Expanding the Nurse Practitioner Role in Treatment Resistant Major Depression

Travis K. Svensson, University of San Francisco


Treatment resistant major depression (TRMD) is a common problem with significant consequences in terms of bio-psycho-social disability and economic impact for the individual, family and community. A 2014 survey of San Francisco bay area community resources confirms that nurse practitioners (NPs) are under represented in the advanced management of TRMD using electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) and ketamine infusion therapy (KIT). An expansion in the role of the NP in the management of TRMD is indicated. The purpose of this project was to develop and implement an education course that prepares a cohort of NPs to demonstrate mastery of advanced clinical techniques through direct provision of safe, tolerable and efficacious care to TRMD populations using ECT, TMS and KIT. Five NPs participated in a continuing education program that included four hours of didactic and twelve hours of bedside clinical continuing education in the advanced management of TRMD. Implementation of this quality improvement project resulted in a high level of satisfaction among NP participants and patient. Upon completion of the training, a considerable increase was evident in self-efficacy in the management of TRMD (95%), ketamine infusion therapy (90%), electroconvulsive therapy (85%), and transcranial magnetic stimulation (80%), relative to pre-training levels. In the 60-day follow-up period, all five NP participants directly managed an average of 8.6 patients with TRMD using advanced techniques. Safety, efficacy and tolerability were comparable to published data for psychiatrist provided services.