Date of Conferral

10-27-2026

Date of Award

October 2026

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Margaret Harvey

Abstract

Walden University College of Nursing This is to certify that the doctoral study by Helen Ohene has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made. Review Committee Dr. Margaret Harvey, Committee Chairperson, Nursing Faculty Dr. Joan Hahn, Committee Member, Nursing Faculty Chief Academic Officer and Provost Sue Subocz, Ph.D. Walden University 2026 Executive Summary: Staff Education Project Staff Education to Increase Staff Competence to Assess and Promote Antidepressant Medication Adherence by Helen Ohene Executive Summary Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University May 2026 1 Summary Depression affects millions of Americans. The purpose of this staff education project was increasing staff self-perceived competency to counsel patients on antidepressant medication adherence and enhancing clinical outcomes among patients with depressive disorders treated at the facility. Untreated depression can increase the risk of recurrent illness, and suicide contemplation can further interfere with functioning and daily activities. The focus of the project question was on whether a staff education project would increase staff self-perceived competency to counsel patients on antidepressant medication adherence. Twenty journal articles were used to devise the staff education project. Ten mental health staff at the project site agreed to participate and provided consent by completing a demographic survey and a pretest confidence questionnaire completion. They attended a 75-minute PowerPoint presentation and completed a posttest confidence questionnaire. I used descriptive statistics (percentages) to examine the program's effectiveness, comparing pre and posttest confidence item averages. Postimplementation, there was an increase in confidence and knowledge in all confidence items, with participants rated confidence or high confidence 100% for five items and 90% for one item. Moreover, all participants evaluated the program as beneficial and supported its potential to improve mental health outcomes. With increased confidence, staff are better equipped to improve treatment outcomes, decreasing the burden of depression and its associated healthcare costs and yielding a positive social impact. Addressing medication adherence and enhancing quality of life among a vulnerable population of patients with depression supports inclusion, equity, and diversity. 2 Background Depression is one of the most common mental health conditions, with antidepressants commonly prescribed for depressive disorders. Despite considerable efficacy in treating depression, patients often fail to take medications as advised by their providers, resulting in suboptimal therapeutic effects and poor mental health outcomes (Almohammed et al., 2022). An identified gap in practice at the project site was poor staff self-perceived competency and confidence related to antidepressant medication counseling to improve adherence rates. The project site recorded poor antidepressant adherence rates recorded among patients with depressive disorders. Staff members felt inadequately prepared to provide comprehensive counseling, aggravating poor antidepressant compliance rates. Moreover, the project site leadership team highlighted the need to address the burden of antidepressant nonadherence that compromised the efficacy of antidepressants and retarded patient recovery by worsening mental health outcomes and quality of life (QoL). The project question was: Will a staff education program increase staff self perceived competency to counsel patients on antidepressant medication adherence? The purpose of the staff education project was to evaluate the effectiveness of staff education on increasing staff self-perceived competency to counsel patients on antidepressant medication adherence. My objectives for the project were to evaluate the effectiveness of staff education on increasing staff understanding of the reasons for nonadherence to antidepressant medications, improve the perceived competency of staff to counsel patients on medication adherence, and enhance clinical outcomes among patients with depressive disorders treated at the facility. 3 I used the Johns Hopkins evidence-based practice model to grade evidence level for 20 peer-reviewed journal articles that informed the staff education project. Three high-quality Level-I studies informed the staff education project. Pillai et al. (2021) reported that a collaborative stepped-up care intervention was linked to higher antidepressant adherence. Del Pino-Sedeño et al. (2024) established that patient centered collaborative care programs and medication reminders decreased the severity of symptoms and improved QoL. Similarly, González de León et al. (2022) reported that collaborative care improved short-term medication adherence. Twelve Level-III good-quality studies were included. According to Almohammed et al. (2022), over 17.5 million adults received a diagnosis of depressive disorder between 2005 and 2016. Lassen et al. (2024) reported a pooled nonadherence rate of 24%. Rathnam et al. (2024) indicated clinician variability in achieving stable treatment and follow-up loss. Several studies highlighted several factors linked to antidepressant nonadherence. Niarchou et al. (2024) reported untoward effects such as headaches and somnolence that increased drop-out rates. Unni et al. (2024) reported short- and long-term adverse effects, forgetfulness, and negative beliefs. Marrero et al. (2020) highlighted the impact of locus of control, self-efficacy, and family support. In addition, Shi et al. (2024) reported high levels of perceived and internalized stigma. Further, Semahegn et al. (2020) indicated a lack of social support, patient behaviors, and treatment-clinical- and healthcare system-related factors that negatively influenced medication compliance. Moreover, in Crowe et al.’s study (2023), participants reported that medication masked the real problem and altered their experiences. Pedrosa-Naudín et al. (2022) highlighted key factors such as using tricyclic antidepressants, living in urban settings, and pain. Khalifeh et al. (2023) 4 linked negative beliefs and high antidepressant nonadherence rates. Jang et al. (2020) indicated that the usual source of care, appropriateness of care, and visiting a psychiatrist improved adherence rates. One Level-IV high-quality study reported nine side effects from 37 antidepressants and the resultant clinical dilemma of avoiding one side effect and increasing the risk of others (Pillinger et al., 2023). Four Level-V studies informed the staff education project. Marasine and Sankhi (2021) reported factors linked with antidepressant nonadherence. Xia et al. (2020) showed that a focus group and person centered counseling increased the adherence rate by 33% and reduced readmissions. Solmi et al. (2021) provided ten clinical recommendations for improving antidepressant adherence. Lastly, Khalifeh and Hamdan-Mansour (2021) reported multifaceted interventions implemented to enhance antidepressant medication adherence. These studies supported the project by highlighting the high prevalence of depression and antidepressant medication nonadherence, underpinning the need for strategies to improve adherence rates. Project Development In this project, my aim was to evaluate the effectiveness of staff education on increasing staff understanding of the reasons for nonadherence to antidepressant medications, improve the perceived competency of staff to counsel patients on medication adherence and enhance clinical outcomes among patients with depressive disorders treated at the facility. The staff education project mental health professionals (MHPs) at the project site. Ten MHPs agreed to participate in the project and provided consent by completing the demographic survey and proceeding to complete the pretest confidence questionnaire. All participants were asked to complete all 5 demographic questionnaires and pre-and posttests using unique identifiers to ascertain anonymity, confidentiality, and privacy in compliance with ethical requirements. Key project materials included the Walden University Staff Educational Manual and Checklists for Staff Education. The Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model was instrumental in staff education development, including the pre-and posttests. The educational module was developed after extensive consultations with the project site leaders and the DNP faculty advisor. Participants were invited to the staff education project and completed demographic questionnaires (See Appendix A) after they were informed it was part of their consent to participate in the project. Participants also completed a baseline pretest confidence questionnaire (See Appendix B). Participants attended a 75-minute PowerPoint presentation (See Appendix C) on antidepressant adherence counseling. After the presentation, they completed the posttest questionnaire and program evaluation (See Appendix D). Demographic and pre-and posttest data were analyzed using descriptive statistics. The program's effectiveness was assessed by comparing changes in confidence levels. The data were compiled to identify changes in confidence before and after the PowerPoint presentation, utilizing descriptive statistics (percentages). Later, the data were summarized and documented, highlighting the impact of the staff education project and future recommendations. Results Ten MHPs participated in the project. Sixty percent of the sample was female. The highest educational qualification was master’s and bachelor’s degrees. Most 6 participants had worked at the project site for between 4 and 6 years. The baseline participants' demographic data are summarized in Table 1. Table 1 Baseline Participants’ Sociodemographic Characteristics Characteristic n % Gender Female 6 70 Male 4 30 Highest Education Bachelor's Degree 5 50 Master's Degree 5 50 Years of Service 1-3 years 3 30 4-6 years 6 60 7-10 years 1 10 Postimplementation, there was an increase in confidence and knowledge in all confidence items, with participants rated confidence or high confidence 100% for five items and 90% for one item compared to baseline scores ranging between 20-60%, showcasing increased confidence. Additionally, all participants indicated that they strongly agreed that the information provided in the training was helpful for MHPs to improve their competence in counseling patients taking antidepressant medications and improving mental health outcomes. The pre-and posttest project findings are summarized in Table 2 below. 7 Table 2 Pre- and Posttest Confidence Results Confidence item Pretest (n = 10) Posttest (n = 10) Identify common antidepressant medications prescribed for depression. Confidence or high confidence 60% 100% Interact and maintain a therapeutic relationship with patients with depression. Confidence or high confidence 40% 90% Assess medication adherence among patients with MDD. Confidence or high confidence 20% 70% Understand the reasons for poor antidepressant adherence and discontinuation. Confidence or high confidence 50% 100% Use effective strategies for antidepressant medication adherence counseling. Confidence or high confidence 20% 100% Link antidepressant medication adherence and positive patient outcomes Confidence or high confidence 60% 100% The staff education project had a profound impact on the healthcare organization. Ten MHPs had an overall increase in confidence related to identifying common antidepressant medications, maintaining a therapeutic relationship, assessing medication adherence, and understanding reasons for nonadherence and discontinuations. Also, they indicated high confidence in leveraging effective antidepressant medication adherence counseling strategies. Overall, the project improved staff’s self-perceived competency to counsel patients on antidepressant medication adherence, increasing the healthcare organization’s capacity to improve treatment outcomes among patients with depression. A few limitations were identified in this project. The evaluation process relied on self-reported confidence, and social desirability bias must be considered. 8 Participants may have provided biased results in pre-or posttests because they did not want to appear inadequate in professional competency in providing depression care. The generalizability of the findings may be limited. The project was conducted in a single mental health clinic with a limited number of participants (n = 10). Despite these limitations, the project is significant. Addressing an upward trend of medication nonadherence in depression is fundamental to decreasing psychiatric morbidity, suicidality, and mortality, increasing healthcare services utilization, and enhancing the QoL of patients (González de León et al., 2022). MHPs must promote adherence and aid recovery from depression. The project promoted MHPs’ confidence to improve antidepressant medication adherence, showcasing a context-specific solution that utilized an educational intervention to improve staff confidence and can improve outcomes. The project can be applied to other psychiatric contexts to improve psychotropic medication compliance. Recommendations First, I recommend the implementation of regular follow-up staff education sessions every 6 months to reinforce knowledge on antidepressant adherence counseling, building on the proven effectiveness of staff training to sustain high confidence levels among mental health professionals. Next, I recommend the integration of adherence therapy protocols into pre-discharge planning for patients with depression, including personalized counseling on medication benefits and barriers, to directly address non-adherence factors identified in the project literature and improve long-term outcomes. I also recommend the development and distribution of evidence-based patient education materials, such as brochures or digital resources, focusing on common side 9 effects, stigma reduction, and family support, to empower patients and complement staff counseling efforts demonstrated in the project. Finally, I recommend the establishment of a monitoring system to track patient adherence rates and staff confidence quarterly, using simple pre/post assessments similar to the project's tools, to evaluate ongoing impact and allow for data-driven adjustments in facility practices. Conclusions Overall, the project improved staff’s self-perceived competency to counsel patients on antidepressant medication adherence. With an increased understanding among MHPs, the healthcare organization is better equipped to improve treatment outcomes among patients with depression. Further recommendations include providing evidence-based information to patients with psychiatric conditions to address negative beliefs and attitudes, creating a supportive psychiatric environment, providing adherence therapy as a pre-discharge protocol for patients with depression, and implementing enhanced self-monitoring and assessment to support adherence programs. Health and social care programs need to be developed to improve therapeutic alliance. Psychological interventions integrating family support and self-control are needed to improve compliance rates (Solmi et al., 2021). Lastly, policies that promote access to quality care and more efficient healthcare systems can improve depression treatment outcomes. Depression is a debilitating disorder linked with significant disability and functional and social impairments with a resultant lower QoL among patients (Crowe et al., 2023). Due to the heightened risk of suicidality, patients require close monitoring and frequent follow-up. Patient counseling improves person-centered care, improving treatment outcomes. Nurses and other clinicians must promote 10 antidepressant adherence (Rathnam et al., 2024). The project yielded a tangible impact by enhancing MHPs’ ability to improve antidepressant medication adherence. There is a potential for improved clinical outcomes, decreased severity of symptoms and disease burden, lower costs, and enhanced patients’ return to daily activities. Improving functioning and QoL among a vulnerable population with depression supports inclusion, equity, and diversity. 11 References Almohammed, O., Alsalem, A., Almangour, A., Alotaibi, L., Al Yami, M., & Lai, L. (2022). Antidepressants and health-related quality of life (HRQoL) for patients with depression: Analysis of the medical expenditure panel survey from the United States. PloS One, 17(4), e0265928. https://doi.org/10.1371/journal.pone.0265928 Crowe, M., Inder, M., & McCall, C. (2023). Experience of antidepressant use and discontinuation: A qualitative synthesis of the evidence. Journal of Psychiatric and Mental Health Nursing, 30(1), 21-34. https://doi.org/10.1111/jpm.12850 Del Pino-Sedeño, T., González-Pacheco, H., González de León, B., Serrano-Pérez, P., Acosta Artiles, F., Valcarcel-Nazco, C., Hurtado-Navarro, I., Rodríguez Álvarez, C., Trujillo-Martín, M. , & MAPDep Team. (2024). Effectiveness of interventions to improve adherence to antidepressant medication in patients with depressive disorders: A cluster randomized controlled trial. Frontiers in Public Health, 12, 1320159. https://doi.org/10.3389/fpubh.2024.1320159 González de León, B., Del Pino-Sedeño, T., Serrano-Pérez, P., Rodríguez Álvarez, C., Bejarano-Quisoboni, D., & Trujillo-Martín, M. (2022). Effectiveness of interventions to improve medication adherence in adults with depressive disorders: A meta-analysis. BMC Psychiatry, 22(1), 487. https://doi.org/10.1186/s12888-022-04120-w Jang, S., Cho, H., Kang, C., & Jang, S. (2020). Antidepressant adherence and its predictors in immigrants with depression: A population-based study. Medicine, 99(51), e23308. https://doi.org/10.1097/MD.0000000000023308 12 Khalifeh, A., & Hamdan-Mansour, A. (2021). Prevalence, barriers, and interventions related to medication adherence among patients with major depressive disorder: A scoping review. Journal of Psychosocial Nursing and Mental Health Services, 59(1), 39–51. Retrieved from https://doi.org/10.3928/02793695-20201015-05 Khalifeh, A., Alhalaiqa, F., Hamaideh, S., Horne, R., & Hamdan-Mansour, A. (2023). The effect of adherence therapy on medication adherence, health beliefs, self efficacy, and depressive symptoms among patients diagnosed with major depressive disorder. International Journal of Mental Health Nursing, 32(3), 778–790. https://doi.org/10.1111/inm.13113 Lassen, R., Gonçalves, W., Gherman, B., Coutinho, E., Nardi, A., Peres, M., & Appolinario, J. (2024). Medication nonadherence in depression: A systematic review and metanalysis. Trends in Psychiatry and Psychotherapy, 10.47626/2237-6089-2023-0680. https://doi.org/10.47626/2237-6089-2023- 0680 Marasine, N., & Sankhi, S. (2021). Factors associated with antidepressant medication nonadherence. Turkish Journal of Pharmaceutical Sciences, 18(2), 242–249. https://doi.org/10.4274/tjps.galenos.2020.49799 Marrero, R., Fumero, A., de Miguel, A., & Penate, W. (2020). Psychological factors involved in psychopharmacological medication adherence in mental health patients: A systematic review. Patient Education and Counseling, 103(10), 2116-2131. https://doi.org/10.1016/j.pec.2020.04.030 Niarchou, E., Roberts, L., & Naughton, B. (2024). What is the impact of antidepressant side effects on medication adherence among adult patients 13 diagnosed with depressive disorder: A systematic review. Journal of Psychopharmacology (Oxford, England), 38(2), 127–136. https://doi.org/10.1177/02698811231224171 Pedrosa-Naudín, M., Gutiérrez-Abejón, E., Herrera-Gómez, F., Fernández-Lázaro, D., & Álvarez, F. (2022). Nonadherence to antidepressant treatment and related factors in a region of Spain: A population-based registry study. Pharmaceutics,, 14(12), 2696. https://doi.org/10.3390/pharmaceutics14122696 Pillai, A., Keyes, K., & Susser, E. (2021). Antidepressant prescriptions and adherence in primary care in India: Insights from a cluster randomized control trial. PLoS One, 16(3), e0248641. https://doi.org/10.1371/journal.pone.0248641 Pillinger, T., Howes, O., Correll, C., Leucht, S., Huhn, M., Schneider-Thoma, J., Gaughran, F., Jauhar, S., McGuire, P., Taylor, D., Young, A., & McCutcheon, R. (2023). Antidepressant and antipsychotic side-effects and personalized prescribing: A systematic review and digital tool development. The Lancet. Psychiatry, 10(11), 860–876. https://doi.org/10.1016/S2215-0366(23)00262-6 Rathnam, S., Hart, K., & Sharma, A. (2024). Heterogeneity in antidepressant treatment and major depressive disorder outcomes among clinicians. JAMA Psychiatry, 81(10), 1003-1009. https://doi.org/10.1001/jamapsychiatry.2024.1778 Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication nonadherence and its associated factors among patients with major psychiatric disorders: A systematic review and 14 meta-analysis. Systematic Reviews, 9(1), 17. https://doi.org/10.1186/s13643- 020-1274-3 Shi, J., Chen, Y., Jiang, Y., Li, Y., Wang, W., Zhao, H., Guo, L., Liao, Y., Zhang, H., Gao, C., McIntyre, R., Zhang, W., Han, X., Lu, C. (2024). Stigma and its associations with medication adherence in major depressive disorder. Psychiatry Research, 331, 115664. https://doi.org/10.1016/j.psychres.2023.115664 Solmi, M., Miola, A., Croatto, G., Pigato, G., Favaro, A., Fornaro, M., Berk, M., Smith, L., Quevedo, J., Maes, M., Correll, C., & Carvalho, A. (2021). How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations. Revista Brasileira de Psiquiatria, 43(2), 189–202. https://doi.org/10.1590/1516-4446-2020-0935 Unni, E., Gupta, S., & Sternbach, N. (2024). Reasons for nonadherence with antidepressants using the Medication Adherence Reasons Scale in five European countries and United States. Journal of Affective Disorder, 344, 446–450. https://doi.org/10.1016/j.jad.2023.10.010 Xia, X., Poremski, D., Ubana, R., & Ravichandran, N. (2020). Promoting medication adherence among psychiatric patients with a history of nonadherence: A clinical practice improvement program. Journal of Psychiatric Practice, 26(4), 284-293. https://doi.org/10.1097/pra.0000000000000482 15 Appendix A: Demographic Survey Unique Identifier______ Date: _________ Instructions: Circle/Cross the right answer. 1. Gender: What gender do you identify with? o Male o Female o Non-binary o Prefer not to say o Other (please specify): ________ 2. Education Level: What is the highest level of education you have completed? o Associate's Degree o Bachelor's Degree o Master's Degree o Doctorate/Ph.D. o Other (please specify): ________ 3. Years of Service: How many years have you been working at this organization? o Less than 1 year o 1-3 years o 4-6 years o 7-10 years o More than 10 years 16 Appendix B: Pretest Confidence Questionnaire Unique Identifier______ Date: _________ Instructions: Circle the right answer 1. I can identify common antidepressant medications prescribed for patients with depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 2. I can effectively interact and maintain a therapeutic relationship with most patients who have depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 3. I can confidently assess medication adherence among patients with depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 17 4. I understand the reasons why patients with depression have poor adherence rates and why some discontinue antidepressant medications. o No confidence o Little confidence o Some confidence o Confidence o High confidence 5. I am confident that I can use effective strategies for counseling patients on antidepressant medication adherence. o No confidence o Little confidence o Some confidence o Confidence o High confidence 6. I am confident that I can describe the importance of antidepressant medication adherence and its link with positive patient outcomes. o No confidence o Little confidence o Some confidence o Confidence o High confidence 18 Appendix C: Staff Education PowerPoint Presentation 19 Appendix D: Posttest Confidence Questionnaire and Program Evaluation Unique Identifier______ Date: _________ Instructions: Circle the right answer 1. I can identify common antidepressant medications prescribed for patients with depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 2. I can effectively interact and maintain a therapeutic relationship with most patients who have depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 3. I can confidently assess medication adherence among patients with depressive disorders. o No confidence o Little confidence o Some confidence o Confidence o High confidence 20 4. I understand the reasons why patients with depression have poor adherence rates and why some discontinue antidepressant medications. o No confidence o Little confidence o Some confidence o Confidence o High confidence 5. I am confident that I can use effective strategies for counseling patients on antidepressant medication adherence. o No confidence o Little confidence o Some confidence o Confidence o High confidence 6. I am confident that I can describe the importance of antidepressant medication adherence and its link with positive patient outcomes. o No confidence o Little confidence o Some confidence o Confidence o High confidence 21 Program Evaluation Instructions: Rate your level of agreement with the following statement. The Rating is from 1 to 5, with 1 being the lowest and 5 representing a high level of agreement. Higher scores indicate a higher level of agreement with the question. Statement: The information provided in this training will help mental health professionals improve their competence to counsel patients taking antidepressant medications to improve mental health outcomes. 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree

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