please follow assignment instructions and rubric that are attached, i will also post the previous assignments that will aid this assignment.
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Module 1 Discussion
Jachai Littlejohn
St. Thomas University
NUR-670-AP3
Dr. Mesa
August 28, 2025
Real-world Problem in U.S. Psychiatric Care
One of the most pressing current issues in U.S. psychiatric care is the profound shortage and unequal distribution of mental health providers, especially across rural and underserved urban areas. As of late 2024, over one-third of Americans, 122 million people live in federally designated Mental Health Professional Shortage Areas (HPSAs), with rural counties disproportionately affected (Mental Health America, 2025). Less than one-third of the U.S. population lives in areas with enough psychiatric providers, and more than half of the counties have none (Modi et al., 2022). These gaps delay diagnosis, limit follow-up care, and worsen symptoms, especially for serious mental diseases such as schizophrenia, bipolar disorder, and major depression. When individuals cannot access timely care, it increases psychiatric hospitalizations, emergency room visits, incarceration, and suicide.
Moreover, access problems are exacerbated by insurance inadequacies and persistent systemic fragmentation. The Mental Health Parity and Addiction Equity Act of 2008 requires equal coverage of mental and physical health services, but insurance limitations like arbitrary "medical necessity" standards, restricted provider networks, denials, and "phantom" provider listings prevent true parity (Modi et al., 2022). Patients often stop therapy due to these hurdles, especially if out-of-pocket expenditures are substantial. In addition, psychiatric services are commonly reserved from primary care, creating fragmented and poorly coordinated treatment. Patients with diabetes or heart disease may receive physical health treatment in one location but struggle to get mental health care in another. Over half of U.S. adults with mental illness go untreated, causing public health and economic issues.
PICO Question
P (Population/Patient Problem): Adults living in the U.S. Mental Health Professional Shortage Areas (HPSAs) who have untreated or undertreated mental illness
I (Intervention): Implementation of integrated telepsychiatry services
C (Comparison): Usual care (limited or in-person psychiatric referral only)
O (Outcome): Increased treatment engagement and reduced symptom severity at 6 months
PICO question: In adults with mental illness residing in U.S. Mental Health Professional Shortage Areas (P), does offering integrated telepsychiatry services through primary care clinics (I), compared with usual care (limited in-person referral only) (C), increase treatment engagement and reduce symptom severity at 6 months (O)?
Why This PICO Question Is Important to Advanced Practice Nursing
This PICO question is critically important for advanced practice registered nurses (APRN) because nurse practitioners and psychiatric nurse practitioners are poised to be frontline providers in models of integrated and technology enabled mental health care. The nationwide mental health provider deficit disproportionately impacts marginalized and rural communities, who commonly use primary care providers for psychiatric needs (Omiyefa, 2025). Telepsychiatry solutions in primary care use existing access points, clinics where patients receive physical health care to increase the APRN's ability to provide specialized psychiatric support remotely. Telepsychiatry integration must be tested to see if it improves efficiency, reduces delays, and improves patient outcomes since primary care professionals provide most U.S. mental health treatments (Calderone et al., 2021). This concept could reduce professional isolation and increase interdisciplinary collaboration for rural and marginalized nurse practitioners by connecting them with psychiatric specialists.
Furthermore, this PICO question addresses systemic barriers beyond workforce scarcity, including insurance limitations, fragmentation of care, and stigma associated with seeking psychiatric services. Integrated telepsychiatry can reduce fragmentation by coordinating physical and mental health treatment in one location (Olawade et al., 2024). Normalizing psychiatric care in primary care may reduce stigma. Advanced practice nurses can use this research to advocate for better reimbursement policies, best practices for integrating telepsychiatry into routine care, and evidence for scaling effective programs nationwide. This PICO question highlights the APRN's unique position in mental health equity, innovation, and quality by emphasizing measurable outcomes like treatment engagement and symptom reduction. Ultimately, answering this question empowers APRNs to expand access to psychiatric care and to directly address disparities that affect millions of Americans.
References
Calderone, J., Lopez, A., Schwenk, S., Yager, J., & Shore, J. H. (2021). Telepsychiatry and integrated primary care: setting expectations and creating an effective process for success. MHealth, 6, 29–29. https://doi.org/10.21037/mhealth.2020.02.01
Mental Health America. (2025). MHA Releases 2024 State of Mental Health in America Report | Mental Health America. Mental Health America. https://mhanational.org/news/mha-releases-2024-state-of-mental-health-in-america-report/
Modi, H., Orgera, K., & Grover, A. (2022). Exploring Barriers to Mental Health Care in the U.S. AAMC. https://www.aamc.org/about-us/mission-areas/health-care/exploring-barriers-mental-health-care-us
Olawade, A. C. D., Olawade, D. B., Ojo, I. O., Famujimi, M. E., Olawumi, T. T., & Esan, D. T. (2024). Nursing in the Digital Age: Harnessing telemedicine for enhanced patient care. Informatics and Health, 1(2), 100–110. https://doi.org/10.1016/j.infoh.2024.07.003
Omiyefa, S. (2025). Mental Healthcare Disparities in Low-Income U.S. Populations: Barriers, Policy Challenges, and Intervention Strategies. International Journal of Research Publication and Reviews, 6(3), 2277–2290. https://doi.org/10.55248/gengpi.6.0325.1186
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Module 2 Discussion
Jachai Littlejohn
St. Thomas University
NUR-670-AP3
Dr. Mesa
September 4, 2025
Module 2 Discussion
Question 1
The PICO question provides psychiatric mental health nurse practitioners (PMHNPs) with a structured framework to address critical clinical issues through evidence-based practice. The PICO question defines the population, intervention, comparison, and outcome to address the pragmatic problems, such as the mental health provider shortage in underserved U.S. locations (Hallas & Lusk, 2021). It helps PMHNPs identify care gaps like psychiatric care access and devise solutions like integrated telepsychiatry. Using research, PMHNPs may improve patient outcomes, eliminate inequities, and optimize resource utilization. The PICO approach streamlines literature searches since only high-quality and recent evidence (Calderone et al., 2021; Modi et al., 2022) may guide practice, which is the PMHNP's responsibility in delivering equitable and evidence-based care.
Furthermore, a PICO question definition allows PMHNPs to be systemic change agents. The question emphasizes the role of the PMHNP in overcoming the barriers to care, such as insurance restrictions and care fragmentation, by emphasizing the measurable outcomes, such as treatment engagement and symptom reduction. It promotes multidisciplinary collaboration, particularly in rural communities where PMHNPs are primary mental health providers. The PICO question also aids professional growth by promoting critical evaluation of evidence, making interventions viable and effective. For example, exploring telepsychiatry’s impact on underserved populations aligns with PMHNPs’ commitment to mental health equity, as noted in Omiyefa (2025). The PICO question will motivate PMHNPs to design, market, and adopt psychiatric care solutions to enhance the access and outcomes of disadvantaged populations.
Question 2
The selected PICO question— In adults with mental illness residing in U.S. Mental Health Professional Shortage Areas (P), does offering integrated telepsychiatry services through primary care clinics (I), compared with usual care (limited in-person referral only) (C), increase treatment engagement and reduce symptom severity at 6 months (O)?—serves advanced practice psychiatric nurses (APPNs) by alleviating the severe shortage of mental health providers, which impacts more than 122 million Americans (Mental Health America, 2025). The question allows APPNs to use clinic infrastructure to provide remote psychiatry by integrating it within primary care. This is crucial in rural and underserved urban regions, where over half of counties lack psychiatric physicians (Modi et al., 2022). The question helps APPNs determine whether telepsychiatry enhances treatment engagement and symptom intensity, affecting their capacity to offer timely, effective therapy. It also places APPNs as pioneers in novel care models that reduce professional isolation via specialized remote cooperation.
For patients, the PICO question addresses barriers to accessing mental health care, such as geographic isolation, insurance limitations, and stigma. By integrating psychiatric services into primary care, integrated telepsychiatry may normalize mental health treatment and reduce stigma (Olawade et al., 2024). This strategy reduces hospitalization, jail, and suicide for schizophrenia and depression patients by providing prompt treatment. The question compares telepsychiatry with the standard care (limited in-person referrals), which assesses whether the intervention enhances engagement, which is crucial since patients tend to abandon therapy because of access barriers or expenses (Modi et al., 2022). By prioritizing measurable outcomes, APNs can promote better reimbursement policies and scalable programs to serve underrepresented populations.
This PICO question is of benefit to the broader population because it can help to resolve systemic inequities in mental health care. Mental Health America (2025) reports that over half of U.S. individuals with mental illness go untreated, worsening public health and economic issues. By examining telepsychiatry's effectiveness, the question helps APPNs design evidence-based care coordination and access strategies for underserved groups. Omiyefa (2025) states that the APPN promotes mental health equality by encouraging multidisciplinary cooperation to minimize service fragmentation and improve population-level mental health outcomes.
In conclusion, the PICO question guides PMHNPs in addressing mental health disparities through evidence-based telepsychiatry interventions. It allows APPNs to improve access, stigma, and results for underrepresented groups, improving equitable, creative psychiatric treatment while addressing structural hurdles.
References
Calderone, J., Lopez, A., Schwenk, S., Yager, J., & Shore, J. H. (2021). Telepsychiatry and integrated primary care: setting expectations and creating an effective process for success. MHealth, 6, 29–29. https://doi.org/10.21037/mhealth.2020.02.01
Hallas, D., & Lusk, P. (2021). Evidence‐based Nursing Practice. 503–511. https://doi.org/10.1002/9781119487593.ch29
Mental Health America. (2025). MHA Releases 2024 State of Mental Health in America Report | Mental Health America. Mental Health America. https://mhanational.org/news/mha-releases-2024-state-of-mental-health-in-america-report/
Modi, H., Orgera, K., & Grover, A. (2022). Exploring Barriers to Mental Health Care in the U.S. AAMC. https://www.aamc.org/about-us/mission-areas/health-care/exploring-barriers-mental-health-care-us
Olawade, A. C. D., Olawade, D. B., Ojo, I. O., Famujimi, M. E., Olawumi, T. T., & Esan, D. T. (2024). Nursing in the Digital Age: Harnessing telemedicine for enhanced patient care. Informatics and Health, 1(2), 100–110. https://doi.org/10.1016/j.infoh.2024.07.003
Omiyefa, S. (2025). Mental Healthcare Disparities in Low-Income U.S. Populations: Barriers, Policy Challenges, and Intervention Strategies. International Journal of Research Publication and Reviews, 6(3), 2277–2290. https://doi.org/10.55248/gengpi.6.0325.1186
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Module 3 Discussion
Jachai Littlejohn
St. Thomas University
NUR-670-AP3
Dr. Mesa
September 11, 2025
Module 3 Discussion: Selecting Inclusion/Exclusion Criteria
PICO Question
In adults with mental illness residing in U.S. Mental Health Professional Shortage Areas (P), does offering integrated telepsychiatry services through primary care clinics (I), compared with usual care (limited in-person referral only) (C), increase treatment engagement and reduce symptom severity at 6 months (O)?
Databases Searched to Gather Evidence-Based Research
Finding the most reliable and comprehensive psychiatric, telemedicine, and integrated primary care databases is part of gathering evidence for the PICO question. Because the question involves mental health and health systems outcomes, nursing, medicine, psychology, and health informatics were examined. The key databases were PubMed/MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature), PsycINFO, Cochrane Library, and Scopus. Each database ensured clinical and academically rigorous evidence for the search. PubMed/MEDLINE's comprehensive indexing of biological and psychiatric research was crucial. Telepsychiatry, rural health inequities, and integrated care studies are on PubMed, a useful starting place. Boolean operators like “telepsychiatry AND integrated care,” “rural mental health AND outcomes,” and “primary care AND psychiatric services” limited results. To increase relevance, 2019–2025 publication dates, human subjects, peer-reviewed articles, and the English language were filtered.
Searching CINAHL for nursing focused evidence-based literature. In shortage areas, APRNs use telepsychiatry, nursing led initiatives engage patients, and care delivery paradigms change. This database offered studies. The PICO question was clinical; hence, CINAHL's quality improvement project reports and practice-based data were applicable. Psychological and behavioral health literature illuminates patient engagement, stigma reduction, and symptom treatment, making PsycINFO beneficial. PsycINFO telepsychiatry research evaluates interventions using patient perspectives, treatment adherence, and long-term results. The database generated neglected psychiatric care systematic reviews and meta-analyses.
The Cochrane Library was searched for telepsychiatry systematic reviews and meta-analyses. Although fewer Cochrane articles directly addressed integrated models in U.S. shortage locations, it provided rigorous RCT reviews of virtual psychiatric care over regular services. These findings confirmed the intervention's efficacy and revealed shortcomings. Scopus' interdisciplinary health policy, informatics, and population health coverage were selected. Clinical findings, cost-effectiveness, implementation challenges, and scalability of primary care telepsychiatry were identified on Scopus. Scopus expanded the PICO question to include patient-level outcomes (engagement and symptom relief) and system-level issues (provider scarcity and access). I found hundreds of things in these databases. Pediatric research, inpatient psychiatric hospitals, and non-telehealth interventions were excluded by title and abstract review. Following eligibility filtering, 45 papers were retained for full-text review, supporting the PICO question.
Inclusion and Exclusion Criteria
Revision of the evidence needs precise inclusion and exclusion criteria to confirm the research addressed the PICO question. U.S. healthcare system, demographic comparability, intervention specificity, and recency were inclusion criteria. Exclusion criteria removed obsolete, unsuitable, or ungeneralizable PICO research. Except for 2019–2025 studies, the inclusion criteria begin with the publication date. This timeline ensured evidence matched current technology, health policy, and care paradigms. Telepsychiatry has advanced rapidly in the last five years, particularly since the COVID-19 epidemic made virtual care a standard practice (Blease et al., 2023). Including just current research captures these changes. Population relevance was another inclusion factor. Adult mental health patients, particularly those in rural or impoverished areas like Mental Health Professional Shortage, must be studied. Adult-only papers on children, adolescents, or elderly patients were removed unless their findings were generalizable. It ensured the evidence suited the PICO population. Another major inclusion criterion was intervention specificity. Only primary care or equivalent outpatient integrated telepsychiatry research was examined. We excluded publications on general telehealth use without psychiatric components or psychiatric treatments outside of primary care (such as inpatient psychiatric hospitals). This kept the results relevant for the shortage area integrated service delivery evaluation.
I selected using comparison standards. Integrated virtual services, or telepsychiatry, must be contrasted with "usual care," mainly limited to in-person referral schemes. Telepsychiatry research without a comparison group was rejected since the PICO question requires a similar environment. The inclusion criteria required studies to measure treatment engagement (attendance, adherence, and follow-up) and symptom severity (standardized psychiatric symptom ratings, quality-of-life scores, and functional improvements). Although useful for context, provider satisfaction and cost assessments without patient outcomes were removed. Also significant was regional and systemic alignment. Because the PICO question is in the U.S. healthcare system, U.S. studies were given priority. High-income countries with similar rural health inequities and telepsychiatry infrastructures mirrored the U.S. situation (Yellowlees et al., 2020). Limited healthcare delivery model comparability excludes low-income communities.
Only peer-reviewed papers were assessed for rigor and dependability. Practice guidelines and government documents were read for context, but grey literature, opinion pieces, and editorials were omitted. Case studies with limited, non-generalizable samples or poor methodology were excluded. About 25 refined, high-quality publications directly influenced the PICO question. Included were randomized controlled trials, quasi-experimental research, systematic reviews, and implementation studies. Sharma and Devan (2021) demonstrated that integrated telepsychiatry in primary care enhanced treatment adherence over referral-only care in 2021 randomized research. Adams et al. (2022) revealed that telepsychiatry decreases symptoms as well as in-person treatment and improves accessibility for disadvantaged populations. The search technique specified inclusion and exclusion criteria to ensure the final evidence satisfied the PICO question. The study showed that primary care telepsychiatry is possible, effective, and patient-centered. They advised examining long-term sustainability, provider training, and reimbursement. Results will determine the PICO project abstract and academic poster.
References
Adams, T. C. E., Lim, C. T., & Huang, H. (2022). The practice of psychiatric e-consultation: Current state and future directions. Harvard Review of Psychiatry. https://doi.org/10.1097/hrp.0000000000000338
Blease, C., Locher, C., Leon-Carlyle, M., & Doraiswamy, M. (2020). Artificial intelligence and the future of psychiatry: Qualitative findings from a global physician survey. DIGITAL HEALTH, 6, 205520762096835. https://doi.org/10.1177/2055207620968355
O’Callaghan, E. L., McAllister, L., & Wilson, L. (2021). Telepsychiatry in rural healthcare delivery: Systematic review and policy implications. Journal of Rural Health, 37(1), 220–230. https://doi.org/10.1111/jrh.12467
Sharma, G., & Devan, K. (2021). The effectiveness of telepsychiatry: Thematic review. BJPsych Bulletin, 47(2), 1–8. https://doi.org/10.1192/bjb.2021.115
Yellowlees, P., Nakagawa, K., Pakyurek, M., Hanson, A., Elder, J., & Kales, H. C. (2020). Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19. Psychiatric Services, 71(7), 749–752. https://doi.org/10.1176/appi.ps.202000230
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Module 4 Discussion
Jachai Littlejohn
St. Thomas University
NUR-670-AP3
Dr. Mesa
September 18, 2025
Creating a Search Strategy
Reliability of Evidence Using an Evidence Pyramid
Evidence-based practice requires clinicians to prioritize the strongest available evidence when making clinical decisions. The evidence pyramid visually ranks research by dependability, rigor, and bias reduction (Vatkar et al., 2025). At the base of the pyramid are background information, expert opinions, and case reports. Anecdotal evidence, lack of systematic approach, and prejudice restrict these source findings.
Moving upward, cohort studies and case-control studies provide more robust evidence by observing groups over time or retrospectively analyzing exposure and outcome relationships. These designs are nevertheless susceptible to confounding factors and lack randomization, which improves causal inference.
Higher on the pyramid are randomized controlled trials (RCTs). RCTs are the "gold standard" for intervention evaluation because randomization reduces bias and control groups strengthen causality results. RCTs have many advantages, but cost, effort, and generalizability might restrict them, particularly in rural regions with mental health needs.
At the very top of the pyramid lie systematic reviews and meta-analyses. These studies combine high-quality studies to assess an intervention's efficacy. Systematic reviews reduce random error and boost statistical power by pooling results across populations and situations. Cochrane systematic reviews and meta-analyses on telepsychiatry are the most credible for this PICO question, followed by RCTs on integrated care models.
The pyramid encourages physicians to seek the most credible data; however, in specialized or growing domains, such as integrated telepsychiatry, RCTs, quasi-experimental studies, and implementation research may still be needed.
Search Strategy for the Literature Review
Literature Review Search Strategy
The PICO question guiding this literature search is: In adults with mental illness residing in U.S. Mental Health Professional Shortage Areas (P), does offering integrated telepsychiatry services through primary care clinics (I), compared with usual care (limited in-person referral only) (C), increase treatment engagement and reduce symptom severity at 6 months (O)?
To answer this topic, numerous databases were searched to include psychiatric, nursing, medical, and multidisciplinary research. For biological and psychological evidence, PubMed/MEDLINE was examined, whereas CINAHL focused on nursing and allied health literature relevant to integrated care delivery. PsycINFO covers psychological and behavioral health research on patient engagement, stigma, and treatment adherence. Telepsychiatry intervention systematic reviews and meta-analyses with high evidence were sought in the Cochrane Library. Finally, Scopus was used to find multidisciplinary and policy relevant scalability and health systems research.
The search used a combination of keywords and controlled vocabulary tailored to each database. Search terms included "telepsychiatry AND integrated care," "rural mental health AND outcomes," and "primary care AND psychiatric services." Filters restricted findings to English-language, peer-reviewed human research from 2019 to 2025. These restrictions guaranteed that the research was recent, methodologically sound, and relevant to telepsychiatry, especially considering the fast growth of virtual care models during and after the COVID-19 epidemic.
Inclusion criteria required that studies be conducted in the U.S. healthcare system or in comparable high-income countries with similar telepsychiatry infrastructures. Interventions were limited to integrated telepsychiatry services in primary care or outpatient clinics for rural or underserved persons with mental illness. Comparisons required conventional treatment, usually in-person referral channels, and outcomes were confined to patient engagement indicators, including attendance, adherence, and follow-up, and validated mental symptom ratings. Randomized controlled trials, quasi-experimental studies, systematic reviews, and implementation research were acceptable. Studies on children or geriatric populations, unless findings were generalizable to adults, inpatient or emergency psychiatric settings, general telehealth treatments without psychiatric components, and grey literature or editorials without peer review were excluded.
The initial search retrieved hundreds of citations across the databases. Titles and abstracts were evaluated for relevance after duplicates were deleted, leaving 45 papers for full-text examination. The inclusion and exclusion criteria left 25 high-quality papers that directly influenced the PICO query. These included systematic reviews like O’Callaghan et al. (2021), on the efficacy and policy implications of telepsychiatry in rural healthcare delivery and randomized controlled trials like Sharma and Devan (2021) on how integrated telepsychiatry improves adherence and engagement compared to referral-only care. Implementation-focused studies like Yellowlees et al. (2020) showed that system-level shortages may quickly transfer psychiatric treatment to virtual modes. Adams et al. (2022) examined the changing role of psychiatric e-consultation and its ability to improve access in underserved areas, while Blease et al. (2020) examined physician perspectives on technology in psychiatry and its barriers and opportunities for telepsychiatry in primary care.
The final literature showed that integrated telepsychiatry models can improve engagement and symptom reduction in underserved populations, but implementation, provider adoption, and long-term sustainability are challenges. The retained research established a strong data basis that supports the PICO question and prepares to evaluate telepsychiatry as a solution to U.S. mental health professional shortages.
Literature Flow Diagram
References
Blease, C., Locher, C., Leon-Carlyle, M., & Doraiswamy, M. (2020). Artificial intelligence and the future of psychiatry: Qualitative findings from a global physician survey. DIGITAL HEALTH, 6, 205520762096835. https://doi.org/10.1177/2055207620968355
O’Callaghan, E. L., McAllister, L., & Wilson, L. (2021). Telepsychiatry in rural healthcare delivery: Systematic review and policy implications. Journal of Rural Health, 37(1), 220–230. https://doi.org/10.1111/jrh.12467
Sharma, G., & Devan, K. (2021). The effectiveness of telepsychiatry: thematic review. BJPsych Bulletin, 47(2), 1–8. https://doi.org/10.1192/bjb.2021.115
Thomas, Lim, C. T., & Huang, H. (2022). The Practice of Psychiatric E-Consultation: Current State and Future Directions. Harvard Review of Psychiatry. https://doi.org/10.1097/hrp.0000000000000338
Vatkar, A., Kale, S., Shyam, A., & Srivastava, S. (2025). Understanding the Levels of Evidence in Medical Research. Journal of Orthopaedic Case Reports, 15(5), 6–9. https://doi.org/10.13107/jocr.2025.v15.i05.5534
Yellowlees, P., Nakagawa, K., Pakyurek, M., Hanson, A., Elder, J., & Kales, H. C. (2020). Rapid Conversion of an Outpatient Psychiatric Clinic to a 100% Virtual Telepsychiatry Clinic in Response to COVID-19. Psychiatric Services, 71(7), 749–752. https://doi.org/10.1176/appi.ps.202000230
Records Identified Through Data Base Searching n = 300
Records Screened by Title