those practicing team-based care
somewhat reported high levels
of satisfaction. On the other
hand, among RNs and NPs who
practice team-based care very
little, more were dissatisfied
than satisfied. This difference
persisted, although the
magnitude diminished
Nursing Economic$
Figure 2.
Type of Training in Team-Based Care Received
70%
60%
50%
40%
30%
20%
10%
0
Formal:

School-based
Formal:
On the job
Educational
videos at place of
employment
Informal on
the job
None
Outpatient mental health RNs All other RNs Outpatient
mental health NPs All other NPs
somewhat relative to that
observed in Figure 3, when
controlling for RN or NP age,
earnings, gender, and
race/ethnicity in a multivariate
regression analysis.
Telehealth
Use of telehealth in the
workplace among outpatient
mental health RNs and NPs was
also examined (see Figure 4).
Overall, nearly half of outpatient
mental health RNs (43%) and

NPs (47%) reported telehealth
was used in their workplaces in
2018, substantially higher than
RNs and NPs working in other
settings.
These differences mirror
reports of higher telehealth use
in providing mental health
services during the pandemic
(IQVIA, 2020). When RNs and
NPs were asked about their
telehealth with patients (as
opposed to whether it was used
in their workplace), only 1 in 5
and 1 in 4 outpatient mental
health NPs had used telehealth,
with use evenly divided among
direct interactions with patients
and provider-to-provider
consults.
Finally, the 2018 NSSRN
asked all RNs and NPs, “What
training topics would have
helped you do your job better?”
Those working in outpatient
mental health responded that
mental health training would
have helped (see Figure 5).
Even among those not working
in outpatient mental health, 31%
of NPs and 23% of RNs
responded they would have

fared better in their job if they
had received training in mental
health. In addition to outpatient
nurses, 51% of RNs working as
school nurses, 44% of RNs in
emergency settings, and 37% of
RNs in public health also agreed
mental health training would
have helped them do their jobs
better.
Discussion
In the context of growing
demand for mental health care,
shortages of mental health
professionals, and innovations in
mental health service provision,
this study used recently released
survey data from the 2018
NSSRN to assess critical
characteristics of nurses
providing outpatient mental
health care in the United States.
RNs’ and NPs’ involvement in
Nursing Economic$
Figure 3.
Job Satisfaction of Outpatient Mental Health RNs and NPs
(Combined) Based on Extent to Which They are
Currently Practicing Team-Based Care
60%

50%
40%
30%
20%
10%
0
A great extent Somewhat Very little
Extremely satisfied
Moderately dissatisfied
Moderately satisfied
Extremely dissatisfied
Nursing Economic$
Figure 4.
Telehealth Use Among Outpatient Mental Health RNs and NPs
and Among All other RNs and NPs
50%
45%
40%
35%

30%
25%
20%
15%
10%
5%
0
Telehealth use in
workplace?
Personal use in
telehealth?
Provider-to-patient
direct calls or e-visits
Provider-to-provider
direct consults
Outpatient mental health RNs All other RNs Outpatient
mental health NPs All other NPs
Figure 5.
Percentage of RNs and NPs Who Agreed that More Training in
Mental Health During their Educational
Program Would Have Helped Them Do Their Current Job Better
80%
70%
60%

50%
40%
30%
20%
10%
0
Outpatient mental
health RNs
All other RNs Outpatient mental
health NPs
All other NPs
team-based care, telehealth, and
other aspects of outpatient
mental and behavioral
healthcare delivery were
assessed and can help illuminate
the adequacy and preparation of
the mental health nursing
workforce. Results can assist
health policy and workforce
planners build the mental health
workforce needed by society,
particularly in light of the
impacts of the continuing SARS

COV-2 global pandemic.
As in the case of earlier
studies (Hanrahan & Gerolamo,
2004; Hanrahan 2009), evidence
indicates RNs and NPs working
in outpatient mental health
settings are significantly older
than other RNs and NPs, which
suggests many mental health
nurses are likely to retire before
the end of the decade. Unless
they are replaced by younger
RNs prepared in mental health,
shortages of nurses in mental
health outpatient settings could
develop and possibly decrease
access to mental health care.
Hunter and colleagues (2015)
found nursing students felt
unprepared to pursue careers in
mental health care, though
additional, positive clinical
experiences could help
overcome this barrier. Delaney
and Vanderhoef (2019) noted a
promising, wide variety of
potential clinical training sites,
including hospitals, ambulatory
sites, schools, prisons, and
Veterans Administration facilities.
Because earnings of RNs in
are substantially lower than
other RNs, employers should

consider their wage policies as a
tool to promote RNs’ interest in
mental health. Although most
RNs working in mental
healthcare settings are female,
they are slightly more racially
diverse than RNs working in
other locations. While the latter
finding contrasts with studies in
the early 2000s referenced
earlier, they are consistent with
more recent work that found
increasing diversity among
recent entrants to the psychiatric
nursing workforce (Phoenix,
2019).
Concerning NPs, results
from the current study show
NPs working in outpatient
mental health settings are similar
to RNs in that they are
considerably older than NPs
working in different settings.
Unlike the lower earnings of
RNs relative to others, NPs
working in mental health
settings earn more than most
NPs working in other settings.
About 75% of outpatient mental
health NPs (and NPs generally)
are White, suggesting efforts to
attract under-represented
minorities into psychiatric and
mental health NP education

programs are needed.
Team-based care and
telehealth are integral to new
and emerging models of mental
health care. Study results reveal
70% of RNs and 57% of NPs
working in outpatient mental
health settings report team-
based care is used to a great
extent in their workplaces.
Because more RNs reported
receiving training in team-based
care in the workplace than NPs,
this could explain some of the
differences in team-based care
between RNs and NPs.
Importantly, team-based care
appears linked to higher levels
of job satisfaction among
and NPs.
Higher proportions of RNs
and NPs working in outpatient
mental health care settings
reported telehealth use relative
to RNs and NPs in other
locations. This difference could
be due to telehealth’s high
efficacy for providing mental
health services (Totten et al.,
2019). Greater use of telehealth
has been noted in numerous
reports during the COVID-19

pandemic, with telehealth being
primarily responsible for
maintaining care levels for
mental health conditions close
to pre-pandemic levels, unlike
most other conditions (IQVIA,
2020). Still, telehealth use
among RNs and NPs in mental
health settings was relatively
low in 2018; around 10% of
both types of nurses had used
telehealth for direct patient calls
or provider-to-provider consults.
RNs’ and NPs’ use of telehealth
with patients has grown during
the pandemic. Some of this
growth is likely to persist once
nurses and other providers and
patients gain experience with
the medium.
Finally, most RNs and NPs in
indicated they could have done
their jobs better had they
received more training in mental
health. This result could reflect
expanded caseloads, increasingly
complex patients, or that mental
health training was inadequate
and could be improved. Even
among those not working in
outpatient mental health, the
large number of RNs and NPs
Nursing Economic$

who responded they could have
done their jobs better if they had
received more training in mental
health suggests training be made
a priority in nursing education
curricula, student clinical
experiences, professional
continuing education offerings,
and in-service education
programs.
Summary
The 2018 NSSRN provides
rich information about crucial
aspects of RNs and NPs
employed in outpatient mental
health treatment settings. This
information enables
development of a critical
baseline on these nurses’
experience, competency, and
training around team-based
care, telehealth, and training in
mental health care. Data
indicate many RNs and NPs
working in these critical aspects
of care have the building blocks
to participate in advanced
models of mental and
behavioral health care and

integration with primary care.
Still, additional training and
experience with mental health
care are critical to future
workforce adequacy.
Future NSSRNs should
continue to include these topics
as well as questions regarding
nurses’ opinions of the efficacy
of telehealth, barriers to
adoption, and optimal use.
Similarly, RNs and NPs could be
asked about the obstacles to
developing and sustaining
effective team-based care, the
benefits of team-based care to
patients, healthcare professionals
and organizations, and their
views about who (physicians,
nurses, NPs, social workers, or
others), in their experience,
makes for effective team
leaders. Finally, future surveys
should also assess the impacts
of COVID-19 on RNs and NPs. $
David I. Auerbach, PhD
External Adjunct Faculty
Center for Interdisciplinary Health Workforce
Studies
Montana State University College of Nursing
Bozeman, MT

Max C. Yates
Research Assistant
Studies
Bozeman, MT
Douglas O. Staiger, PhD
John Dickey 3rd Century Professor
Department of Economics
Dartmouth College
Hanover, NH
Research Associate
National Bureau of Economic Research
Cambridge, MA
Peter I. Buerhaus, PhD, RN, FAAN,
FAANP(h)
Professor of Nursing
Director
Studies
Bozeman, MT
NOTE: This research was funded by the
Health Workforce Technical Assistance
Center, which is supported by the Health
Resources and Services Administration
(HRSA) of the U.S. Department of Health and
Human Services (HHS) as part of an award

totaling $446,482. The contents are those of
the authors and do not necessarily represent
the official views of, nor an endorsement, by
HRSA, HHS, or the U.S. Government. For
more information, please visit HRSA.gov
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EvergladesCapstoneProject.edit
ed2.docx
by Jean Valcin
Submission date: 04-Dec-2021 09:31PM (UTC-0500)
Submission ID: 1720706663
File name: EvergladesCapstoneProject.edited2.docx (84.97K)
Word count: 1744
Character count: 8444
Please identify all the species in your food web. It makes a big
difference.
species? species
This falcon does not
occur in the
Everglades - or in N.
Am.
species?
also not in the Everglades or N Am
8

species? Not relevant here - or are you
implying humans are eaten in
the Everglades? by falcons?
does not occur in Everglades - or maybe even in
Florida?
I don't
understand this
argument here.
Wheat is an
endangered
species?
I have already commented above on the species in your web that
do not occur in the Everglades so any discussion of
them in this part are not relevant. Also without knowing what
species you are discussing, your discussion of them are
also not valid. All moths are not alike in habitat or diet or
trophic connections.
why not? This cannot be true
!
1
1

10
please
support all
these
statements
maybe, but not here
I want to see the
actual link. In this
case, I am curious
as to how you
selected this
species for this
assignment.
7 and 8. You don’t really answer the questions. Density
dependent limiting factors can
be things such as; availability of food, predation, disease, and
migration. However the
main factor is the availability of food, and, in the Everglades,
some limitation on their
habitat. Please explain why all this could/would occur, not just
that it is so.
1
6
7
9

absolutely not
9. You are missing the concept of what a keystone species is.
They provide habitat for species other than themselves. In
the Everglades, it is the American alligator. Alligator is
considered a keystone species because they create “gator holes.”
The holes typically retain water throughout the winter dry
season and serve as a refuge for a huge variety of wildlife
when the rest of the system dries out. Without these holes, many
species would decline in the dry season.
You need to review what an endangered species is, not one of
the most abundant species on the planet.
2
3
4
5
14%
SIMILARITY INDEX
9%
INTERNET SOURCES
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PUBLICATIONS
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STUDENT PAPERS
1 2%
2 2%
3 2%
4 2%
5 2%
6 1%
7 1%
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lume.ufrgs.br
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Liyuan Hou, Hongjie Wang, Qingfu Chen, Jian-
Qiang Su, Mahmoud Gad, Jiangwei Li,
Sikandar I. Mulla, Chang-Ping Yu, Anyi Hu.
"Fecal pollution mediates the dominance of
stochastic assembly of antibiotic resistome in
an urban lagoon (Yundang lagoon), China",
Journal of Hazardous Materials, 2021
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peerj.com
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V. A. Vinogradov, K. A. Karpov, S. S. Lukashov,
M. V. Platonova, A. V. Turlapov. "Search for
8 1%
9 1%
10 1%
Exclude quotes Off
Exclude bibliography Off
Exclude matches Off
Fulde–Ferrell–Larkin–Ovchinnikov
Superfluidity in an Ultracold Gas of Fermi
Atoms", Journal of Surface Investigation: X-
ray, Synchrotron and Neutron Techniques,
2021
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PAGE 1
PAGE 2
Text Comment. Please identify all the species in your food
web. It makes a big
difference.
Text Comment. species?
Text Comment. species
Text Comment. This falcon does not occur in the Everglades -
or in N. Am.
Text Comment. also not in the Everglades or N Am
PAGE 3

Text Comment. Not relevant here - or are you implying humans
are eaten in the
Everglades? by falcons?
Text Comment. does not occur in Everglades - or maybe even
in Florida?
Text Comment. I don't understand this argument here. Wheat is
an endangered
species?
Text Comment. I have already commented above on the species
in your web that do not
occur in the Everglades so any discussion of them in this part
are not relevant. Also without
knowing what species you are discussing, your discussion of
them are also not valid. All
moths are not alike in habitat or diet or trophic connections.
PAGE 4
Text Comment. why not? This cannot be true
Text Comment. !
PAGE 5
PAGE 6
Text Comment. please support all these statements

Text Comment. maybe, but not here
Text Comment. I want to see the actual link. In this case, I am
curious as to how you
selected this species for this assignment.
Text Comment. 7 and 8. You don’t really answer the questions.
Density dependent
limiting factors can be things such as; availability of food,
predation, disease, and migration.
However the main factor is the availability of food, and, in the
Everglades, some limitation on
their habitat. Please explain why all this could/would occur, not
just that it is so.
PAGE 7
Text Comment. absolutely not
Text Comment. 9. You are missing the concept of what a
keystone species is. They
provide habitat for species other than themselves. In the
Everglades, it is the American
alligator. Alligator is considered a keystone species because
they create “gator holes.” The
holes typically retain water throughout the winter dry season
and serve as a refuge for a
huge variety of wildlife when the rest of the system dries out.
Without these holes, many
species would decline in the dry season.
PAGE 8
Text Comment. You need to review what an endangered species
is, not one of the most
abundant species on the planet.

STUDY PROTOCOL Open Access
Behavioural activation by mental health
nurses for late-life depression in primary
care: a randomized controlled trial
Noortje Janssen1,2,3, Marcus J.H. Huibers4, Peter Lucassen2,
Richard Oude Voshaar5, Harm van Marwijk6,7,
Judith Bosmans7, Mirjam Pijnappels8, Jan Spijker1,3,9 and
Gert-Jan Hendriks1,3,9*
Abstract
Background: Depressive symptoms are common in older adults.
The effectiveness of pharmacological treatments
and the availability of psychological treatments in primary care
are limited. A behavioural approach to depression
treatment might be beneficial to many older adults but such care
is still largely unavailable. Behavioural Activation
(BA) protocols are less complicated and more easy to train than
other psychological therapies, making them very
suitable for delivery by less specialised therapists. The recent
introduction of the mental health nurse in primary
care centres in the Netherlands has created major opportunities
for improving the accessibility of psychological
treatments for late-life depression in primary care. BA may thus
address the needs of older patients while improving
treatment outcome and lowering costs.The primary objective of
this study is to compare the effectiveness and
cost-effectiveness of BA in comparison with treatment as usual
(TAU) for late-life depression in Dutch primary care.

A secondary goal is to explore several potential mechanisms of
change, as well as predictors and moderators of
treatment outcome of BA for late-life depression.
Methods/design: Cluster-randomised controlled multicentre trial
with two parallel groups: a) behavioural
activation, and b) treatment as usual, conducted in primary care
centres with a follow-up of 52 weeks. The main
inclusion criterion is a PHQ-9 score > 9. Patients are excluded
from the trial in case of severe mental illness that
requires specialized treatment, high suicide risk, drug and/or
alcohol abuse, prior psychotherapy, change in dosage
or type of prescribed antidepressants in the previous 12 weeks,
or moderate to severe cognitive impairment. The
intervention consists of 8 weekly 30-min BA sessions delivered
by a trained mental health nurse.
Discussion: We expect BA to be an effective and cost-effective
treatment for late-life depression compared to TAU.
BA delivered by mental health nurses could increase the
availability and accessibility of non-pharmacological
treatments for late-life depression in primary care.
Trial registration: This study is retrospectively registered in the
Dutch Clinical Trial Register NTR6013 on
August 25th 2016.
Keywords: Behavioural activation, Late-life depression,
Primary care, Older adults, Depressive symptoms
* Correspondence: [email protected]
1Behavioural Science Institute, Radboud University, Nijmegen,
The
Netherlands
3Institute for Integrated Mental Health Care “Pro Persona,
Nijmegen, The

Netherlands
Full list of author information is available at the end of the
article
© The Author(s). 2017 Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the data made available in this article, unless otherwise stated.
Janssen et al. BMC Psychiatry (2017) 17:230
DOI 10.1186/s12888-017-1388-x
http://crossmark.crossref.org/dialog/?doi=10.1186/s12888-017-
1388-x&domain=pdf
http://orcid.org/0000-0001-5529-3275
http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6013
mailto:[email protected]
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
Background
With a point prevalence of 13,4% clinically relevant late-
life depressive syndromes are common [1, 2]. A study in
Dutch primary care practices found that major depression
was prevalent in 13,7% and minor depression in 10,2% of
the elderly patients [3]. However, most older patients with
depression remain untreated [4]. Often older adults attri -
bute their depressive symptoms to the ageing process or

declining physical health [5–7], have low expectations
about existing treatments [6], and/or feel adversity
towards treatment in mental health clinics [8]. A large
3-year longitudinal cohort study on late-life depression in
32 Dutch primary care centres (PCC’s) showed the
prognosis to be poor [9]. The direct economic costs of
depression treatment as well as the indirect costs of
depression associated with premature mortality and
morbidity are high, as people with depression have a
higher healthcare consumption than non depressed
people [10–12]. The increasing ageing population in the
Netherlands will raise healthcare costs and un(der)treated
older patients with clinical depression will add to the
burden.
Although late-life depression can be treated effect-
ively, there is space for both improvement and devel -
opment of alternative treatments [9, 13, 14].
Furthermore, especially in older adults, the use of
psychoactive agents like antidepressants is associated
with risks and adverse events, such as falls and ad-
verse interactions with somatic medications [2, 15,
16]. Although older adults prefer psychological treat-
ment over pharmacological treatment [1], only 3% of
older patients with minor depression and 10% of
older patients with major depressive disorder are re-
ferred to a mental health professional [15]. There are
several barriers that can explain this underutilization
of mental health services [17]. Older adults report a
fear of stigmatization and have difficulties identifying
their need for help, believing that their symptoms are
normal [17]. Furthermore, there is a lack of psycho-
therapists trained in treating older adults and most
facilities treating older patients for depression are lo-
cated outside the PCCs [8]. Patients thus experience
practical barriers such as transportation problems and

are held back by the costs of treatment [13, 16, 17].
Many of these barriers could be overcome if an ef-
fective psychological treatment was available in pri-
mary care, one that acknowledges but does not
medicalize the depressive feelings older adults experi -
ence. Behavioural activation (BA) might be that
treatment.
BA aims to create a personal environment of positive
reinforcement by increasing functional and pleasurable
behaviour, and by decreasing avoidant and depressed
behaviour [18, 19]. BA protocols are less complex, easier
to train and to implement than other psychological
therapies, making them very suitable for implementation
in primary care, as studies from the UK have already
shown for non-older adults [20, 21]. Currently, cognitive
behavioural therapy (CBT) and interpersonal therapy
(IPT) are the most frequently used treatments for de-
pression, but research suggests that BA might be equally
effective [22–25]. Recent introduction of the mental
health nurse (MHN) in PCCs in the Netherlands has
created major opportunities for the delivery of psycho-
logical treatments, such as BA, for late-life depression.
The availability of BA in PCCs may improve accessibility
and acceptability of psychological treatment for older
patients [8]. BA may thus address the needs of older pa-
tients while improving treatment outcome and lowering
costs [1, 26].
Effectiveness of BA
Several meta-analyses [27, 28] as well as a recent RCT
[24] among depressed patients found BA to be at least
equivalent to CBT in the acute phase and at follow -up,
and more effective than control conditions and some
other psychological therapies for depression in adults.

Moreover, MHN-delivered BA is both feasible, effective
and cost-effective in managing depression in primary
care [20, 21].
Meta-analyses with respect to BA treatment for
late-life depression confirm its benefits for this age-
group, although included studies were small and had
low methodological quality [29–31]. Furthermore, two
small observational studies showed that BA delivered
by master level students and by social workers is
feasible [32, 33].
Further evidence for the effectiveness of BA for late-
life depression stems from a large RCT on care man-
agement for patients with late-life depression that sug-
gest that activity scheduling, which exhibits similarities
with BA, could be a major contributor to treatment
gains [34]. This trial did not directly compare BA and
TAU. In another RCT ‘collaborative care’ BA was the
principal treatment compared to TAU for older adults
with subclinical depressive symptoms. The study found
a small to medium effect of collaborative care on de-
pressive symptoms compared to TAU [35]. In both
studies, BA was only a component of a new care man-
agement plan, so the direct effects of BA on depressive
symptoms could not be determined.
Despite the growing evidence of the effectiveness of
BA in managing depression, no methodologically sound
and well-conducted studies have evaluated the effective-
ness and cost-effectiveness of BA by MHNs as a stand-
alone treatment for older depressed adults in primary
care. BA, delivered by MHNs, could increase the
Janssen et al. BMC Psychiatry (2017) 17:230 Page 2 of 11

availability and accessibility of non-pharmacological
treatments for late-life depression in primary care.
Mechanisms, predictors and moderators
As stated before, recent studies show that BA is non-
inferior to CBT in adults [22]. Several other studies
suggest that most psychological interventions for de-
pression are equally effective, a phenomenon also re-
ferred to as the “dodo-bird verdict” [36, 37]. This
doesn’t mean that all interventions are equally effect-
ive for all patients. Therefore we are specifically inter -
ested in the underlying mechanisms and predictors
that can explain how therapeutic change comes about
in BA.
BA theory suggests that changes in activation cause
and precede the decline of depressive symptoms [18,
19, 38]. This has been demonstrated in a recent small
scaled study that found that changes in activation pre-
ceded or co-occurred with changes in depression in
adults, while in TAU this pattern was not found [39].
Another potential therapy-specific mechanism of BA is
rumination. In BA, rumination is specifically targeted
as a behavioural problem that can be actively tackled
with behavioural interventions. BA attempts to change
the act of rumination, thereby leaving more time for
constructive and social behaviour, rather than challen-
ging the content of the dysfunctional thoughts [18].
Several non-specific factors that are potentially re-
lated to treatment gain in depression as well as po-
tential predictors of the (differential) effects are also
investigated, such as loneliness, physical activity,

cognitive functioning, therapeutic alliance, behavioural
limitations, general psychopathology and treatment
expectations [40–43].
Objectives and hypotheses
In the current trial, we aim to evaluate the effectiveness
and cost-effectiveness of BA, delivered by mental health
nurses for older adults with moderate to severe depres-
sive symptoms in PCCs. The study will investigate the
effectiveness of BA in real life primary health care, with
the aim to generalize results to primary care in the
Netherlands and abroad.
The second aim of this study is to investigate whether
treatment gains in BA can be explained by treatment-
specific factors based on BA-theory, such as the degree
of activation, or non-specific factors, such as the thera-
peutic alliance or treatment expectations. An example of
a possible mechanistic pathway that might explain the
effectiveness of BA can be seen in Fig. 1.
The following main research questions were formulated:
1. What is the effectiveness of BA compared to TAU
for older adults with clinically relevant depressive
symptoms over the course of 12 months?
2. What is the cost-effectiveness of BA compared to
TAU from a societal perspective for older adults
with clinically relevant depressive symptoms, over
the course of 12 months?
3. What are the mechanisms of change that account
for the effectiveness of BA compared to TAU?
Fig. 1 Theoretical framework for potential mechanisms of
action

4. What are the predictors and moderators of outcome
of BA compared to TAU?
In line with previous research, we hypothesize that BA
is more effective and cost-effective than TAU [21–31].
Methods
Study design
The design of this study is a cluster randomized controlled
multicentre trial with two parallel treatment groups with a
follow up of 52 weeks. The treatment conditions are
behavioural activation (BA), and treatment as usual
(TAU). Data are collected at general practices in the
South-Eastern region of the Netherlands. Only practices
that employ a mental health nurse (MHN) are included.
Currently, more than 80% of Dutch PCCs employ an
MHN [44]. A list of currently participating PCCs can be
found on http://beatdepressie.nl/voor-deelnemers/. We
will report the study according to the SPIRIT guidelines
[45]. The study has been approved by the local medical
ethical committee of the Radboud University Medical
Centre (CMO Arnhem-Nijmegen).
Eligibility criteria
General practitioners and mental health nurses are
responsible of the recruitment of participants. They
include eligible patients during consultations (see proce-
dures for details). We will include 200 older adults
(≥65 years). All patients presenting with depressive
symptoms or depression are asked to participate. Those
who have a PHQ-9 score > 9 and have given informed

consent will be included in the study. Patients will be ex-
cluded from the trial in the case of 1) current severe
mental illness in need of specialized treatment, including
bipolar disorder, obsessive-compulsive disorder, (history
of) psychosis, high risk of suicide, drug and/or alcohol
abuse, 2) psychotherapy in the previous 12 weeks or
current treatment by a mental health specialist and 3)
moderate to severe cognitive impairment. Patients with
antidepressants are eligible provided that a stable dose
has been maintained for at least 12 weeks before partici -
pating in the study.
Interventions
BA aims to increase activation levels by helping patients
engage in rewarding activities and reduce avoidance
behaviour that diminishes distress in the short term but
has adverse consequences in the long term [18]. Our BA
protocol is based on the model developed by Martell
and colleagues [18]. This original BA model consists of
12 to 24 one-hour sessions and is designed for patients
referred to specialised mental healthcare institutions for
treatment. The patients eligible for treatment in PCCs
will be a more mixed population suffering from clinically
relevant depressive symptoms although less severe than
patients referred to specialist care. In studies on collabora -
tive care for depressed older adults, BA-treatment by
MHNs is delivered in 8 to 10 15–45 min sessions [34, 35].
We decided to adjust BA intensity to a level that would fit
the contemporary Dutch model for MHN-delivered care
in PCCs.
BA will be delivered in eight 30-min face-to-face ses-
sions within eight weeks, with the first session lasting
45 min. All key elements of the original BA-protocol of
Martell et al. are kept in, including a functional analysis,

activity registration, activity scheduling and relapse pre-
vention [46]. Prior to the start of the study, all MHNs of
the BA group received a two-day training by licensed
specialists on the use of the BA protocol. While treating
patients, MHNs receive two-weekly online (skype)
supervision in groups of three, led by one of the BA
specialists that provided the training. MHNs fill in a ses-
sion checklist for every patient to check for therapy
adherence.
Treatment as usual (TAU) will be unrestricted and
involves the GPs treatment options consistent with the
guidelines of the Dutch College of GPs [47, 48]. At base-
line GPs indicate their intended treatment, such as
pharmacological treatment, psychological treatment by a
MHN or a psychologist, or watchful waiting. At post-
treatment GPs confirm whether the intended treatment
plan was followed and which changes were made.
Although activation is addressed as an advice to patients
suffering from depression or depressive symptoms in the
before mentioned guidelines, it is not offered as a sys-
tematic and protocolised intervention and therefore not
comparable to the BA protocol adopted in our study.
Procedure
Older adults that visit their GP with depressive symptoms,
complaints of loneliness, reduced social functioning, med-
ically unexplained symptoms, and/or frequent attenders
without a clear somatic diagnosis will be screened for po-
tential eligibility. If the GP or MHN suspects depressive
symptoms or if the patient fulfils one of the aforemen-
tioned criteria, the GP or MHN will screen the patient
with the first two questions of Mini International Neuro-
psychiatric Interview (M.I.N.I. 5.0.0.) [49] on depressive
symptoms. If one or both of the questions is answered
affirmatively, the GP will provide the patient with basic

information about the study and will ask whether (s)he
agrees to be contacted by our research assistant.
Eligible participants receive a letter with study infor-
mation and are contacted by a research assistant to plan
a baseline visit, that takes place approximately one week
after they’ve received the letter. This will allow them to
make an informed decision about their participation. At
the baseline visit a research assistant will visit the patient
http://beatdepressie.nl/voor-deelnemers/
at home to assess whether (s)he fulfils the inclusion
criteria and is willing to participate. During this visit,
also several cognitive tests will be performed, and the
presence of depressive disorder will be established with a
semi-structured clinical interview M.I.N.I. 5.0.0 [49].
After the baseline meeting, the patient will receive the
online or paper-pencil baseline questionnaire, which
they will be asked to complete within the following
week. Furthermore, the patient will wear an accelerom-
eter for one week. Approximately one week after the
baseline meeting the BA- or TAU-treatment is started.
During the treatment phase (baseline to 9 weeks),
patients in both research conditions will receive a ques-
tionnaire every two to four weeks at home. BA patients
also fill in a short questionnaire during the weekly
sessions with the MHN. Nine weeks after the baseline
assessment, patients will receive a call from a research
assistant for the post-treatment assessment consisting of
two cognitive tests, as well as a short interview to estab-
lish the presence of depressive disorder. After this,

patients will wear the accelerometer for another week,
and complete the post-treatment questionnaire within
that week.
In the follow-up period (3 to 12 months after base-
line), patients will receive a follow-up questionnaire
every three months. After twelve months the last follow -
up home-visit by a research assistant will be planned.
For a detailed schedule of all measurements per time-
point, see Table 1.
Outcomes
Clinical outcome measures
Depressive symptoms
The Quick Inventory of Depressive Symptomatology
(QIDS-SR) will be used as the primary outcome measure
of depressive severity. The QIDS-SR is a 16-item self-
report instrument assessing depressive symptoms during
the last two weeks. It can be administered in 5–7 min
and has good psychometric properties [48].
The Patient Health Questionnaire- 9 (PHQ-9) is a 9-
item self-report instrument assessing depressive symptoms
during the last week. It will be used as a secondary out-
come measure and to assess changes in depressive symp-
toms over the course of treatment. The psychometric
properties of the PHQ-9 are good [50, 51]. Patients scoring
Table 1 Participant timeline
Treatment phase (weekly) Follow up (3 monthly)
Measuresa -1 0 1 2 3 4 5 6 7 8 3 6 9 12
Clinical outcome measures

Depression (PHQ-9)b • • • • • • • • • • • • •
Mini 5.0 (2 questions) •
MINI 5.0 interview (baseline complete, T8 only depression) • •
Cognitive (MoCA) • •
Depression (QID-S) • • • • • •
Well- being & moodc (visual analogue scale) • • • • • • • •
Psychopathology (BSI-SF) • • •
Limitations (WHODAS) • • •
Process BA-specific
Behavioural activity (BADS) • • • • • • • •
Physical activity (accelerometer) • •
Ruminative brooding (RRS) • • • • • • • •
Process general
Loneliness (S&ES) • • • • • • •
Therapeutic alliance (SRS)c • • • • • • • •
Cognitive (STROOP & DSST) • • •
Expectancy (Expectancy and credibility list)c •
Cost effectiveness

TIC-P • • • • •
EQ-5D • • • • • •
a− 1 = screening by GP, 0 = baseline measurement by research
assistant, 8 = post-treatment measurement by research assistant
badministered weekly in BA and
two-weekly in TAU. conly administered in BA
PHQ-9 > 9 are classified as having clinically relevant
depressive symptoms [52].
Depressive disorder and psychiatric comorbidity
To distinguish patients with a major depressive disorder
(MDD) from patients with only clinically relevant symp-
toms a research assistant will administer the complete
Mini International Neuropsychiatric Interview (M.I.N.I.
5.0.0). Furthermore, this instrument assesses psychiatric
co-morbidity. The M.I.N.I. 5.0.0 is a short diagnostic
interview that assesses current psychological disorders,
based on DSM-IV diagnostic criteria. The reliability and
validity of the M.I.N.I are good [49]. The M.I.N.I. can be
administered in about 15 min [53].
Economic evaluation
Quality of life
Quality of life will be evaluated using the five level
version of the self-report EuroQol questionnaire (EQ-
5D-5 L) [54]. The EQ-5D-5 L consists of five health-
state dimensions on which respondents indicate their
perception of their health-related well-being. Each
dimension is rated as causing ‘no problems’, ‘slight prob-

lems’, ‘some problems’, ‘moderate problems’ or ‘extreme
problems’. The Dutch EQ-5D tariff will be used to calcu-
late Quality-Adjusted Life-Years (QALYs) [55]. The EQ-
5D-5 L appears to be a valid extension of the reliable
and valid EQ-5D-3 L [56].
Health care utilisation
Healthcare consumption and productivity losses will be
recorded every three months in both study conditions
using a modified version of the Trimbos and iMTA
questionnaire on Costs associated with Psychiatric illness
(TiC-P) [57]. Healthcare costs include the number of
consultations with health care providers, medication and
admissions to hospitals. Lost productivity costs are
defined as the productivity lost due to absenteeism from
(unpaid) work and reduced efficiency at work.
Process and predictor variables
Psychopathology
Psychopathology will be measured using the Brief Symp-
tom Inventory-18 (BSI-18) [58, 59]. The BSI-18 has
three subscales: depression, anxiety and somatic symp-
toms, that together make up the Global severity Index
(GSI) of psychological distress. Patients rate on a five-
point Likert scale how much they have been bothered by
each symptom in the last 7 days. The BSI-18 is a valid
and reliable measure for psychological distress, and can
detect depression and anxiety based on a DSM-IV classi-
fication in older adults [60].
Behavioural limitations
To assess the behavioural limitations that patient experi-
ence in daily life, The World Health Organization
Disability Assessment Schedule 2.0 (WHODAS, short
version) will be used [61]. The short version of the
instrument has 12 items on a 5-point Likert scale. The

instrument has proven to be able to measure the impact
of health conditions such as depression on daily life and
can monitor the effectiveness of interventions [62].
Cognitive functioning
To test baseline cognitive functioning the Montréal
Cognitive Assessment Scale (MoCA) is used. The MoCA
is a short cognitive screening tool that tests a wide range
of cognitive functions [63]. The tool has a high sensitiv-
ity as well as specificity for detecting mild cognitive im-
pairment, and is especially interesting for the population
of depressed elderly because it measures executive func-
tioning [63].
Behavioural activation
To measure perceived active behaviour in both BA and
TAU conditions the Behavioural Activation for Depres-
sion Scale (BADS) can be used. The BADS is a 25-item
self-report instrument measuring behavioural activation
[64]. Four domains of behavioural activation are distin-
guished: Activation, avoidance/rumination, work/school
impairment and social impairment. The work/school do-
main may seem less relevant for our population, but the
questions are formulated in such a way that they could
easily be applied to general responsibilities like house-
hold chores and volunteering. The psychometric proper-
ties of the BADS are good [64].
Rumination
To assess the extent of depressive brooding, the brood-
ing subscale of the Rumination Response Scale (RRS)
will be used [65–67]. The brooding scale consists of 5
questions on a 4-point Likert-scale. The reliability, and
convergent and discriminant validity of the brooding
scale are appropriate, and it predicts depressive symp-
toms prospectively [66].

Physical activity
The expected influence of BA on physical activity of de-
pressed participants can be objectively registered with an
accelerometer (DYnaPort MoveMonitor). Daily physical
activities will be measured over a 1-week period at the
start of the intervention and 10 weeks after baseline.
Participants will be asked to wear a sensor at their lower
back, by use of an elastic belt around their waist. The
amount of daily activities will be determined, based on
the MoveMonitor algorithms, which classifies the accel -
eration data into 4 types of activity: sitting, lying,
standing and locomotion. Also, non-wearing time per
day will be detected. Subsequently, the duration of loco-
motion, lying, sitting, and standing, movement intensity,
the number of locomotion bouts and transitions to
standing, and the median and maximum duration of
locomotion will be calculated per day [68].
The quality of daily activities will be determined as the
median values of gait characteristics, calculated over all
episodes of locomotion during the week according to [69].
These characteristics include local divergence exponent,
inter-stride variability, and entropy. In addition, we will
determine the complexity of physical activity, based on
the concept of ‘barcoding’ [70]. Such a barcode reflects
different states of physical activity, based on features such
as type, intensity, and duration of lying, sitting, standing
and locomotion, and is quantified by structural complexity
metrics and sample entropy. The accelerometer can be
worn at all times except during water activities such as

swimming or showering. For a detailed schedule of the
timing of several measures, see Table 1.
Loneliness
The De Jong Gierveld Short Scale for emotional and
social loneliness, a 6-item self-report measure will be
used [71]. Patients answer three questions about social
loneliness, characterized by a smaller number of friends
than is considered desirable, and three questions about
emotional loneliness, characterized by a lack of intimacy
in current relationships, on a 6-point scale. The sum of
both subscales indicates overall loneliness. The Dutch
version of this short form has good psychometric prop-
erties [71].
Therapeutic alliance
To measure therapeutic alliance, the Session Rating
Scale (SRS) is the instrument of choice. It consists of 4
visual analogue scales and aims to measure the self-
reported therapeutic alliance by the patient [72]. The
psychometric properties of this instrument are satisfac-
tory and the feasibility in clinical practice is found to be
good [72].
Psychomotor performance
With the Digit Symbol Substitution Test (DSST) the de-
generation or improvement of psychomotor perform-
ance can be measured [73]. The DSST is pencil and
paper test in which the patient is given a combination of
numbers and matching symbols and a test section with
numbers and empty boxes. The patient is asked to fill as
many empty boxes as possible with a symbol matching
each number within 90 s.
Executive functioning
To measure whether behavioural activation is effective

regardless of the level of executive functioning of the pa-
tient, the Stroop-task will be used [74, 75]. Patients will
be presented with three different sheets of words and/or
colours. The first sheet contains colour names in black
ink. Patients are asked to read the colour names. The
second sheet consists of squares printed in different
colours. Patients are asked to name the colours on the
sheet. The last sheet contains the words “red”, “green”
and “blue” that are printed in sometimes the same (e.g.
the word red in red ink) and sometimes a different
colour ink. The task is to name the colour of the ink
in which the word is printed as quickly as possible.
The increase in time taken to perform the latter task
compared with the basic task is referred to as “the
Stroop interference effect”.
Treatment expectations
To asses treatment expectations, the credibility & ex-
pectancy questionnaire will be used [76]. The question-
naire consists of six questions that are assessed on a 9
point Likert-scale. The questionnaire appears to have
high internal consistency within each factor and good
test–retest reliability [77]. Expectancy measures will not
be used to ensure initial equivalence between two com-
pared treatments, but to measure individual differences
in expectancy within the BA group.
Sample size
Comparing the effects BA for depression to a waiting list
condition, Cuijpers et al. reported an effect size of 0.9 in
a meta-analysis [27]. Since we will be comparing BA to a
more active treatment condition (TAU) in depressed
older patients, we estimate the effect size for depression
outcome of BA versus TAU to be 0.50, a modest but
clinically relevant value. Based on this estimate
(alpha = 0.05, power (beta) = 0.80, 2-tailed test) and data

clustering within PCCs (ICC of 0.05 and a cluster size of
n = 6) 100 patients are required per group with two
groups of 14 clusters (based on 14 potential patients per
PCC and a 50% refusal and a 20% dropout rate).
Recruitment
Several general practices in the South-Eastern region of
the Netherlands are recruited to participate in the study.
General practitioners and mental health nurses are
responsible of the recruitment of participants.
Assignment of interventions
PCCs are the units of randomization. PCCs that employ
the same MHN will be in the same treatment condition,
preventing contamination. An independent statistician
will use pairwise matching to randomize the PCCs,
taking into account the amount of MHNs in a PCC, as
well as the sex of the MHN and the size of the patient
population. In half of the PCCs the MHNs are trained to
give BA-treatment while the other half will treat patients
as usual. GPs, patients and MHNs are not blinded to
treatment condition because PCCs are the units of
randomisation, but the research assistants that assess
depression after treatment are blind to condition.
Data management
Data are handled confidentially as each patient is coded
with a number. The link between the patient code and
patient information is preserved in a digital document
that will be protected by a password. This document is
only available to the principal investigator, the executive

researcher and the two research assistants. Coded
patient data are kept in a folder that is stored within a
different section of the RadboudUMC database than the
source data. Informed consent forms are kept in a
locked closet, separated from the paper and pencil ques-
tionnaires that also will be archived in a locked closet.
Digital data are stored in Castor EDC, a program with a
built in audit trail. Patients will send the filled in ques-
tionnaires by mail or e-mail. A research assistant will
call patients when there is missing information in a
questionnaire, or when a questionnaire is not returned
in time. When a patient does not want to continue in
the study, all the information up until then is used in
the analyses but no additional information is collected.
Statistical analyses
Clinical outcomes
Data analyses include intention-to-treat analyses and
per-protocol analyses. The relative effectiveness of
behavioural activation and treatment as usual will be
analysed using mixed linear regression modelling. In
addition, we will determine the proportion of patients
that show reliable and clinically significant improvement
on the outcome measures, based on the model of Jacobson
and Truax [78, 79]. Relapse (episode of MDD after remis-
sion) and recurrence (episode of MDD after recovery) will
be assessed in the course of follow-up (6, and 12 months)
using survival analysis (Cox proportional hazards regres-
sion). Intention to treat analyses as well as per protocol
analyses will be conducted.
Economic evaluation
The aim of the economic evaluation is to relate the
difference in societal costs between BA and TAU to the
difference in clinical effects. Both a cost-effectiveness
and a cost-utility analysis will be performed with a time

horizon of 12 months. The analysis will be performed in
accordance with the intention-to-treat principle. Missing
cost and effect data will be imputed using multiple
imputation. Bivariate regression models will be used to
estimate cost and effect differences between the groups
while adjusting for relevant confounders. Incremental
cost-effectiveness ratios (ICERs) will be calculated by
dividing the difference in mean total costs between the
two treatment groups by the difference in mean effects.
Bias-corrected accelerated bootstrapping with 5000 rep-
lications will be used to estimate 95% confidence inter-
vals around cost and effect differences, and uncertainty
around the ICERs. Uncertainty surrounding ICERs will
be graphically presented on cost-effectiveness planes.
Cost-effectiveness acceptability curves will also be esti -
mated showing the probability that BA is cost-effective
in comparison with TAU for a range of different ceiling
ratios thereby showing decision uncertainty [80].
Process variables and predictors
To identify mechanisms of change and the magnitude of
the factors involved, both multilevel mediation models
and structural equation models (using path analysis,
such as Latent Difference Score (LDS) Models) will be
used. Predictors (prognostic factors) and moderators
(prescriptive factors) of outcome will be identified using
mixed regression, building on the effectiveness models.
Monitoring
Given the negligible risks of this study, the monitor is an
independent researcher of the Primary and Community
Care department (ELG) of the Radboud University
Medical Centre.
Harms

We will report all Serious Adverse Events (SAEs) to the
sponsor without undue delay after obtaining knowledge
of the events. We will report the SAEs through the web
portal ToetsingOnline to the accredited Medical Ethics
Committee that approved the protocol, within 7 days of
first knowledge for SAEs that result in death or are life
threatening followed by a period of maximum of 8 days
to complete the initial preliminary report. All other
SAEs will be reported within a period of maximum
15 days after the sponsor has first knowledge of the
serious adverse events.
Discussion
The aim of this study is to investigate whether BA will
be more (cost-)effective than TAU for older adults in
primary care. Although BA has been proven to be an ef-
fective treatment for depression in adults, the effective-
ness of BA delivered by MHNs in older adults, as well as
the possible mechanisms of change are not yet clear.
The results of the study can be used to improve the
quality and availability of treatments for depressed older
adults in primary care.
The main strength of this study is that procedures
followed in this effectiveness trial closely match the daily
practice of PCCs. Therefore the results can be easily
generalized to other PCCs. Furthermore, our BA proto-
col is adapted to a primary care setting, is very easy to
train, and therefore easily implemented in other PCCs
throughout the Netherlands and abroad.
However, this study also has some limitations that will

be taken into account. The main limitation derives from
the fact that patients as well as some research assistants,
GPs and MHNs are not blinded to patient allocation,
due to cluster randomisation. This might influence their
judgement of severity of depression of the patients. To
prevent biased opinions on whether or not patients (still)
have MDD post-treatment, the clinical interview will be
performed by an independent research assistant that will
be blinded to patient allocation.
Furthermore, we realize that the recruitment of
patients in primary care could be challenging [81]. We
are aware of the fact that Lasagna’s law, that states that
medical investigators tend to overestimate the number
of patients available, holds in Dutch primary care
research [82]. It might be difficult for GPs to inform
depressed older adults about the study in their 10 min
sessions. Therefore the only task GPs will have, is to ask
patients whether they may be contacted by a research
assistant to provide them with more information. From
there on, the research assistant will take over.
Lastly, older adults might have difficulties filling in
questionnaires due to physical problems such as visual
impairments, concentration problems or unfamiliarity
with psychological questionnaires. Therefore an inde-
pendent research assistant, blinded to patient allocation,
is available when needed to help patients at home or by
phone with the questionnaires.
If proven effective, BA can be a valuable addition to
current guidelines for the treatment of older adults with
moderate to severe depressive symptoms in primary care.
Abbreviations

BA: Behavioural Activation; BADS: Behavioural Activation for
Depression Scale;
BIA: Budget Impact Analysis; BSI − 18: Brief Symptom
Inventory-18; CBT: Cogni-
tive Behavioural Therapy; CEA: Cost effectiveness Analysis;
DSST: Digit Symbol
Substitution Test; EuroQol-5D-5 L: European Quality of Life
Self-report Question-
naire; GP: General Practitioner; IPT: InterPersonal Therapy;
M.I.N.I. 5.0.0: Mini
International Neuropsychiatric Interview; MDD: Major
Depressive Disorder;
MHN: Mental Health Nurse; MoCA: Montréal Cognitive
Assessment scale;
PCC: Primary Care Centre; PHQ-9: Patient Health
Questionnaire- 9;
QALYs: Quality-Adjusted Life-Years; QIDS-SR: Quick
Inventory of Depressive
Symptomatology; RCT: Randomised Controlled Trial; RRS:
Rumination Response
Scale; SRS: Session Rating Scale; TAU: Treatment As Usual;
TiC-P: Trimbos and
iMTA questionnaire on Costs associated with Psychiatric
illness;
WHODAS: World Health Organization Disability Assessment
Schedule 2.0
Acknowledgements
We thank Anouk Peters, Lotte School and Carla Walk for their
assistance.
Funding
The study is funded by the Ministry of Health Funding-program
for Health
Care Efficiency Research ZonMw (843001606). Prior to
granting the funding

by ZonMw extensive peer review during two phases has been
carried out.
ZonMw is not involved in the design of the study and does not
participate
in the data collection, analysis of the data and writing of the
manuscript.
Availability of data and materials
Not applicable, collection of participants and data is still
ongoing.
Authors’ contributions
All authors participated in the design of the study. GJH
obtained funding. NJ
drafted the manuscript and carries out recruitment and data-
collection. GJH,
PL, MJH, ROV, HVM, MP, JS and JB revised the manuscript.
All authors have
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests to
disclose.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The Medical Ethics Committee of Radboud University Medical
Centre (CMO
Arnhem-Nijmegen) (http://www.ccmo.nl/nl/erkende-metc-
s/cmo-regio-arnhem-
nijmegen) approved the study protocol. The study is registered
at Dutch Clinical
Trial Register (NTR6013). Before written informed consent is
obtained all partici-

pants are provided with printed study information and visited
for oral explan-
ation of the study.
Sponsor
Institute for Integrated Mental Health Care “Pro Persona”,
Nijmegen, the
Netherlands.
Workplan for knowledge transfer and sustainable
implementation
The main goal of this study is to change routines in Dutch
primary care for
older patients suffering from depression and to increase the
availability of
non-medical treatments for late-life depression in primary care.
The main
strategy for disseminating the results of this study, apart from
congresses
and scientific publications, is the incorporation of the trial
results into the
update of the Depression Guideline of the Dutch College of
General
Practitioners. Our research project group has direct access to
the Dutch GP
Depression Guideline (van Marwijk). The guideline has a
national reach and
is primarily directed at general practitioners and primary care
nurses.
The activities to actively change clinical practice consist of the
initiation of
an ‘implementation working group’, linked to the research
group. Members
of this group are patient and general practitioners of the trial
sites and of
the health plans paying for the treatment. A patient and

professional
member from the Dutch Association of Mental Health Nurses
(Landelijke
Vereniging POH-GGZ) will also join this implementation group,
as well as a
representative from the Dutch Depression Association (national
patient
organization). During the first three years of the study, the
research group
will consult the implementation group about barriers and
facilitators related
to the introduction BA in primary care centres.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Author details
1Behavioural Science Institute, Radboud University, Nijmegen,
The
Netherlands. 2Department of Primary and Community Care,
Radboud
University Medical Centre Nijmegen, Nijmegen, The
Netherlands. 3Institute
for Integrated Mental Health Care “Pro Persona, Nijmegen, The
Netherlands.
4Department of Clinical Psychology, VU University
Amsterdam, Amsterdam,
The Netherlands. 5University Medical Center Groningen,
Interdisciplinary
Center for Psychopathology of Emotion regulation (ICPE),
University of
Groningen, Groningen, The Netherlands. 6Centre for Primary
Care, Institute
for Population Health, University of Manchester, Manchester,

UK.
7Department of Health Sciences and EMGO Institute for Health
and Care
Research, Faculty of Earth and Life Sciences, VU university
Amsterdam,
http://www.ccmo.nl/nl/erkende-metc-s/cmo-regio-arnhem-
nijmegen
http://www.ccmo.nl/nl/erkende-metc-s/cmo-regio-arnhem-
nijmegen
Amsterdam, The Netherlands. 8MOVE Research Institute
Amsterdam, Faculty
of Human Movement Sciences, VU University Amsterdam,
Amsterdam, The
Netherlands. 9Department of Psychiatry, Radboud University
Medical Centre
Nijmegen, Nijmegen, The Netherlands.
Received: 29 May 2017 Accepted: 16 June 2017
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Running head: NURSES CARE FOR MENTAL HEALTH 2
NURSES CARE FOR MENTAL HEALTH 2
Nurses care for mental health
Nancy Allie
Chamberlain College of Nursing
Transition to Nursing
NR103-63691
Dr. Hilary Fulk & Dr. Melissa Luten
December 18, 2021

Nurses care for mental health.
Nursing is career established in professional morals, principles,
and standards. Nursing being one of the difficult careers to
achieve and maintain. Nurses must secure certain qualities such
as effective communication, optimistic, compassionate,
knowledgeable, and empathetic etc. Compassion being one of
the key factors one could acquire as a nurse, helps shaped
patients’ life.
Is mental health on a rapid rise in the United States of America?
The growing demand for mental health services, together with
current and increasing shortages of mental health professionals
and increasing adoption of integrated models of care delivery,
suggest nurses will become increasingly needed to provide
mental health services (David et al., 2021). The use of
substance abuse, opioids, severe depression, rampant gun
violent has led to the rise of mental and Behavioral health.
In my current job as a Case Manager in a mental facility, the
majority of our patients are adults with serious depression,
anxiety, mood disorder and more. People with a mental disorder
diagnosis are at more than double the risk of all-cause mortality
than the general population. Most at risk are those with
psychosis, mood disorder and anxiety diagnoses (Cite). These
individuals are mostly involved in suicidal attempts or harming
themselves or others around them, giving behavioral health
organizations to create care plans for them managed my nurses,
social workers, case workers and more.
Census shows the demand for nurses in the mental health sector
therefore Registered Nurses RN’s and Nurse Practitioners NPs
earn more than other nurses in other areas. Registered Nurses
who work in mental health services create patients’ diagnosis,
they develop treatment plans for patients, organize and assess
treatments together with other activities. The increasing demand
for mental health services coupled up with the shortage of
outpatient mental health professionals suggests nurses will be
highly needed to provide healthcare services for mental health

patients.
Census from (David et al., 2021) revealed that Registered
Nurses ready to work in the mental health services are relatively
females and older and they are white compared to other sectors.
RNs working in outpatient mental health are considerably older
than other
RNs, with just under 10% under age 35 compared to 22% of all
other RNs, and nearly half are 50 and over. Outpatient mental
health nurses RNs and NPs practiced team-based care. Majority
of NPs and RNs hired receive information while training on the
job. NPs stand a chance of receiving training while in studies
which makes outpatient NPs do not get team-based care
training.
Mental health is a growing concern in the United States,
majority of mental health patients are homeless and some of
them are living in the homeless shelter. Economy in the United
States is a major factor leading to the larger number of mental
health patients and living condition and individual entitlements
from the federal Government is a great contribution the high
rise of mental health patient and their homelessness. States
should take a great caution in training nurses as the high rise of
mental health patients leads to high demand of nurses for
mental health. Shortage of nurses leads to burnouts, fatigues
and mental disorder in nurses.
References
Author: David et al. (2021)
Title: Characteristics of Registered Nurses and Nurse
Practitioners Providing Outpatient Mental Health Care
Retrieved from:
https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox?projecto
r=1
Author: Dickens et al. BMC Nursing (2019)
Title: Mental health nurses’ attitudes, experience, and
knowledge regarding routine physical healthcare: systematic,
integrative review of studies involving 7,549 nurses working in
mental health settings

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MayJune 2021 Volume 39 Number 3 111Nursing Economic$